Factors associated with delayed referrals of patients with sepsis from primary to tertiary healthcare in Blantyre, Malawi: a qualitative study | BMC Primary Care

From the analysis, seven key themes emerged: (1) Poor communication, (2) poor road network, (3) low socioeconomic status, (4) ambulance prioritization (5) patient and guardian preferences (6) delayed treatment-seeking action, and (7) a shortage of healthcare workers. Below we synthesize the key findings according to the different levels of the three delays model include the delay in seeking care, the delay in reaching care and the delay in receiving care which informed our analytical process and supported by direct quotations from study participants. The characteristics of the patients interviewed are provided in Table 1 while those of key informants are in Table 2.

Phase 1: the delay in seeking care

Socio-economic status

A few healthcare workers stated that the low socioeconomic status of patients with sepsis is one of the causes of delay in referral pathways, especially when the patients are asked to use their transport other than when they are using an ambulance. The majority (65%) of patients indicated that socioeconomic status directly affects the referral pathway of patients with sepsis to seek advanced care. Most participants stated that some patients were asked to use their means of transport because the Blantyre District Health Office (DHO) does not have enough ambulances to transport all patients requiring ambulance transfers. For example:

“Some patients they don’t afford to use their own transport money to seek healthcare service to advanced hospital after referral, they don’t receive it well because they have already spent maybe 2000 or 3000 Malawi Kwacha from community to primary health care, so they feel overburdened to use their transport to a referral hospital”. (CL 02)

However, some patients felt that asking patients to use their transport from primary health centres to referral hospitals overburdens them because they have already spent a lot of money travelling from their homes to the health centre. Circumstances of this kind, delay patients from receiving sepsis treatment because, in most cases, they return home to raise money for transportation to a referral hospital.

“They gave me the referral letter, and I told them that I should first go back home and get ready in terms of transport”. (P 03)

Some Health care workers expressed that patient who did not have money were delayed in being referred to the central hospital because they did not have adequate funds to sustain themselves while receiving treatment at the district hospital. Health workers spend much time convincing patients that they will find well-wishers to assist them. However, if the patient insists on not going to the referral hospital, in this case, they receive treatment at the primary health centre, waiting for the patient to source money for their survival at the referral hospital.

“The challenge that we face is that most patients refuse referral; they say they do not have money, how am I going to stay even if an ambulance is here, they refuse to go saying they don’t have money. We convince them you cannot lack food and the like if you go there. Some well-wishers are going to help you”. (CL 01)

Patient and guardian preference

A few healthcare workers said that patients and their guardians delayed the referral. When an ambulance is unavailable, guardians and patients are asked to find their means of transport to get to a referral hospital; therefore, some guardians would prefer to go home first before going to the referral hospital, so they stay longer at home.

‘’Sometimes the guardians themselves tell us to release them to go home. They complain that they have other duties and have left children at home. We see it as a challenge because the patient might be very sick, but they prefer to go home first than minding about the health of the patients, so it’s a challenge. This is so because when they go home, they delay very much such that when they go to QECH, it is difficult to document time, it might seem as if you have referred them late yet it’s them who have delayed”. (CL 01)

Delay treatment-seeking action

About half (54%) of the interviewees reported that treatment-seeking behaviour contributed to a delay in referring patients to tertiary hospitals. For instance, patients opted to buy medicines from a drugstore to self-medicate or use herbs before seeking medical treatment at a referral hospital in a primary health facility.

“I took bwamoto herbs (local medicine) and the blue gum leaves, mixed them, and took the mixture. After that, it never worked out; that’s when people hired a motorbike to take me to the clinic”. (P 05)

Persistent symptoms made study participants seek medical care at a primary healthcare/health centre, where they tested negative for malaria, which made the health workers (HCW) refer the patient to QECH for further investigation and management.

Most participants stated that the other pattern used before seeking medical treatment was a religious belief that before going to the health facility to seek medical treatment, people took them somewhere for prayers. Still, the persistence of the symptoms made them visit the primary hospital to seek medical care.

“So, when they came, they prayed for me, and after prayer, a motorbike from my relative came to pick me up. We all rode on that motorbike (name of the health centres), and when we got there, I fainted. After that, they started finding means of transport for us to come here”. (P 02)

After the tests were conducted at the primary hospital, the patient was referred to the Queen.

Elizabeth Central Hospital (QECH) because sepsis was suspected.

Phase 2: the delay in reaching care

Long distance to health facility

Some participants in hard-to-reach communities reported that it is difficult for them to follow the referral pathway due to the distance and geographical position. They prefer to be referred to the closest health care centres of their choice which is not feasible at times. This has an impact on monitoring the patients and if they are going to follow through with the treatment

‘The closest hospital to my home is Chikhwawa Hospital, not Queen Elizabeth Central Hospital. So, can you just help me, like write me a referred to Chikhwawa?”. (CL 02)

Ambulance prioritisation

Most patients felt ambulances were prioritised for maternal and obstetric patients rather than the Out-Patient Department (OPD). When a gynecology’s and obstetrics emergency patient need to be referred, a health worker (HCW)calls for an ambulance, as usual. However, patients with sepsis take advantage of ambulance comes to pick up that patient maternal condition, according to the findings of this study, an ambulance was not sent for suspected sepsis. However, it is sent in the case of an obstetric case/patient.

“Let us say you have an OPD that needs a referral; you will be lucky if an ambulance comes, but not that it was sent for that OPD. Even if you tell them that the patient has fainted, they don’t send an ambulance’’. (CL 04)

“If we happen to have a patient from maternity and at the same time there is a patient from OPD, they use the same transport”. (NU 02)

‘’If you mention that it’s maternal, then it comes, but not with OPD”. (NU 04)

A few (5%) of the health care workers (HCW) mentioned instances where a nurse had to lie that they had a maternal condition patient from maternity for an ambulance to come.

‘’It happens (to lie) they shout at us, the driver shouts, and we tell them, the patient has given birth already, and so you can just pick this one, so they pick the patient”. (NU 04)

Poor road network

All healthcare (100%) mentioned that an ambulance did not go to a particular health centre during the rainy season because of poor road networks. Most of the patients cited that when roads get muddy, the ambulance does not reach the facility; and it stops at one point, so the patient with maternal have to walk about 8 km to get to where the ambulance stops.

‘’During the rainy season, the ambulance doesn’t come here because of the road’s poor condition, so it stops at Manyowe township, and our patients walk from here to get to where the ambulance is’’. (CL 04)

“Our roads are in poor condition, and most cross rivers without bridges, rendering them impassable during the rainy season”. (P 04)

One participant stated that if the patient with suspected maternal sepsis was seriously sick and had no means of transport, the patient was carried on a stretcher to get to where the ambulance was.

‘’ They are carried on the stretcher up there”. (NU 03)

Phase 3: the delay in receiving care

Communication

Most healthcare workers (53%) indicated that poor communication between healthcare workers and transport officers contributed to delayed referrals of suspected patients with sepsis. Some health care workers stated that when a patient is present at a centre, it is managed at the health centre. Healthcare workers, through the flying squad group, call a transport officer to send an ambulance for a suspected patient with sepsis to be referred. This study found that ambulances were not sent immediately. Sometimes, it takes several hours for healthcare workers to be told that ambulances are not coming, delaying the referral of patients with suspected sepsis.

‘’Sometimes they even call you to say tell them to find their means of transport, an ambulance will not come, for example, last year, we had a patient whom we called for an ambulance, we were told it was coming but, at around 4 o’clock, we were told that they should find their means transport, sometimes you can refer the patient at 8 am, and the ambulance can be coming at 4 pm afternoon”. (NU 04)

Most healthcare workers (HCW) (60%) reported receiving only occasional or no feedback from the referral hospital after patients had been referred. Interview respondents in primary healthcare stated that this was not standard practice. The referral system sometimes lacked effective reporting procedures and feedback systems, which hindered communication between the primary health facility, referral hospital and the patients with sepsis.

“I have never received feedback from referral hospital after discharge from referral hospital. If I want to get feedback, I use my unit [phone credit]”. (CL 02)

The only formal provision is dedicated space in a referral letter for writing feedback. Healthcare workers (HCW) explained that even when filled in, patients usually return to their homes after discharge from the referral hospital; therefore, these documents are typically lost to the system, and feedback relies on the initiative of the more proactive clinicians who follow up via phone.

Shortage of healthcare workers

A few 35% healthcare workers reported that understaffing contributed to referral delays for patients with suspected sepsis. Sometimes, patients must wait before they are attended to because only two healthcare workers are on duty that day, and these two should attend to all departments available in that facility.

‘’Shortage of staff makes us not treat the patient well; we can say on a day, only two clinicians are assigned on duty, and there is Antiretroviral therapy that needs to be attended, a patient can faint when you are somewhere, then you rush to see that patient, so we delay the services for the patients”. (CL 01)

Another factor affecting the provision of quality referral care at the primary healthcare level, leading to self-referral and bypassing primary healthcare institutions, was a shortage of competent healthcare professionals, equipment, and medications.

“Shortage of staff is a problem; patients have to wait for a long time, and some conditions worsen in the waiting queue”. (P 06)