cover ref system fileTechnical Guidelines Health Service Referral System West Nusa Tenggara Cooperation between: West Nusa Tenggara Province Health Office and GTZ Siskes Mataram

Technical Guidelines

Health Service Referral System

West Nusa Tenggara

Cooperation between:

West Nusa Tenggara Province Health Office and GTZ Siskes Mataram

First Print, Mataram, 2009

B

AA

DK AT SI H U

Technical Guidelines Health Service Referral System

West Nusa Tenggara Province

Cooperation between:

West Nusa Tenggara Province Health Office and GTZ Siskes Mataram, 2008.

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No............. Catalogue in Publication, NTB West Nusa Tenggara Provincial Health Office p Title: Technical Guidelines for the Health Service Referral

System. Cooperation of the West Nusa Tenggara Provincial Health

Office & GTZ Siskes First Edition, Mataram, September 2008.

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FOREWORD

Praise to God Almighty, for through His Grace and Blessing, these Technical Guidelines on the Health Service Referral System in West Nusa Tenggara Province have been developed. These technical guidelines are derived from Decree of the Minister of Health 032/Birhup /1972 dated 2 September 1972 concerning Referral Systems, and are for use by personnel in health service facilities in West Nusa Tenggara Province.

These technical guidelines received input from the results of the assessment of the referral system in five districts/municipalities – Mataram Municipality, Lombok Barat District, Sumbawa District, Sumbawa Barat District, and Bima Municipality – conducted by a joint team from the West Nusa Tenggara University Research Centre and GTZ Siskes in 2007; and from the outputs of various workshops involving health personnel from village midwifery clinics, primary health centres, district and provincial general hospitals, the health offices of these five districts/municipalities, the provincial health office, and professional organisations (Association of Indonesian Doctors and Association of Indonesian Midwives) in West Nusa Tenggara province, as well as resource people from the Ministry of Health’s Directorate General of Medical Services, and GTZ Siskes Mataram.

After conducting field trials in Lombok Barat District in the fourth quarter of 2008, these technical guidelines will be distributed to all public and private health facilities in West Nusa Tenggara Province to be used as standards by health personnel implementing health service referrals, including maternal and neonatal referrals and referrals of poor patients.

I would like to thank GTZ Siskes, who have worked with us to strengthen the referral system and health development in West Nusa Tenggara Province; and also the design team from the West Nusa Tenggara Provincial Health Office and resource people for the hard work they put in to completing these technical guidelines.

Feedback and suggestions from users for improving these technical guidelines will be welcomed.

Mataram, September 2008.

Head of Health West Nusa Tenggara Provincial Health Office

Dr. Baiq Magdalena Level 1 Senior Administrator, IV/c Civil Service No. 140 186 344

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FOREWORD

The “Deutsche Gesellschaft fuer Technische Zusammenarbeit (GTZ) GmbH” is an international cooperation agency of the Federal Republic of Germany contributing to sustainable development through technical cooperation projects in developing countries. One of the projects supported by GTZ in Indonesia is SISKES which is co-financed by the German and the British governments and is implemented jointly with the Ministry of Health and provincial governments of East Nusa Tenggara for a period of 2000-2009 and West Nusa Tenggara for 2006-2009.

The GTZ/SISKES project in NTB focuses as well on health system management aspects with a specific focus on maternal and neonatal health as on health services management and their clinical service quality. Integrated planning, performance budgeting and data based monitoring, health financing, especially for the poor are part of the support across the province as well as community empowerment and participation in health related action in selected districts linked to maternal health.

A health system that has clear guidance how each part of the system is interlinked and shows fast action throughout the levels of the system in case of emergency is crucial in order to achieve MDGs and to improve the health indicators. For this reason, GTZ SISKES warmly welcomes and supports the development and publication of these technical guidelines for the referral health system for West Nusa Tenggara province being based on MoH guidelines for MPS referral from 2004 and the general guidelines on referral from 1972. Proper dissemination and utilization of the guidelines at all levels of health service providers, including village maternity clinics, village health posts, primary health centres, district hospitals and provincial hospitals across the whole province will contribute to strengthening the local health system and is expected to contribute to the reduction in maternal and neonatal fatalities.

My appreciation goes to the team having produced and revised this output and I hope that the guidelines will be of benefit to the people of West Nusa Tenggara Province, particularly the poor and the vulnerable, and assist other provinces in Indonesia to follow the example of West Nusa Tenggara.

Mataram, April 2009.

Dr. Gertrud Schmidt-Ehry, MPH Principal Advisor GTZ Siskes and HRD.

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TABLE OF CONTENTS Page

TITLE PAGE i

FOREWORD BY THE HEAD OF THE NTB PROVINCIAL HEALTH OFFICE iii

FOREWORD BY THE HEAD OF GTZ SISKES iv

TABLE OF CONTENTS vii

LIST OF TERMS viii

CHAPTER I INTRODUCTION 1

A. Background 1

B. Goal & Objectives 3

C. Situational Analysis 3

CHAPTER II TECHNICAL ASPECTS OF IMPLEMENTATION OF THE REFERRAL SYSTEM

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A. Definition 5

B. Activities included in the referral system 5

C. Organisation and management of the implementation of the referral system

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CHAPTER III PROCEDURES FOR IMPLEMENTATION OF THE REFERRAL SYSTEM

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A. Referring and Receiving Referred Patients 10

B. Referring and Receiving Referred Specimens 15

C. Knowledge and Specialist Referrals 18

D. Procedure for Monitoring and Evaluating Implementation of the Referral System

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CHAPTER IV THE PRINCIPLES OF REFERRAL OF OBSTETRIC AND NEONATAL EMERGENCIES

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A. Principles and Authority of Service Facilities 21

B. Principles of Making and Receiving Maternal and Neonatal Patient Referrals

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CHAPTER V CONCLUSION 27

BIBLIOGRAPHY 28

APPENDICES

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LIST OF TERMS

7T Timbang Berat Badan; Tekanan Darah; Tinggi Fundus Uterus; Tetanus Toxoid; Tablet Tambah Darah; Tatap muka; Tes Urine.

APN Asuhan Persalinan Normal ASKES Asuransi Kesehatan PT. ASKES BBL Bayi Baru Lahir BBLR Berat Badan Lahir Rendah BKMM Balai Kesehatan Matra Masyarakat Depkes Departemen Kesehatan GAKIN Keluarga Miskin IMD Inisiasi Menyusu Dini Jamkesmas Jaminan Kesehatan Masyarakat untuk Keluarga Miskin Jamsostek Jaminan Sosial Tenaga Kerja KB Keluarga Berencana KKP Kantor Kesehatan Pelabuhan LABKES Laboratorium Kesehatan MTBM Manajemen Terpadu Balita Muda MTBS Manajemen Terpadu Balita Sakit Obgyn Obstetri Gynecologi Polindes Pos Persalinan Desa (village maternity clinics) PONED Pelayanan Obstetri Neonatal Dasar PONEK Pelayanan Obstetri Neonatal Komprehensif Poskesdes Pos Kesehatan Desa (village health posts) Posyandu Pos Pelayanan Terpadu (integrated service posts) Pusk Puskesmas (primary health centres) Pustu Puskesmas Pembantu (auxiliary primary health centres) RB Rumah Bersalin (maternity clinics) RS Rumah Sakit RSU Rumah Sakit Umum RSUD Rumah Sakit Umum Daerah Sp.A Spesialis Anak Sp.OG Spesialis Obstetri dan Ginekologi

[translator’s note: this list of terms is not applicable as none of these terms appears in the English version]

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CHAPTER I

INTRODUCTION A. Background

Implementation of the Health Referral System in West Nusa Tenggara

Province is based on Decree of the Minister of Health 032/Birhup/72 dated 4

September 1972 concerning Implementation of Referral Systems, Decree of the

Minister of Health 128/2004 concerning Basic Policy for Primary Health Centres,

and the 2007 Action Plan of the Directorate General of Medical Services, Ministry

of Health.

The referral system in West Nusa Tenggara Province covers three aspects

of primary health services: patient referrals, specimen referrals, and knowledge

referrals. All three may be horizontal, vertical, or a combination of the two, from a

lower level to a higher level. Primary health services are available at all levels,

from village maternity clinics, auxiliary primary health centres, primary health

centres, and private practices, through to district/municipal public hospitals and

provincial public hospitals. If a village maternity clinic, auxiliary primary health

centre, primary health centre or private practice receives or treats an emergency

case, but does not have the authority or does not feel it has the capacity to provide

certain medical care or supporting health services, it must refer the patient to a

level with more competent and comprehensive health facilities, such as the

nearest hospital.

Implementation of the health referral system in West Nusa Tenggara

Province is currently not optimised at all levels of health facilities, as indicated by

the incidence of maternal and child death and other cases that require referral and

counter referral but are not dealt with satisfactorily. There are several factors

contributing to this lack of referral including: 1) lack of comprehensive technical

guidelines for frontline health personnel, 2) lack of adequate counselling for

patients or their families by health personnel, and 3) the absence of analysis or

follow up by the local health office to address the problem of health referrals.

There are several types of referral primary health centres and their

equivalent can make, including obstetric referrals, neonatal referrals, referrals of

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cases of child malnutrition and cases of communicable disease (suspicion for

outbreaks), specimen referrals, and knowledge referrals.

Assessment of referral systems in five districts/municipalities in West Nusa

Tenggara by consultants from West Nusa Tenggara University in 2007 identified

several problems that may have negative bearing on the implementation of patient

referrals, including:

1) The initial point of contact that emergency patients have is not with trained

medical personnel. Personnel at the initial point of contact tend only to go through

the routine procedure of accepting a patient, such as pointing out the registration

desk, asking the family to purchase a card, etc., and fail to take into account the

safety of the patient at the initial point of contact.

2) Doctors and midwives, as the trained personnel, are not in the frontline.

3) The slow procedure for accepting referrals due to bureaucratic administration,

including reporting.

4) Hospitals do not have blood banks or have blood banks that do not function

properly.

5) Not all districts/municipalities and blood banks in district/municipal hospitals

have blood transfusion units, there is no immediate supply of blood for patients

who need it.

6) Limited supporting diagnostic services due to a lack of health personnel,

facilities, and equipment.

7) The limited skills of primary health centre personnel for dealing with maternal

and neonatal emergencies.

8) Feedback or back referral from district/municipal hospitals is frequently ignored

by primary health centre or equivalent personnel because it is generally perceived

that the services provided by the district/municipal hospital have fully addressed

the problem referred.

9) The absence of locally adapted technical guidelines on the health referral

system.

10) Limited public knowledge of the signs of maternal and neonatal

emergencies frequently delays referrals.

11) Culturally, many members of the patient's family must be involved in decision

making, and the patient's inability to make independent decisions frequently

delays referrals.

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In view of the above, technical guidelines on the health referral system in

West Nusa Tenggara Province, need to be prepared as a reference for all

personnel in all health facilities.

B. Goal & Objectives 1. Goal

Implementation of a standard health referral system across all levels

of health facilities in West Nusa Tenggara Province.

2. Objectives a. Implementation of standard technical and administrative procedures

for case referral and back referral,

b. Implementation of standard technical and administrative procedures

for specimen referral and back referral,

c. Implementation of standard technical and administrative procedures

for medical / midwifery knowledge referral.

d. Implementation of referral and back referral recording and reporting

systems in health facilities.

C. Situational Analysis 1. Primary Health Centres, Auxiliary Primary Health Centres, and Village

Maternity clinics The number of primary health centres in West Nusa Tenggara Province is

increasing, from 127 in 2005, to 130 in 2006, and 135 in 2007 and 142 in

2008. They include 53 primary health centres with in-patient facilities, and

89 primary health centres without in-patient facilities. Similarly, the number

of auxiliary primary health centres and village maternity clinics has been

growing, reaching a total of 528 and 550 units respectively as at the end of

2007. The average ratios are 1 primary health centre per 32,000

population, or 3.1 primary health centres per 100,000 population; 1 auxiliary

primary health centre per 8,200 population or 12.2 auxiliary primary health

centres per 100,000 population; and 1 village maternity clinic per 7800

population or 12.7 village maternity clinics per 100,000 population.

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The average ratio of GPs to population is 8 per 100,000 population;

and for nurses/midwives is 84 per 100,000 population.

The average crude disease rate in West Nusa Tenggara Province in

2007 was 32 per 100 population. The number of high risk pregnancies was

27,873, or 25 per 100 pregnant women. And the number of high risk

neonates referred was 3,367 or 3.47 per 100 neonates.

In 2006, there were 99 maternal deaths, 95 in 2007 and 92 in 2008.

There were 290 neonatal deaths in 2007.

2. Hospitals In 2007, there were 13 registered hospitals in West Nusa Tenggara,

comprising 8 provincial/district public hospitals, including a psychiatric

hospital; 3 private general hospitals; and 1 military/army hospital and 1

police hospital. The average ratio of specialist doctors to population was 1.7

per 100,000 population, and the average hospital bed availability was 25

per 100,000 population.

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3. District/Municipal Health Offices In 2008, there were nine district/municipal health offices (10 in 2009)

on the island of Lombok (4 (5) districts/municipalities) and the island of

Sumbawa (5 districts/municipalities). Regarding the referral system and

outbreak management, the head of the district/municipal health office

provides assistance for referral facilities to primary health centres and other

health facilities in the district/municipality, and in turn, may request the

assistance of referral facilities and health personnel from the head of the

provincial health office, the nearest district/municipal health office, other

source.

4. West Nusa Tenggara Provincial Health Office. The Head of the West Nusa Tenggara Provincial Health Office has

the authority to regulate the implementation, coordination, and supervision

of the health referral system in West Nusa Tenggara Province. In situations

where organisation of this health referral system requires the involvement of

other sectors/parties, the Head of the West Nusa Tenggara Health Office

may consult with the head of that other sector/party on the approval of

Governor of West Nusa Tenggara, or consult directly with the Minister of

Health or other relevant official in the Ministry of Health.

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CHAPTER II

TECHNICAL ASPECTS OF IMPLEMENTATION OF HEALTH SERVICE REFERRAL SYSTEMS

A. Definition

Implementation of this health referral system was developed based on

Decree of the Minister of Health 032/Birhup/72 concerning Referral Systems,

which is defined in Chapter I, General Provisions, Article 1 as follows: “A referral system is a health service measure between various levels of medical service units within a certain region, or across the Republic of Indonesia." In the Indonesian version of these Technical Guidelines, 'referral

system' is referred to as 'sistem rujukan'.

B. Activities included in the referral system

1. Sending patients Patients should be referred as early as possible for further care or

treatment to a more fully-equipped health facility. If the patient has received

further treatment, the health service unit receiving the referral must refer the

patient back to the health facility that sent him or her, for monitoring of

treatment and care, including subsequent rehabilitation.

2. Sending specimens a. Consultation

A specimen sent to a referral laboratory for accurate laboratory

examination.

b. Cross check Some specimens examined in primary health centre/hospital

laboratories are sent to district/municipal laboratories to cross-check

and validate the results of the first examination.

3. Transfer of knowledge and skills Specialists from hospitals may periodically visit primary health

centres. Assistant specialists / senior residents may be placed in

district/municipal hospitals that need them or in districts that do not have

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specialists. Transfer of knowledge and skills to GPs, midwives and nurses

from primary health centres or district/municipal general hospitals may take

the form of internships in better equipped hospitals.

4. Referral Information Systems Information on patient referrals is prepared by the referring health

personnel and recorded in the patient's referral letter sent to the doctor the

patient is being referred to. The letter should have a reference number and

include information about the date and time patient was sent, the status of

the patient's family (poor or not poor and general information), whether or

not the patient has Askes health insurance or Jamsostek health insurance,

the purpose of the referral, the name and identity of the patient, a resume of

the patient's medical history, results of physical examination, diagnosis,

action taken and drugs given, including supporting examinations, treatment

progress, and any other information considered necessary (see form R/1/a,

Patient Referral Letter).

Back referral information is prepared by the doctor receiving the

referred patient, and having treated the patient, he or she records the back

referral information in a back referral letter which is sent to the person who

referred the patient. The letter should be dated and have a reference

number, and include information about the status of the patient's family

(poor or not poor and general information), whether or not the patient has

Askes health insurance or Jamsostek health insurance, the purpose of the

referral, the name and identity of the patient, post treatment diagnosis,

condition of the patient on discharge from treatment, and recommended

follow up (See Form R/1/b, Counter Referral Letter), if any.

Information about specimens sent is provided by the person sending

the specimen by completing the Specimen Referral Form, which has a

reference number and is dated, and includes information about the status of

the patient's family (poor or not poor and general information), whether or

not the patient has Askes health insurance or Jamsostek health insurance,

the purpose of the referral, the type of specimen sent and specimen

number, the date the specimen was taken, the type of examination

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requested, the name and identity of the patient providing the specimen, and

the clinical diagnosis. (See Form R/2, Specimen Referral Letter).

Back information about the results of the examination of the referred

specimen is prepared by the laboratory receiving the specimen and

immediately sent to the person referring the specimen using the

laboratory's forms as applicable.

Information on requests for specialists is prepared by the Head of the

Primary Health Centre or District/Municipal General Hospital and sent to the

Head of the District / Municipal Health Office or by the District/Municipal

Health Office and sent to the Provincial Health Office, by completing a

Letter of Request for Specialist, which is dated, has a reference number,

has as its subject 'Request for Specialist', and indicates the type of

specialisation required, the time and place the specialisation is requested

for, the purpose of the request for the specialisation, and the source of

funding or amount of funding available (See Form R/3, Request for

Specialist).

Information on the sender, carer, or person requesting the specialist

must include his or her name, clearly written, the name of the institution,

and contact landline or mobilie phone number. Open communication

between the sender and receiver in terms of providing additional

information is necessary for the safety of the patient, specimen or medical

specialist.

For referral information system recording and reporting, the standard

form is RL.1 for hospitals and form R.4. for primary health centres (see

appendix). The follow up of referral reporting shall follow the established

reporting flow.

C. Organisation and Management in Implementation of the Referral System For this referral system to be implemented effectively and efficiently,

attention should be given to its organisation and management. The chain of

authority and responsibility of each health service unit involved, with regard to

regulation and coordination, must be clear. The following is a description of the

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criteria for division of service areas within the referral system and for

coordination between health service units.

1. Criteria for division of service areas in the referral system Because health personnel and health funding are limited, effective and

efficient use must be made of available medical service facilities. The

government has established the concept of division of service areas in the

public health system.

In this referral system, each health unit, including village maternity

clinics, auxiliary primary health centres, primary health centres, and

hospitals, will provide health services to the public according to its area and

the competence of its personnel and facilities. The exception to this rule is

emergency referrals. Thus, division of service areas in the referral system

are based not only on government administrative boundaries, but also on

other criteria, including:

a. The competency or comprehensiveness of the health facility, for

example hospital facilities according to their classification.

b. Cooperation between the hospital and a medical faculty.

c. The existence of a transport system or facilities that can be used to

travel to the referral health facility or hospital.

d. The geographical condition of the area where the health facility is

located.

In implementing the concept of referral areas, the wishes of the patient

/ the patient's family will be a major determining factor in the choice of

referral facility.

2. Coordination of referrals between health facilities Provision of equally distributed health services to the public requires

effective coordination in provision of referral health services. This

coordination can be achieved by drawing lines of authority and

responsibility for each health service unit. The lead in the coordination of

referrals is the Head of the West Nusa Tenggara Provincial Health Office.

Because the referral system area covers more than one

district/municipality, coordination between the district/municipal health

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offices concerned is vital. The highest referral hospital in West Nusa

Tenggara Province is Mataram General Hospital.

3. Referral Flow The differences and similarities in level, area and competence of each

health facility in West Nusa Tenggara Province make it necessary to design

a general flow for patient referrals, not including emergency referrals or

special referrals. There are several aspects that need to be taken into

account in the referral flow:

a. Hospital Classification Provincial general hospitals are classified B, and are the referral

centres for district/municipal general hospitals classified C or D or other

health facilities, such as the Military Hospital, Bhayangkara Hospital and

private hospitals in West Nusa Tenggara Province.

b. Location of District/Municipality District/municipal hospitals are the referral facilities for primary health

centres. District / municipal general hospitals have specialists in four main

fields who should be able to deal with referrals from the nearest

district/municipal general hospitals that do not have specialists in that

particular field. Primary health centres are the main referral facilities for

primary health centres, auxiliary primary health centres, village maternity

clinic, desa siaga, cadres, and members of the public in their area.

c. Coordination between technical units Other technical units that are referral facilities coordinated at the

West Nusa Tenggara provincial level include: the Regional Health

Laboratory, the psychiatric hospital, eye clinic, and Port Health Office.

Figure 1.

REFERRAL SYSTEM FLOWCHART

GP / midwifery practices

Class A/Special Hospitals Jakarta/Surabaya

Provincial Public / Private General Hospitals

in NTB provincial capital

Class C Public/Private General Hospitals

In Districts/Municipalities

Class D Public/Private General Hospitals

In Districts/Municipalities

Health Labs KES Psychiatric Hosp. Special Hosp. Eye Clinic

Port Health Office

in Mataram

Primary health centers, Primary Health Centers with Inpatient Facilities, Primary Health Centers Providing Basic Obstetric and Neonatal Services

Maternity clinics / Individuals

Integrated Health Posts

Village Health Posts

Village Maternity clinics

Aux. Primary Health Centers

MEMBER OF PUBLIC / CADRE WITH THE PROBLEM

Note: This flowchart does not apply to emergency/special referrals.

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CHAPTER III.

PROCEDURES FOR IMPLEMENTATION OF THE REFERRAL SYSTEM

To provide guidelines for health service units on implementation of the

referral system, this section describes the following:

1) Standard procedure for referring patients and receiving referred patients.

2) Standard procedure for referring specimens and receiving referred

specimens.

3) Standard procedure for knowledge and specialist referrals.

4) Procedure for monitoring and evaluation of the referral system.

A. Referring Patients and Receiving Referred Patients. Patients should be examined properly for referral. A patient can be referred

if at least one of the following criteria is met:

1) The results of the physical examination confirm that the case cannot be

dealt with.

2) The results of the physical examination and supporting medical examination

confirm that the case cannot be dealt with.

3) There is a need for further supporting medical examination requiring the

presence of the patient.

4) Even after treatment and care, there is a need for additional examination,

treatment and care at a more competent health facility.

In the procedures for referring and receiving referred patients, there are two

parties involved, the party making the referral (referral source) and the party

receiving the referral (referral target). These procedures are described in detail in

this section:

1) Standard procedure for referring patients,

2) Standard procedure for receiving referred patients,

3) Standard procedure for back referral of patients,

4) Standard procedure for receiving back referral of patients.

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1. Standard procedure for referring patients

a. Clinical procedure:

1) Take anamnesis, perform physical examination, and define possible

differential diagnosis and main symptoms.

2) Perform pre-referral measures as indicated: for example set up oxygen

supply, drip, administer injections as needed, and prevent bleeding if

necessary.

3) Decide where the patient is to be referred to.

4) Emergency cases must be accompanied by medical

personnel/paramedic.

5) If the patient is transported by primary health centre vehicle or

ambulance, the vehicle must wait for the patient at the appointed

emergency unit until the patient has been treated and a decision has

been made as to whether the patient is to be treated as an inpatient or

outpatient.

b. Administrative Procedure:

1) Do this after the patient has received pre-referral measures.

2) Record the identity of the patient in the patient referral register. 3) Make notes on the patient’s medical record, and prepare a resume of

the medical record to be given to the referral unit when the referred

patient is received.

4) Prepare a patient referral letter in duplicate (Form R/1/a, attached). The

top copy should be sent to the referral unit with the patient. The bottom

copy is filed for reference purposes.

5) Arrange transportation and as soon as possible make contact with the

referral unit.

6) The patient should be dispatched as soon as the administration is

completed.

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2. Standard procedure for receiving referred patients.

a. Clinical Procedure:

1) Immediately receive and deal with the referred patient as per procedure.

2) Stabilise the patient.

3) Send the patient to an elective care room for further treatment, or refer

the patient to a more competent health facility.

4) Monitor and evaluate the patient’s clinical condition.


1) Receive and sign the patient referral letter, which will be attached to the

patient card.

2) Check and sign the patient’s medical record cards, if the patient can be

received, then prepare a patient receipt as per unit procedure.

3) If the unit (primary health centre or hospital) is not equipped to treat the

case, the patient must be referred to a more competent hospital, by

preparing a patient referral letter in duplicate (see Form R/1 attached).

The original should be sent with the patient, following the same

procedure for referring patients.

4) Record the identity of the patient in the appropriate register.

5) Note the results of examination and treatment and care on the referral

medical card, and send this to the treatment unit appropriate to the

patient’s condition.

6) Prepare letter of informed consent (concerning treatment, inpatient care,

early discharge, etc)

7) Immediately inform the accompanying health personnel/patient’s family

about decisions on action to take / care to be given.

8) Hospitals must prepare quarterly reports using form RL.1 (page 2, point

7, and page 6, point 24.3).

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3. Standard procedure for back referral of patients.

a. Clinical Procedure:

1) A hospital or primary health centre receiving a referred patient must

refer the patient back to the hospital / primary heath centre / village

maternity clinic that referred the patient, upon completion of the

following process:

a) Medical examination, treatment and care have been administered,

but recovery requires follow up by the hospital / primary heath centre

/ village maternity clinic that referred the patient

b) After medical examination, clinical emergency measures have been

taken, but further treatment and care can be administered by the

hospital / primary heath centre / village maternity clinic that referred

the patient.

2) Conduct physical examination and diagnose that the patient can be

released from the care of the hospital / primary health centre, where:

a) The patient is fit and healthy.

b) Sufficient clinical progress has been made as to allow outpatient

treatment.

c) No clinical progress has been made, and the patient must be

referred elsewhere.

d) The patient dies.

3) If a referred patient is released, the hospital / primary health centre that

received a referred patient must provide a report / medical information /

feedback to the hospital / primary heath centre / village maternity clinic

that referred the patient concerning the patient’s most recent clinical

condition. This also includes providing information on a patient’s death

and its cause.


1) The hospital / primary health centre caring for the patient must prepare a

back referral letter (see form R/1/b attached) for each referral patient

received, for the hospital / primary heath centre / village maternity clinic

that referred the patient.

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2) The back referral letter may be delivered via the patient’s family, and

confirmation of the back referral information may be made by the health

personnel to whom it is addressed by any means, including telephone,

mobile, fax, etc.

3) Hospitals must complete quarterly reports, using form RL.1 (page 6,

point 24.3).

4. Standard procedure for receiving back referral patients.

a. Clinical procedure:

1) Visit the patient’s home and conduct a physical examination.

2) Take note of the action recommended by the hospital / primary health

centre that last cared for the patient.

3) Carry out public health follow up or care, and follow up on the clinical

condition of the patient until he or she has recovered. This includes

making home visits and should include IEC measures to avoid

preventable disease episodes in the future.


1) Examine the content of the back referral letter and record this

information in the referral patient register, then date and file the letter in

the patient’s medical record.

2) Immediately confirm receipt of the back referral letter with the doctor that

sent the patient.

B. Referring Specimens and Receiving Specimen Referrals.

Specimen examination may be referred if the examination requires more

laboratory equipment / expertise, and the specimen can be sent and examined

without the patient accompanying. The hospital or health unit that receives the

specimen referral must send a report of the results of the specimen

examination after it has been examined.

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1. Standard procedure for sending specimen referrals.

a. Clinical procedure.

1) Package the specimen appropriately with due regard for sterility,

communicable disease contamination, the safety of the patient and

others, and in a manner suitable for the examination required.

2) Ensure that the specimen sent is in a suitable condition and its

identification is clear and unique for each.

b. Administrative Procedure.

1) Complete the form and specimen referral letter (see form R/3 attached) accurately and clearly, including letter reference number,

status of the patient (poor/not poor, Askes/Jamsostek health

insurance), information about the specimen, the examination

required, the identity of the patient, the preliminary diagnosis, and

the identity of the sender.

2) Record information required in the appropriate register.

3) Send the specimen referral letter to the target, and file the copy.

4) Monitor the estimated time of return of the referred specimen.

2. Standard procedure for receiving specimen referrals.

a. Clinical procedure.

1) Receive and examine the specimen in a manner appropriate to the

condition in which it is received, with due regard for: sterility,

communicable disease contamination, the safety of the patient and

others, and in a manner suitable for the examination required.

2) Ensure that the specimen is in a suitable condition to be examined as

requested.

3) Perform the standard laboratory or pathological examination, as per the

type and method of examination requested by the sender.

4) Make a written report of the results of the examination using the unit's

standard format to the head of administration.

24


1) Check the content of the specimen referral letter accurately and clearly,

including letter reference number, status of the patient (poor/not poor,

Askes/Jamsostek health insurance), information about the specimen,

the examination required, the identity of the patient, the preliminary

diagnosis, and the identity of the sender.

2) Record the necessary information in the appropriate unit register / file. 3) Make sure that confidentiality is guaranteed

3. Standard procedure for back referral of specimen examination results.

a. Clinical Procedure.

1) Ensure that standard and complete examination has been made of the

specimen as requested in the accompanying specimen referral letter.

2) Ensure that the results of the examination are accountable.

3) Double check that no mix-up and confusion between several specimen

can happen


1) Record the results of the examination in the register for filing.

2) Complete the unit's appropriate examination results report form.

3) Ensure that the results of the examination remain confidential and reach

the intended recipient.

4) Immediately send the results of the examination to the address of the

sender, and confirm by any communication means available that the

report has been received.

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C. Knowledge / Specialist Referral.

Knowledge referrals may take the form of requests for and dispatch of

specialists in a particular field. A request may come from a primary health

centre or district / municipal general hospital and be directed to a hospital or

regional health office that is able to provide the specialist required.

Parties involved in specialist referrals include:

1) The hospital / primary health centre that requires the specialist, for example

a district / municipal general hospital.

2) The hospital / health facility that is able to provide the specialist, for

example the provincial general hospital.

3) The head of the district / municipal health office in which the hospital /

primary health centre requiring the specialist is located.

4) The head of the provincial health office in which the hospital that will be

providing the specialist is located.

The scope of specialist referrals includes:

1) Clinical guidance for early detection of referral cases.

2) Clinical guidance for pre-referral measures.

3) Clinical guidance for management of cases that are within the scope of

authority of primary health centres that provides basic obstetric and

neonatal services.

4) Clinical guidance for follow up of back referral cases received by primary

health centres, auxiliary primary health centres and village maternity clinics.

5) Short courses or refresher courses on clinical handling of common cases in

primary health centres, auxiliary primary health centres and village

maternity clinics.

26

1. Standard Procedure for Knowledge (Specialist) Referrals

a. The primary health centre / district/municipal hospital requiring the

specialist prepares a specialist request letter.

b. The request is directed to the head of the district / municipal health office

or the West Nusa Tenggara Provincial Health Office.

c. The head of the district/municipal health office or the provincial health

office forwards this request for a specialist to the director of the hospital

concerned, with a copy to the head of functional medical staff, within 14

days of receipt of the letter of request.

d. Prepare to receive the specialist, including agenda, accommodation,

honorarium or other incentives, as per local regulations.

e. Undertake monitoring and evaluation of the process and its

implementation.

f. Prepare an implementation report for the head of the local health office,

with a copy to the hospital or health facility sending the specialist.

g. Hospitals must complete quarterly reports on form RL.1 (page 6, point

24.2).

2. Standard Procedure for Sending Specialists

a. The hospital / health facility sending the specialist consults with the

provincial health office to match the request with the province's referral

program.

b. Upon approval from the provincial health office, the hospital / health

facility prepares a schedule for the visit and a letter of instruction for the

specialist as requested.

c. Evaluate and prepare implementation report, send to the provincial

health office, with a copy to the file.

d. Hospitals complete quarterly report form RL.1 (page 6, point 24.1).

27

D. Procedure for Monitoring and Evaluation of the Implementation of the Referral System.

Parties involved in the referral system are required to undertake monitoring

and evaluation as follows:

1) Collect data and information about the referral services that have been

provided by the health service unit.

2) The head of the health service unit prepares a referral system

implementation report (form R/4 for primary health centres and form RL1 for

hospitals), dan patient referral implementation report (form R/5/a, b, c and

R/6 attached.)

3) The report is typed, double space, and signed, in duplicate.

4) The top copy of the report is sent to the local health office as input for

evaluation of the implementation of the referral system.

5) The second copy of the report is filed by the health service unit.

Responsibility for monitoring and evaluation of the implementation of the

referral system lays with the head of the provincial health office and the heads

of district/municipal health offices. The role and tasks of personnel in the

district/ offices municipal and provincial health include:

1) Making regular visits to village maternity clinics, village health posts,

auxiliary primary health centres, health centres and hospitals, guided by

the monitoring and evaluation forms (forms R/5/a, b, c and R/6, attached).

2) Receive, read, study and assess reports from all health units in its area,

and reports from other sources, concerning problems with implementation

of the referral system.

3) Make decisions as to whether or not it is necessary to conduct a field

investigation. If necessary, a field visit must be conducted immediately,

and a report of its findings prepared.

4) Prepare periodic reports on the condition of the referral system in its area.

5) Reports of district/municipal health offices are submitted to the Head of

the West Nusa Tenggara Provincial Health Office.

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CHAPTER IV

PRINCIPLES OF REFERRAL OF OBSTETRIC AND NEONATAL EMERGENCIES

Emergency obstetric and neonatal referral services are based on the

principle of: rapid and appropriate, efficient and effective response within the capacity and authority of the service facility.

A. Authority of Service Facilities

1. Village Maternity Clinics Village maternity clinics are one type of community-based health

measure set up by the community based on deliberated consensus.

The midwife in a village is the provider of village maternity clinic

services, and also the spearhead of maternal and neonatal health

measures that require basic knowledge of danger signs so that emergency

cases can be referred as soon as possible to a more suitably equipped

service unit once the patient is stabilised (pre-referral measures).

As well as providing normal delivery services, the midwife in a village

may also handle cases involving certain complications depending on her

level of authority and competence, or make referrals to primary health

centres, primary health centres with basic obstetric and neonatal facilities

(PONED), and hospitals with comprehensive obstetric and neonatal

facilities (PONEK).

The roles and functions of the village midwifery clinic include the

following:

1) A place providing maternal and child health services, and other health

services.

2) A place for guidance and extension activities and personal counselling

on maternal and child health.

3) The centre of community empowerment in maternal and child health.

4) The centre for partnerships with traditional birthing assistants (dukun

bersalin). In providing antenatal and postnatal examination services and

29

assisting deliveries at the village midwifery clinic, the midwife in the

village is expected to make use of these opportunities to forge

partnerships with traditional birthing assistants.

5) Providing off-site services. The midwife in the village not only provides

health services on site in the clinic, but also off site, for example doing

home visits, etc.

The type and scope of maternal and neonatal health services provided

at the village midwifery clinic include:

a. Antenatal check-ups, which include measuring body weight, blood

pressure and fundal height, administering tetanus toxoid immunisations,

supplying iron tablets, having face-to-face contact, and administering

urine tests (the so-called ’7T’ in Indonesian).

b. Delivery preparation

c. Prevention of postpartum and neonatal infection

d. Assisting normal deliveries

e. Postnatal check-ups, including initiating early breastfeeding

f. Neonatal health services (umbilical cord care, eye ointment, vitamin K

injections, first hepatitis B immunisation)

g. Integrated neonatal services (MTBM) and integrated management of

infant diseases (MTBS)

h. Contraceptive services for women of fertile age

i. Administering first aid in obstetric and neonatal emergencies the midwife

is qualified to perform, including:

(1) Stabilising obstetric and neonatal emergency patients

(2) Applying bimanual pressure to women with postpartum

haemorrhage.

(3) Manual extraction of the placenta in cases of placental retention

(4) Digital curettage in cases of partial placental retention

(5) Simple resuscitation in cases of neonatal asphyxia.

(6) Application of the kangaroo method for babies with a birth weight of

more than 2000 grams.

j. Making maternal and neonatal patient referrals

30

2. Standard primary health centres In terms of maternal and child health services, primary health

services are divided into primary health centres with basic obstetric and

neonatal facilities and standard primary health centres, which are primary

health centres that do not provide obstetric and neonatal services. The

function of standard primary health centres is similar to that of village

midwifery clinics, but they have more health personnel and more adequate

facilities and equipment, such as doctors, midwives, nurses, vehicles, etc.

Standard primary health centres may assist normal deliveries;

manage cases presenting certain complications according to their authority

and expertise, or make referrals to primary health centres with basic

obstetric and neonatal facilities and hospitals with comprehensive obstetric

and neonatal facilities.

Standard primary health centres must at least be able to stabilise

obstetric and neonatal emergency patients who come to the centre

voluntarily or are referred by a village midwife or traditional birth attendent

assistant/cadre, before being referred to a primary health centre with basic

obstetric and neonatal facilities or a hospital with comprehensive obstetric

and neonatal facilities.

The type and scope of maternal and neonatal health services provided

at standard primary health centres include:













31





(2) Applying bimanual pressure to women with postpartum

haemorrhage.

(3) Manual extraction of the placenta in cases of placental retention

(4) Digital curettage in cases of partial placental retention

(5) Simple resuscitation in cases of neonatal asphyxia.

(6) Application of the kangaroo method for neonates with a birthweight

of more than 2000 grams.

j. Making maternal and neonatal patient referrals

3. Primary health centres with basic obstetric and neonatal facilities

A primary health centres with basic obstetric and neonatal facilities is

a primary health centre that has a team of competent, trained and qualified

doctors and midwives and adequate facilities and equipment for providing

basic obstetric and neonatal services.

Primary health centres with basic obstetric and neonatal services

provide antenatal, delivery, postnatal and neonatal services to walk-in

patients and to patients referred by standard primary health centres, village

midwives, or cadres/traditional birthing assistants.

Primary health centres with basic obstetric and neonatal facilities

may assist deliveries or neonates presenting certain complications

according to their authority and expertise, or make referrals to hospitals with

comprehensive obstetric and neonatal facilities.

The type and scope of maternal and neonatal health services

provided by primary health centres with basic obstetric and neonatal

facilities include:





32













(2) Administering oxytocin parenterally or by intravenous drip

(3) Administering antibiotics by injection or intravenous injection

(4) Managing postpartum haemorrhage

(5) Performing manual extraction of the placenta in cases of placental

retention

(6) Performing curettage in cases of partial placental retention

(7) Management of pre-eclampsia / eclampsia by administering MgSO4

(8) Assisting breech presentation deliveries

(9) Assisting deliveries presenting shoulder dystocia

(10) Performing vacuum extractions and forceps extractions in cases of

partus protractus

(11) Management of postpartum infection

(12) Resuscitation in cases of neonatal asphyxia

(13) Management of neonates of low birthweight (1500 - 2500 grams)

(14) Management of neonatal hypothermia

(15) Management of neonatal hypoglycaemia

(16) Management of neonatal icterus

(17) Management of neonatal feeding problems

(18) Management of neonatal breathing problems

(19) Management of neonatal convulsions

(20) Management of neonatal infection

j. Making maternal and neonatal referrals

33

k. Hospitals with Comprehensive Obstetric and Neonatal Facilities In maternal and neonatal health services there are also hospitals

with comprehensive obstetric and neonatal facilities (PONEK). This is a

hospital that provide 24-hour obstetric and neonatal services and has a

team of competent and qualified obstetricians, paediatricians, and

midwives, and adequate supporting facilities and equipment to provide

basic and comprehensive emergency obstetric and neonatal services to

provide antenatal, delivery, postnatal and neonatal services to walk-in

patients and to patients referred by primary health centres with basic

obstetric and neonatal facilities, standard primary health centres, village

midwifery clinics, or members of the public/cadres/traditional birth

attendants.

In general hospitals with comprehensive obstetric and neonatal

services are district/municipal general hospitals that obstetricians and

paediatricians on staff.

The scope of maternal and neonatal health services provided at

hospitals with comprehensive obstetric and neonatal facilities is all obstetric

and neonatal services, including blood transfusions, caesarean sections,

and intensive neonatal care.

B. The Principles of Making and Receiving Maternal and Neonatal Patient Referrals

The procedure for making and receiving maternal and neonatal referrals is

based on these principles:

1) Avoiding delayed decision, delayed referral and delayed assistance (the so-

called ’3T’ in Indonesian). Maternal and neonatal referrals are emergency

patients and must be given immediate assistance.

2) Planned referrals. Patients who have been prepared for possible referral from

the first or any later antenatal check-up according to defined risks.

3) Stabilising the patient. Health personnel must stabilise the patient before

referring the patient.

34

4) Not within the competency of the personnel. A patient must be referred if the

patient requires care that the facility concerned does not have the authority to

administer.

5) Early communication. Make early contact with the facility that will be receiving

the referred patient to guard against the possibility of the facility not being able

to manage the patient or there being a delay in management of the patient

because the specialists required are not available.

The clinical procedure and administrative procedure for maternal and

neonatal patient referrals are the same as those for other patient referrals.

However, maternal and neonatal referral patients may go through the emergency

unit or directly to the on-call obstetric and neonatal polyclinic or the hospital’s

delivery room, or the day-time obstetric and neonatal polyclinic.

For maternal and neonatal patient referrals use the standard form for

patient referrals (see form R/1 attached).

The administrative and clinical procedures for receiving and making back

referrals of maternal and neonatal patients follow the standard procedure for back

referrals. If the patient is released from care / the hospital, use form R/1/b (attached) to prepare a back referral report to be sent to the party making the

referral.

35

CHAPTER V

CONCLUSION

These Technical Guidelines on Health Referral Services in West Nusa

Tenggara Province are based on Ministry of Health handbooks, the results of an

assessment of the referral system conducted by consultants from West Nusa

Tenggara University, and other sources.

Through two workshops at the provincial level and numerous discussions of

the internal design team, it has been agreed that these technical guidelines will be

piloted in Lombok Barat District in the fourth quarter of 2008, in 19 primary health

centres, 78 auxiliary primary health centres, 94 village maternity clinics, Patuh

Patut Patju General Hosptial in Lombok Barat District, and the Provincial General

Hospital in Mataram. The aim of this trial is to identify the feasibility of adopting

these guidelines in the field, for adoption across the board by all health facilities in

West Nusa Tenggara Province. After evaluation they final form will be adapted and

widely spread to all districts.

-f-

36

BIBLIOGRAPHY

1. Ministry of Health, Republic of Indonesia:

Guidelines for Development and Supervision of Health Service Referral Systems in Indonesia. Directorate of Hospitals, Ministry of Health. Jakarta. 1978

2 Ministry of Health, Republic of Indonesia:

Guidelines for Maternal and Neonatal Referral Systems at the District/Municipal Level. Directorate General of Public Health. Jakarta. 2005.

3 Ministry of Health, Republic of Indonesia:

Hospital Information Systems in Indonesia (Hospital Reporting System Revision V), Decree of the Minister of Health 1410/Menkes/SK/X/2003, dated 1 October 2003. Directorate General of Medical Services. Jakarta. 2003.

4. UNTB Research Unit, GTZ Siskes:

Report on the Assessment of the Health Referral System in West Nusa Tenggara Province. Cooperation between West Nusa Tenggara University Research Centre and GTZ-SISKES Mataram. 2007.

Documents

cover ref system fileTechnical Guidelines Health Service Referral System West Nusa Tenggara Cooperation between: West Nusa Tenggara Province Health Office and GTZ Siskes Mataram