Integrated Health System:

Referral System
NURUL FATMA DIYANA BINTI AHMAD, 2019-48807
REFERRAL ?
What is referral system?

The set of activities undertaken by a health care

provider or facility in response to its inability to
provide the necessary medical intervention to
respond to a patient’s need.

REFERRAL SYSTEM
Mechanism whereby clients or local health
networks are managed and “moved” between
various components of that network.
 TYPES OF REFERRAL
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EXTERNAL vs INTERNAL
 BASIS OF REFERRAL
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STEP UP CARE

STEP DOWN
FAMILY REQUEST.
CARE

SAME LEVEL
CARE
FRAMEWORK FOR HEALTH REFERRAL
Your SYSTEM
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State/ Regional Hospital

District Hospital District Hospital

without specialist with specialist

Primary Care Providers (Clinics)

RESPONSIBILITY OF DESIGNATED REFERRING (SENDING)
INSTITUTION
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DECIDE WHETHER PATIENT NEEDS TO BE

TRANSFERRED

ENSURING SAFE AND TIMELY

TRANSPORTATION

RESUSCITATION AND STABILIZATION

COMPETENT PATIENT OR REPRESENTATIVE

SHOULD BE INFORMED OF THE REFERRAL
RESPONSIBILITY OF DESIGNATED REFERRAL (RECEIVING)
INSTITUTION
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RECEIVING, ARRANGING FOR PROPER

EXAMINATION AND ADMISSION

ACCOMODATING OR FINDING BED FOR

PATIENT

PROVIDING FEEDBACK TO THE REFERING

HOSPITAL

TRANSPORTATION OF PATIENT BACK TO

THE REFERRING INSTITUTION
Professional Roles
 DOCTOR / SPECIALIST

Direct appropriately Discuss situation with

trained staff to accompany primary team & referral
hospital
Make decision to transfer
Ensure relevant following consultation
medical documentation
fully completed

Ensure receiving unit

has full details
Inform next kin
Liase with staff at of the decision
receiving unit
 NURSING STAFF

Ensure arrangement Discuss transfer arrangement

are made for the transfer of with receiving hospital
patient’s valuable
Contact ambulance control
Ensure all appropriate
Document is completed
Obtain time of transfer

Being available to
Provide nursing support
Identify nursing staff
Ensure full explanation Required to accompany
given to patient
 NURSE / PARAMEDIC ACCOMPANYING PATIENT

Ensure patient & staff safety

Ensure details of patient

Given to the receiving Ensure ambulance is
unit driven safely

Monitor and record

patient’s condition
Ensure necessary equiptment
Ensure appropriate documentation and medication are available
accompanies patient
Referral Records

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 REFERRAL RECORDS

Referral letter X-rays Lab Reports Medication Other Information

Referral Letter Feedback Letter

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Transfer & Transport

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1. DECISION TO TRANSFER & COMMUNICATION
Key Elements of Patient Transfer

Decision to transfer
- Exposure of patient and
staff to additional risk and
additional expenses for
relatives and hospital

Communication
- Sharing of complete
information

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2. PRE TRANSFER STABILISATION & PREPARATION
Key Elements of Patient Transfer

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3. MODE OF TRANSFER
Key Elements of Patient Transfer

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 4. ACCOMPANYING PATIENT
Key Elements of Patient Transfer

Patients who can be managed at the level of ward - usually not required to be
0 accompanied by any specialised personnel

Patients who are at risk of deterioration in their condition - paramedic or a

1
trained nurse

Patients who require observation or intervention for failure of single organ

2 system - trained and competent personnel

Patients with requirement of advanced respiratory care during the transport

3 with support of at least two failing organ systems - competent doctor with a
nurse & paramedic
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5. EQUIPMENT, DRUGS, AND MONITORING
Key Elements of Patient Transfer

Equipment Drug Monitoring

Airway Management Muscle Relaxants Electrocardiogram Monitoring

Oxygenation Sedatives Non-invasive blood pressure

Ventilation Analgesics Oxygen Saturation
Haemodynamic Monitoring Inotropes End-tidal Carbon Dioxide
Resuscitation Resuscitation drugs Temperature
6. DOCUMENTATION
Key elements of patient transfer

Patient’s condition, reason

for transfer
Names and designation of
referring and receiving clinicians

Details and status of vital

signs before transfer

Clinical events during the

transfer and the treatment given
AND CHALLENGES

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State hospital (1)
Major Specialist Hospital (4)
Minor Specialist Hospital (6)
Special Institution (1)
Hospital without Specialist (11)

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State hospital (1)
Major Specialist Hospital (4)
Minor Specialist Hospital (6)
Special Institution (1)
Hospital without Specialist (11)

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State hospital (1)
Major Specialist Hospital (4)
Minor Specialist Hospital (6)
Special Institution (1)
Hospital without Specialist (11)

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State hospital (1)
Major Specialist Hospital (4)
Minor Specialist Hospital (6)
Special Institution (1)
Hospital without Specialist (11)

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STOP??

Stop?

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Referrence:
1. Guideline for Referral and Transfer of Patient between MOH Hospital.
Director General of Health Circular 2/2009. Medical Development Division.
Ministry of Health Malaysia. Mei 2009.
2. Guideline for Flying Doctor Service in Sabah and Sarawak, Family Health
Development Division. Ministry of Health Malaysia. 2015.
3. Health Referral System Manual, Integrated Community Health Services
Project, Department of Health, Republic of the Philippines.
4. Guideline for Inter Facilities Transfer Across Malaysia and Thailand Border
2017.
5. Recommendations of Minimum Standards for Inter-facility Transport of the
Critically Ill Patients, College of Anaesthesiologists, Academy of Medicine of
Malaysia.
6. Referral Systems – A Summary of Key Processes to Guide Health Services
Managers, World Health Organisation. Available at:
https://www.who.int/management/facility/referral/en/
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