Referral Guidelines for the common conditions for Institutions under

DME & DHS in Kerala (Guidelines for referring cases from Secondary to
Tertiary Care Institutions.(District Hospitals, General Hospitals, Medical College Hospitals
and other specialty institutions )
Index Page No

A.1. Background 1

A.2. General Guidelines 4

A.3.a. Formalities at referring end

A.3.b. Formalities at receiving end
A.3.c. Guidelines for back referral

B. Discipline wise guidelines

B.1. General Medicine 11-23

B.2. General Surgery 24-27

B.3. Orthopedics 28-31

B.4. Otolaryngology 32-40

B.5. Obstetrics & Gynecology 41-45

B.6. Pediatrics 46-56

C.1. Definition of terms 57-58

C. 2. Sample referral card 59

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Referral Guidelines for the Institutions under DME & DHS in Kerala
Guidelines for referring cases from secondary to tertiary care institutions. (District
Hospitals, General Hospitals and Medical College Hospitals, other Specialty
Institutions)

Background
Read: 1. G O (MS) No.2674/2011 H&FWD dated 25-7-2011

2. G O(MS) No.391/2011 H&FWD dated 14-11-2011

3. G O(MS) No.05/2010 H&FWD dated 07-01-2010

4. Minutes of the principal’s meeting held on 12-08-2011 at the Directorate

of Medical Education

5. G O(Rt) No. 817/2004/H&FWD dated 18-03-2004

The High power committee on health services (1979) under the

chairmanship of Dr.K. N. Pai has recognized the real need for a well

organized referral system in Kerala. The Government Medical collegiate

hospitals have been declared as referral- hospitals, years’ back. But in

course of time the referral system got diluted and the collegiate hospitals

have become overcrowded and unwieldy due to the inordinate rush of

patients . Most of the patients were those whose ailments could be treated at

primary level by utilizing the facilities available in nearby primary or

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secondary level hospitals. Genuine cases therefore go unnoticed. Hence the

real benefits of referral system could not reach the public.

As per the G O cited, as (1) Govt. ordered that implementation of

referral system should be strengthened through preparation of suitable

referral guidelines/protocols. In order to materialize this, expert

committees were constituted with senior faculty from medical colleges

and senior Consultants from health services with delegation of

responsibilities to specific departments and institutions. As per reference

cited as (4), the Clinical Epidemiology Resource & Training Centre

(CERTC), medical college Thiruvananthapuram was entrusted to arrange

a workshop for development of referral protocols. The CERTC,

conducted an initial workshop for formulation of draft guidelines and

subsequent several workshops at the state institute of health and family

welfare as well as the medical colleges mentioned in reference(1) for

discussion and finalization of the protocols. The suggestions and

consensus in these workshops and meetings were consolidated and

circulated among experts for vetting and the guidelines were thus

finalized.

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General guidelines for referral of patients from referring institutions to
referred institutions
Formalities at the referring institution
v The medical officer who is treating the patient is to take
initiative for referral and sign in the referral card.
v A Patient should be referred only if there is a definite and

convincing indication felt by the referring doctor for referral.

v Referral form should be always used for referral.(Sample

appended)

v The reasons for referral should be clearly indicated in the

referring letter.

v Referral should be accompanied with sufficient documents

like referral letter and supporting materials like X-ray, ECG

or other similar investigation reports.

v Basic patient work up at the level of referring center should

as far as possible be completed depending on the availability

of facilities for investigation as well as time. Efforts should

be taken from the referring end to provide investigation

results pending if any to be later collected and sent to the

referred institution through the relatives of the patient.

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 v Writing in any communication and correspondence should

be legible and easily readable.

v The indications for referral should be guided by the

discipline-wise guidelines provided with this document

v The diagnosis to be recorded is the most likely working

diagnosis felt by the referring doctor at the time of referral.

v For the case of elective referrals if a specialist is available in

the referring institution he/she may be consulted in advance

as far as possible in person or over phone.

v Necessary information should be passed on to the patient

and relatives. This should be in the form of counseling about

the need of referral and necessary supportive information

and guidance. In most of the situations of conflict proper

lack of communication or misgivings of matters to patients

end up in hostile situations. Proper care must be taken to

avoid such situations.

v The details about the patient being referred should be written

in the ‘referral out register’ kept in the institution. This

register can be one for each ward for inpatients and one for

Outpatient section and one for Casualty. Similarly details

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 about the patient being received should be written in the

‘referral in register’ kept in the institution. This register can

be one for each ward for inpatients and one for OP and one

for Casualty.

v In the case of emergency referrals transport should be

arranged from the referring institution based on the clinical

condition of the patient as decided by the referring doctor.

The hospital administration or the Local self-Government

institution may arrange the transport on request of the

doctor.

v In the case of emergency referral if the patient’s condition is

critically dangerous warranting continuing medical support,

or there is a chance to worsen demanding emergency

resuscitation, an appropriately functional medical

ambulance should be made available.

v In the case of emergency referrals the details of patient’s

condition including brief summary of vital signs at the time

of sending the patient and medications given should be

clearly written in the referral card.

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 v Timely referral is important in saving lives and avoiding

complications. Hence once decided the patient should be

sent at the earliest.

v Even if a patient is referred, all possible treatment and care

at that referring institute level should be given to that patient

and then only referred.

Formalities at the receiving end

v All referred cases should be promptly received and taken

care of at the casualty or the OP section.

v The details should be written in the referral in register kept

in the referred institution. This can be a common register

kept in the admission counter. This arrangement can be

planned according to the policy of the respective institution.

v When the referring doctor enquires about the condition of

the patient (through phone or in person) a responsible staff

should attend and necessary information to be furnished

courteously. Usually this communication between referring

doctors and receiving end is seen as happening through

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 telephone and both ends should behave courteously and in

the most understanding way.

v Even if the doctors in the receiving institution feels that the

patient would have been managed in a different or better

way, at the referring end no open comments which can

undo the morale of either party should be passed in

presence of the patients or relatives or over phone to any

persons in this regard.

v All enquiries regarding patients or similar information to be

communicated to press or media to be made only through

the respective hospital administration.

v All emergency referrals to be accepted without fail and also

unnecessarily “shunting” the patients should be avoided.

Guidelines for back referral

The process of referral should be integrated with the health system and
should be a continuous activity for the patient
Back referral helps the referring facility to know what exactly happened to

the patient at the higher centre and helps in providing follow up care from

referring centre. If the patient prefers follow up care in another institution,

this must be mentioned in the ‘referral out’ letter and the matter informed to

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the referred doctor through phone or email. Back referral also helps in

continuous quality improvement in the whole system of referral process.

Expectations about performance at the receiving institution after referral also

should be clearly mentioned in the back referral letter especially procedures

for wound care, expected day of stitch removal etc.

1 Back referral should be after reasonable period of care from

higher centre.

2 Back referral should be with sufficient directions for provision

of care.

3 The back referral letter can be the same as the discharge card

presently provided. There should be details about back referral

especially follow up care, when to come for review, whom to

be referred back etc.

4 If the patient is discharged at request by them, voluntarily this

matter can be written in the back referral card and all follow up

instructions to be given forthwith.

5 If a patient is being discharged against medical advice this

matter should be specifically documented and the signature of

patient/guardian taken in the case-sheet. However the patient

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 should be told of all the consequences and counseled against

this attempt.

6 The contact number in case of emergency and also the possible

and anticipated complications as well as the first aid in such

instances should be clearly written in the back referral letter.

7 Back referrals are to be entered in back referral register kept in

the institution.

Monitoring the referral process: There are state level and district level
committees for monitoring referral process and to make this effective,
prompt feedback should be given by concerned doctors to these committees.

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 Discipline wise guidelines

B.1.General Medicine

Guidelines for referral from secondary level institutions to tertiary level

centers
For selected general medical conditions

1. Leptospirosis: The diagnosis is considered in any patient

presenting with abrupt onset of fever, chills, conjunctival suffusion,

headache and myalgia.
Typically four clinical categories are defined
Mild (influenza like) illness, Weils syndrome (Jaundice, renal failure,
hemorrhage, mayocarditis), Meningoencephalitis and pulmonary
hemorrhage with respiratory failure.
Patients with any of the following complications should be referred to a
tertiary care centre.
1. Hypotension

2. Decreased urine output

3. Deep Jaundice
4. Hemoptysis
5. Breathlessness
6. Bleeding tendency
7. Irregular pulse
8. Altered level of consciousness
9. Pre-existing chronic disease (Chronic Liver Disease, Diabetes Mellitus,
Hyper Tension, Coronary Artery disease, Chronic Kidney Disease etc.) or
existence of any other co-morbidities

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10 Severe alterations in Liver function tests
* For detailed account of guidelines: Read Guidelines for prevention and
Control of leptospirosis, DGHS, Pp33-36, 2011
· Patients suspected of leptospirosis should not be treated with
NSAIDs.
2. Dengue fever
A detailed assessment should be made at the periphery and all steps for
stabilization of the condition of patient to be undertaken *
Red flags or Warning signs are more important than platelet count alone.
Referral criteria (Red flag signs) for referring patients to tertiary care centre are
· Inability to maintain hydration status, persistent vomiting or
abdominal pain
· Any bleeding tendency: Hematemesis, hematochezia/melena,
bleeding from nose etc
· Hypotensionor Altered sensorium or toxic look.
· Significant Thrombocytopenia or rising haematocrit value.
· Abnormal behavior or drowsiness
· Any evidence of Dengue hemorrhagic fever/ Dengue shock syndrome
· Unusual presentations- Acalculus cholecystitis, hepatitis,
Hemorrhagic serositis involving pleura, peritoneum, ARDS.
· Features of fulminant hepatic failure, Acute renal failure, myelitis,
seizures, intracerebral bleeding or hepatorenal syndrome
* Please read Dengue guidelines and treatment DGHS Pp: 20-23, 2011

3. Enteric fever
All patients with prolonged fever of more than 7 days should be evaluated
for diagnosis of typhoid fever. Evaluation of blood counts and renal
function tests should be done if possible.
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 Cases should be referred to tertiary care centre when any of the following is
found to be present
Evidence of complications like Perforation, peritonitis, pneumonitis,
Shock, severe dehydration, Gastro-intestinal bleed, Myocarditis,
Glomerulonephritis, Encephalopathy
Rare complications like

· Meningitis, neuritis, Guillenbarie syndrome

· Myocarditis, endocarditis, pericarditis, pancreatitis
· pyelonephritis, osteomyelitis
· Patients having apathy, psychosis, coma
· Presence of unexplained tachypneoa or basal crepitations
· If there is any diagnostic confusion or if no response to primary or
secondary line of antibiotics
4. Malaria
According to ministry of health national guidelines all patients suffering
from uncomplicated malaria should be treated in peripheral hospitals.
However the following conditions can be considered for referral to higher
level institutions.
· Suspected Cerebral malaria—altered sensorium, convulsions
· Persisting Hypoglycaemia,
· Features of metabolic acidosis, /renal failure(S creatinene>3mg/dl)
· Features of Renal / Hepatic failure, D I C, pulmonary
edema/ARDS/shock
· Hemoglobinuria
· Hyperthermia

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 · Hyperparasitemia(>5% parasitized RBC in low endemic and >10% in
hyperendemic area)
· Jaundice
· Pregnancy with severe malaria
· Severe anemia (Hb<5gm %)
· Any other significant co morbidities
· If the physician feels that unable to manage due to resistant
falciparum or mixed infection.

5. Influenza including H1N1 illness

According to ministry of health national guidelines patients with H1N1 of
category A &B should be treated at district hospitals. Referral is needed in
all severe cases (Category C) or with respiratory failure to medical colleges

Especially look for cyanosis/chest pain/breathlessness/hypotension/hemoptysis

Or any other complications like
· Primary influenza viral pneumonia
· Secondary bacterial pneumonia
· Mixed pneumonia
· Reye’s syndrome, Myositis, Rhabdomyolysis, Myoglobinuria
· Myocarditis, Encephalitis
· Worsening of co-morbid condition
· ARDS
6. Community acquired pneumonia

· Patients requiring mechanical ventilation or patients with hypotension

should be urgently referred.
· Severe pneumonia(May need transfer to ICU at any time)

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 · Non-resolving pneumonia
· High fever, Severe dyspnoea/confusion or disorientation/marked
hypoxia
· Haemodynamic instability
· Significant co- morbidities
· Hypotherrmia/Leukopenia/ Thrombocytopenia/Uremia
· Neutropenia or in an immunocompromized host

7. Chronic Obstructive Pulmonary Disease

All cases of uncomplicated COPD can be managed at the periphery.

Referral is needed when any of the following is present
· Uncertain diagnosis or for initial evaluation
· Onset of Cor- pulmonale
· Suspected bullous lung disease
· Severe dyspnoea with increased work of breathing
· Failure to improve with treatment
· Acute respiratory failure—SPO2 less than 90%
· Resp. rate >35/mt with Silent chest
· Associated co-morbid conditions—CAD, metabolic abnormalities,
sepsis/Pneumonia/Arrhythmias, altered mental status

8. Bronchial Asthma

As far as possible all asthma cases need to be managed in the periphery.

Referral is needed in following situations
· Presence of hemoptysis

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 · All cases of uncontrolled asthma not responding with three
nebulisations or refractory asthma/status asthmaticus
· Severe persistent asthma refractory to treatment
· Near fatal/Life threatening episode
· Cyanosis not improving with administration of Oxygen
· Significant Comorbidities(Pulmonary hypertension, diabetes mellitus)
· All cases of acute breathlessness found to be not improving in one
day time of management.

9. Diabetes Mellitus

· If the physician feels that it is to be evaluated in detail (as initial work

up) and then only managed, such cases can be referred.
· Such evaluation can be done at tertiary centers, but follow up may be
done at the peripheral institutions through effective back-referral.
· However all diabetes patients should be as far as possible to be
managed at the level of peripheral institutions.
· In the management of diabetes, patient education and convincing the
patient is the most crucial step for success.
The following cases needs referral
· Cases of diabetes with any signs of unstable angina
· Any case of uncontrolled diabetes.
· Diabetic ketoacidosis if not showing signs of improvement.
· Hypoglycemia if not improving with medication.
· Acute complications like diabetic ketoacidosis, Hyper-glycemic/
hyperosmolar state.

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 · Chronic complications as Diabetic retinopathy/ Nephropathy,
Peripheral neuropathy/vascular or any other complications.

10. Hypertension

Diagnosis and follow up activities are possible and expected at

periphery. The following Conditions need referral
· Hypertensive emergencies which need intravenous drug & monitoring
· Difficult to control hypertension: Accelerated hypertension
(BP>180/110 with signs of papilloedema or retinal hemorrhage
· All cases of other hypertensive emergencies
· Hypertension with any Complications
· If secondary hypertension /or rare cause suspected: suspected
pheochromocytoma(Labile or postural hypotension with
headache/palpitation/pallor/diaphoresis)/Cushings syndrome or other
adrenal causes/Intracranial space occupying lesions/Coartation of
aorta.)

11. Coronary Artery Disease

· Mild ischemia and Chronic stable angina may be managed after

explaining the facts to the patient.
· Any cases of persistent ischemia needs referral
· Acute coronary syndrome both ‘STEMI & Non STEMI’ to be
referred.
· If there is no ICU facility available then also cases can be referred.
· Cases of Congestive Heart Failure need to be referred

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 · Cases of Hemodynamic compromise requiring angioplasty need to be
referred.
· NYHA Class 3 & 4 may be managed at higher level institutions.
· Cases with features of Acute pulmonary oedema need to be referred
· Refer all cases after thrombolysis if PCI is indicated
· If difficult arrhythmias to be referred immediately.
Established & investigated cases may be managed at all levels for
follow up. Stabilize the patient with following measures before
referring. Give initial treatment with Prompt analgesia with
Inj.Morphine& Inj. Phenergan300 mg. Aspirin ,300 mg. Clopidogrel
4omg,O2administrationwill be helpful in thrombolysis.I/V
Furosemide/I/Aminophylline/I/V hydrocortisone and other supportive
measures In the event of Acute coronary syndrome if cardiac ICU is
available with trained staff, the cases can be managed at the
periphery.Availability of trained staff is an important consideration in
management.

12. Cerebrovascular Accidents

· Cases of acute ischemic Stroke which are fit for thrombolysis to be

referred.
· Other cases which are haemodynamically stable may be treated in the
peripheral level.
· Patients with depressed level of consciousness need to be referred.
· Unexplained progressive or fluctuating symptoms need to be referred.
· Cases with papilloedema need to be referred.

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13.Seizures

Diagnosed cases other than Status epileptics may be treated in the periphery.
New cases to be referred after symptomatic treatment for detailed evaluation
Cases of suspected CNS infections may be referred All cases of refractory
seizures may be referred.

14. Acute Kidney injury

Start measures like correction of pre renal factors, fluid challenge, frusemide
etc and if not improving then refer.
Cases of Chronic Kidney Disease/ ESRD may be managed in the periphery.
If fit for renal replacement therapy then may be referred.
15. Urinary tract infections

All patients with pyelorephrits with decreased urine output or

encephalopathy or CAD with LV dystruction or Myocarditis or septic
shock, may be referred to Medical College Hospital
· Uncomplicated UTI should be managed at the level of peripheral
institutions.
· Bedridden patients on long term catheter should be managed by
physician in a peripheral centre and may be referred if required as
per clinical discretion of the physician

16.CKD/Chronic renal failure:

· If failure of conservative treatment can be referred for transplant.

· If physician feels that there is a need for detailed work up to find out
the etiology can be also referred.

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 · In case of suspected Obstructive uropathy: to be referred for detailed
work up
· All cases of stage IV or V CKD (Uremic symptoms and symptoms of
fluid overload )
· All cases with higher levels of proteinuria (ACR 70mg/mmol or more)
· Rapidly declining GFR
· CKD with poor control of hypertension
· Suspected renal artery stenosis

17.Snake bite

According to ministry of health national guidelines, all patients with snake

bites should be managed at peripheral level hospitals and be referred if
needed. All patients reported with snake bite should be kept under
observation not less than 24 hours. Time of bite, circumstance of bite etc
should be recorded.
During observation monitoring of the patient is important. Look for
evidence of systemic envenomation: neurological as well as hematological
evidence. Tests of bleeding and clotting time done every thirty minutes for
the first three hours and then hourly after that. If systemic envenomation is
suspected 8-10 vials of ASV is administrated after test dose.
Systemic envenomation must be managed in a place where competent
physician’s service is available. Hence to be referred
The patients with any of the following complications may be referred to
higher centre
· Prolonged clotting time/bleeding time(haematological),
· Respiratory difficulty or evidence of respiratory failure/ARDS,

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 · Extraocular muscle involvement, Ptosis, Opthalmoplegia
(Neurological)/encephalopathy
· Evidence of early capillary leak,
· Features of impending renal failure.
· Any bleeding manifestations
· Adverse reaction to ASV administration
In the case of neurotoxic bites the primary concern is respiratory failure and
this may need mechanical ventilation. While it is possible to maintain a
neurotoxic victim by simply using a resuscitation bag and this should always
be used as a last resort. The best means of support is mechanical ventilation
operated by qualified staff.
Renal failure is a common complication of Russel’s viper and pit viper bites
and the common other complications being intravascular hemolysis, DIC,
direct nephro-toxicity or hypotension. Renal damage can occur very early in
Russell’s viper bite and even when the patient is arrived the damage might
have been already happened. Studies have shown that even when ASV is
administered within 1-2 hours of bite it was incapable of preventing acute
renal failure. The early indicators of renal failure are 1) declining or no urine
output although not all cases of renal failure exhibits oliguria. 2) Serum
Creatinine>5mg/dl or rise of >1 mg/day, Blood urea more than
200mg/dl/serum potassium >5.6mg/dl or hyperkalemia with ECG changes/
clinical evidence of uremia or metabolic acidosis
Declining renal parameters require referral to a specialist with access to
dialysis facilities. Peritoneal dialysis can be undertaken in secondary level
institutions. Hemodialysis is preferred in cases of hypotension or
hyperkalemia.

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18.Dog Bite: The current IDRV and SDCMC protocols* may be used for
guidelines for referral
*Operational guidelines for rabies prophylaxis: Department of Health& Family welfare,
Govt. of Kerala, 2010

19.Poisoning

Timely administration of antidotes like Atropine or Pralidoxime is important

to save life.
All attempt to remove poison to be undertaken in the periphery before
referral.
Stomach wash to be done within four hours of consumption of poison
Drugs which neutralize poison can be tried. Efforts to stabilize vital signs
should be made. Any samples like vomitus or empty bottle or left over tablets
should be sent with the patient.
· Teritiarry care is important if there is a need for ventilator support and
hence such cases where mechanical ventilation is expected need to be
referred.
· If patient has arrhythmia needs referral
· Haemodynamic instability is another reason for referral.

19. Alcohol withdrawal

Early alcohol withdrawal should be treated at district hospital in consultation

with a psychiatrist. However severe withdrawal should be referred to further
referral centre
Withdrawal cases with delirium tremens (Agitation/hallucination/delusion)
or with seizures need urgent referral.

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20. Acute Hepatitis/chroni hepatitis/CLD

All uncomplicated should be managed in the periphery .

The following features are looked for and referred if any is present
· Increasing Bilirubin & Liver enzymes (Unexpected sudden increase in
SGOT/SGPT)
· Development of Hepatic decompensation as evidenced by sudden
decrease of liver size/Pedal oedema/Ascitis.
· Persistent vomiting
· Altered sensorium
· Altered sleep rhythm
· Intractable vomiting posing risk of dehydration
· Hepatitis along with dengue(Hemorrhagic cases)
· Cirrhosis liver, Portal Hypertension if Haemodynamically unstable or
hematemesis .
· Pregnancy particularly third trimester
21.Chronic liver disease:

· Usually diagnosed in the periphery and referred to higher level

institutions for work up. Needs detailed investigations to understand
the etiology and interaction with specialist may be needed in between.
· If the treating physician feels that there is a diagnostic dilemma
regarding etiology this should be referred.
· Evaluation of undiagnosed ascitis is another reason to refer to tertiary
care institutions
· Patients with suspected hepatic encephalopathy/spontaneous bacterial
peritonitis/upper Gastrointestinal bleed also should be referred

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 B.2.General Surgery

General considerations of surgical referral:

Surgical management of cases is always a team activity than an
individual activity. Theatre facilities and state of art equipment is
vital in management of surgical cases. Apart from the operating
surgeons and anesthetists, the competence of theatre assistants, nurse
and other paramedics as well as team involved in postoperative care
are important considerations.
Second opinion can be sought at any time for any elective cases as
well as emergency cases from the referred institutions also
If the surgeon is confident and facilities are available the case can be
managed at peripheral centers also and in that case referral can be
avoided

Elective cases to be referred to Tertiary care centers if any of the

following is present

- Anesthesia risk due to co-morbid conditions

- Acute Limb ischemia
- Diagnostic dilemmas
- Lack of expertise and facilities
- Recurrent hernias
- *Conditions which requires vascular interventions to avoid
amputation (Because may need help for vascular surgery)
- Gastrointestinal malignancies
- High fistulas & complicated fistulas, Recurrent fistula(Because
further recurrence rate is high)

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 - Chest wall tumor, Retroperitoneal tumors (Because may need plastic
surgery, double layer rotation flap, defect replacement surgery etc.)
- Complicated thyroid disease ( because the patient may need
postoperative ventilator support)
- Malignancy thyroid
- Retrosternal goiter( Because the patient may need thoracotomy and
specialized anesthetic care)
- Toxic Multi nodular goiter ( because it is high risk category,
Preoperative stabilization more important, post operative bleeding
rate more)
- Large thyroid swelling( because it is a real challenge to surgeon, may
need postoperative ventilator care)
- Parotid tumours (Because the area is high risk for facial nerve
injury)
- Radical Neck dissections
- Cervical rib( Because vascular compromise is expected)
- Obstructive jaundice( If periampullary carcinoma whipples resection
needed, if CBD stone the procedure is risky)
- Hepatic tumours
- Pancreatic tumours
- Elective Splenectomy
- Head & Neck Cancers
- Inguinal block dissection(may extent to external iliac or
retroperitoneum)
- Carcinoma Penis

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 - A.V. Malformations(Need detailed assessment and preoperative
evaluation)
- Testicular tumours
- Soft tissue sarcoma
*Major Amputation can be done in referral centers. Amputations like

toe, mid tarsal, digital can be undertaken in lower level centers. In

cases where the surgeon is less confident opinion can be taken from
higher centers.

III. Emergency cases to be referred to Medical Colleges

- Poly trauma, Head injury ( with wound certificate)

- Perforations, blunt injury abdomen
- Chest injury after tube/thoracostomy ( if possible and indicated)
- Major burns
- Pancreatitis: Mild pancreatitis which is likely to resolve within a
week with medical management may be managed at periphery. All
cases of severe pancreatitis need to be referred.
- Intestinal obstruction
- Vascular injuries

Case, which can be managed at the periphery**

- Minor cases like
- Hernia - uncomplicated
- Hydrocoel/Acute scrotum
- Hemarrhoids
- Fistula – uncomplicated
- Vericocele
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 - Vericose vein
- Pilonidal sinus
- Lympnode biopsy
- Ingrowing toe nail
- Ganglion, corn foot, ulcer biopsy
- Gynecomastia
- Uncomplicated goiter
- Amputation
- Mastectomy(After discussion and decision from the Tumor board
at higher centre) , Benign breast lumps
- Diabetic foot ( Clearance operation to be done in
periphery,Vascular compromise is usually present and elective
amputation may need secondary opinion and can be referred for
second opinion if necessary)
- Fibroadenoma, Neurofibroma, Lipoma, abscess, sebaceous cyst
** In the absence of significant co-morbid conditions.

IV. Emergency cases/procedures which can be undertaken in

Peripheral Centers

· Appendicectomy
· I& D of abscess
· Repair of obstructed hernia
· Duodenal ulcer perforation
· Acute scrotum
· Suprapubiccystostomy(Open/trocar)
· Tracheostomy
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 B.3. Orthopedics:

Orthopedics is a fast changing specialty and concepts regarding

acceptable treatment change very frequently. Hence setting proper
guidelines for all orthopedic conditions is impossible unlike many
medical specialties. However general guidelines are proposed for
making the system more efficient and maximizing benefit for the
patients.

Conditions needing Referral

A. Trauma cases.

1. Uncomplicated fractures and dislocation like fracture Tibia, Colles

fracture, Fracture Humerus, fracture patella; ankle fracture etc can be
managed in the secondary level center.

2. Uncomplicated fractures of neck of femur in elderly without

co-morbid medical conditions can be managed in secondary center.
Adequate anesthesia and theatre facility including ‘C Arm’ should be
available in secondary center.

3. Polytrauma should be transferred to tertiary centre only after

adequate haemodynamicstabilisation and splinting. One dose of
broad spectrum antibiotic (cephalosporine) along with tetanus
prophylaxis should be given.

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 2. Complicated fractures like open fracture which require urgent
surgical intervention may be referred to tertiary center.
3. Spinal injuries: Stable fractures (< 50% compression, without
neurological deficits) may be managed in secondary center. Unstable
spinal fractures (> 50% compression, 2 column involvement, with
Neurological deficits) may be referred to higher center. One dose of
methyl prednisolone in a dose of 30mg/kg body weigh may be given
as a bolus dose. Along with intravenous pantoprazole 40 mgs. Can
also be given. Then patient may be transported taking care not to
produce further damage (spinal board).
4. Knee problems like internal derangement requiring diagnostic and
therapeutic arthroscopy may be referred, till trained personnel and
equipment is made available in secondary centre.
5. Hand injuries, requiring surgical procedures and reconstructive

procedure/ reimplantation may be referred preferably to plastic

surgery department.

B. Orthopedic diseases

1. Common orthopedic problems like Tennis elbow, plantar fascitis, de

Querveins disease, low back ache, neck pain, knee pain, CTS etc can
be initially assessed and treated in secondary center .If he/she faces
any therapeutic or diagnostic dilemmas, it can be referred to tertiary
center with proper documentation.
2. Spinal diseases like IVDP, Spondylolisthesis, Tuberculous spine,
spinal canal stenosis and scoliosis which require surgical intervention
may be referred.

29
 3. All cases which require joint replacement arthroplasty may be
referred till adequate infrastructural facilities made available in
secondary centres.
4. Acute infective conditions like osteomyelitis and septic
arthritis which require surgical treatment may be referred if facility is
not available.
5. Specific infections like bone and joint tuberculosis may be managed
in secondary center. However if it develops complications or requires
surgical management may be referred.
6. Rare orthopedic problems like developmental disorders, neuro-
developmental conditions, complex bone and joint deformities
requiring reconstructive procedures like LRS/ Ilizarov may be
referred. And those ideal for academic discussion may be
also referred. Examples1.Perthes disease 2.Cerebral palsy 3.Bone
dysplasia 4.Muscular dystrophies 5.Metabolic bone diseases

Musculoskeletal tumors

Musculoskeletal tumors and tumor like condition may be referred

because biopsy and definitive treatment can be done in these centers.
However benign conditions like osteochondromas which can be managed
in secondary center need not be referred.

Congenital anomalies:

Common anomalies like CTEV may be treated but complications like

relapse and neglected clubfoot may be referred. DDH, Pseudoarthrosis tibia,
and spinal dysrrhaphism, which require complicated surgical procedure
may be referred.
30
Removal of implants as far as possible should be done in secondary centre.

Investigations:

If the patients need higher investigations (Doppler, MRI, and CT) may be
referred to Radiodiagnosis in tertiary center. It may be assessed by the
surgeon in the secondary centre and referred if necessary.

Back referral Special considerations for Ortho referral

1. Patients should be kept only for a minimum period in tertiary centre

2. Patients with uneventful postoperative period may be referred back to
the nearest Govt. hospital where orthopedic surgeon is available
3. The hospital should arrange ambulance facility for referral and back
referral as many patients are not willing to co operate due to the high
transportation cost involved.
4. Suture removal to be done in the respective secondary centers.
5. Change of plaster of Paris cast can be done at the secondary level
institutions
6. Follow up of minor operation cases can be done at the secondary level
institutions

31
 B.4. Otorhinolaryngology
Special guidelines for ENT referral
· General co-morbidities causing added risk including uncontrolled
diabetes, uncontrolled hypertension, cardiac, neurological, hepatic,
hematologic or renal diseases complicating ENT disease, anesthetic
risk for surgerySuspicion of impending airway compromise or any life
threatening complication during treatment or surgery, Poly-trauma
involving ENT and other areas should be first seen by appropriate
specialist/general surgeon/Physician and referred.
· Diagnostic dilemma or cases non-responsive to usual lines of
management for reasonable time can be referred.
· Elective cases from PHC and CHC may be referred to Taluk / District
hospitals where ENT specialist is available. Cases may be referred by
the concerned ENT surgeon to medical college, only if indicated.
· Patients attending primary care centers after routine OP hours may be
advised to attend the OP of secondary care hospital next day after
symptomatic treatment, instead of referring to Medical College.
· Adequate support from higher authorities when patient lands in
complications after refusing referral need to be sought in advance.
· HIV, HCV and HBsAg positive patients should be managed at
secondary care centers and not shunted for this reason alone.
· Referral should not be used as a means of shunting patients. Specific
guidelines are given below.
· In all medico legal cases, wound certificates should be written by the
attending doctor from the referring institution. The following

32
 surgeries may be under taken as far as possible at the secondary care
centre.
Tonsillectomy & Adenoidectomy
Septoplasty, Submucous resection & Functional Endoscopic
Sinus Surgery (FESS)
Mastoidectomy, Myringotomy and grommet insertion &
Tympanoplasty
Direct laryngoscopy and Hypopharyngoscopy
· Any post operative complication not controlled by usual means can be
referred along with adequate information and other accompaniments
like specimen in relevant situations.
Specific conditions for referral
This list is not exhaustive or all encompassing. Discretion of the referring
surgeon at primary and secondary care centers is very well solicited.
A. Ear
Cases which can be managed at the primary care centers:
1. Furuncle ear
2. Simple diffuse external otitis
3. Uncomplicated acute suppurative otitis media
4. Uncomplicated chronic suppurative otitis media

Cases which can be managed at the secondary care centers:

1. Pre-auricular sinus
2. Hematoma pinna
3. Wax ear
4. Keratosis obturans
5. Pseudocyst pinna

33
 6. Complicated diffuse external otitis
7. Otomycosis
8. Foreign body ear in external canal
9. Injury pinna including cartilage injury
10. Traumatic perforation of tympanic membrane
11. Perichondritis pinna
12. Herpes zoster oticus
13. Myringitis bullosa and granulosa
14. Otitis media with effusion aero-otitis
15. Chronic suppurative otitis media for mastoidectomy and
myringoplasty
16. Chronic suppurative otitis media attico-antral disease
17. Bell’s palsy
18. Otosclerosis – conservative management
19. Menière’s disease – conservative management
20. Benign paroxysmal positional vertigo (BPPV)
21. Deafness assessment and certification

Cases which are to be referred to tertiary care centers:

1. External canal atresia
2. Pinnaplasty
3. Foreign bodies in ear – impacted or in middle ear
4. Malignant otitis externa
5. Intractable referred otalgia and tinnitus for detailed evaluation
6. Trauma ear or temporal bone with neural and labyrinthine
involvement or CSF otorrhoea
7. Chronic suppurative otitis media for ossiculoplasty

34
 8. Complicated chronic suppurative otitis media suggested by
fever, headache, nausea, vomiting, nerve involvement, vertigo,
abscess formation, visual field defects
9. Facial nerve decompression
10. Otosclerosis – for surgery
11. Revision mastoidectomy and revision tympanoplasty
12. Menière’s disease – for surgery
13. BPPV not responding to usual management
14. Sudden sensorineural hearing loss
15. Tumors of external, middle, inner ear or CP angle
16. Deaf for cochlear implantation
B. Nose and paranasal sinuses
Cases which can be managed at the primary care centers:
1. Uncomplicated furuncle nose
2. Acute rhinitis and rhinosinusitis
3. Allergic rhinitis and vasomotor rhinitis

Cases which can be managed at the secondary care centers:

1. Complicated furuncle nose with cellulitis or minor abscess
formation
2. Uncomplicated fracture nasal bone
3. Deviated nasal septum and its surgeries
4. Mild and moderate epistaxis
5. Minor complications of sinusitis like cellulitis with facial
edema
6. Septal hematoma
7. Septal abscess

35
 8. Foreign body nose & rhinolith
9. Fronto-ethmoidal mucocoele
10. Atrophic rhinitis
11. Nasal myasis
12. Simple nasal polyposis and antrochoanal polyp
13. Headache and facial pain
14. Benign lesions of nasal cavity requiring excision
15. Malignant lesions of nose and PNS – biopsy may be taken

Cases which are to be referred to tertiary care centers:

1. Congenital anomalies like choanal atresia, nasal dermoid,
meningocoele, glioma
2. Fracture nasal bone with telescoping into ethmoid
3. Fracture upper, middle and lower third of face with airway
compromise or orbital complications
4. Severe epistaxis requiring post nasal packing and arterial
ligations
5. Major complications of sinusitis as suggested by persistent
fever, headache, nausea vomiting, proptosis, dimness of
vision, double vision, restriction of eyeball movement or
osteomyelitis of facial bones
6. Oro-antral fistula
7. Rhinitis requiring detailed evaluation including allergic testing
8. Granulomatous diseases and fungal infections
9. CSF Rhinorrhoea with or without meningocoele or
meningoencephalocoele
10. Recurrent nasal polyposis requiring detailed evaluation

36
 11. Allergic fungal rhinosinusitis
12. Headache not responding to usual lines of management and
requiring detailed radiological and ENT evaluation
13. Benign and malignant lesions of nasal cavity requiring
extensive surgery or radiotherapy
C. Oral cavity, pharynx, larynx head and neck
Cases which can be managed at the primary care centers:
1. Benign oral ulcers including aphthous ulcers
2. Acute tonsillitis and pharyngitis
3. Chronic tonsillitis and pharyngitis – medically managed
4. Acute laryngitis.
5. Uncomplicated viral and suppurative parotitis

(All cases with persistent hoarseness of more than two weeks to be referred
to higher centre for indirect laryngoscopy and or direct laryngoscopy)

Cases which can be managed at the secondary care centers:

1. Oral ulcers with suspected malignancy which may be biopsied
if needed.
2. Benign tumors of the oral cavity
3. Premalignant conditions of the oral cavity if biopsy is negative
for malignancy and there is no progress of the disease
4. Peritonsillar abscess
5. Chronic tonsillitis and adenoids for surgery
6. Benign tumors and cysts of oropharynx if not compromising
airway
7. Pharyngeal ulcers and growths – may be biopsied if needed
8. Chronic laryngitis

37
 9. Gastro-esophageal reflux disease and laryngo-pharyngeal
reflex
10. Uncomplicated foreign bodies of oropharynx or hypopharynx
11. Benign thyroid diseases
12. Benign neck swellings
13. Benign laryngeal tumors
14. Uncomplicated blunt trauma of neck
15. Superficial wounds of neck not involving larynx, pharynx or
neurovascular bundles
16. Malignant laryngeal tumors with no airway compromise –
may be biopsied
17. Terminal malignancies requiring only palliative care
· Tumors with airway compromise or impending airway compromise
may be managed if facility and competency for tracheostomy are both
available
· Malignancy of any area if confirmed and requiring radiotherapy may
be referred to department of radiation oncology after proper staging,
with slides for pathological review if needed.
Cases which are to be referred to tertiary care centers:
1. All neonates, infants and toddlers with airway compromise
2. Membranous tonsillitis
3. Lingual tonsillitis/abscess
4. Lingual thyroid
5. Peritonsillar abscess with: severe trismus, parapharyngeal or
retropharyngeal space involvement, impending airway
compromise
6. Ludwig’s angina
38
 7. Retropharyngeal and parapharyngeal abscesses
8. Acute epiglottitis especially in children
9. All cases of acute laryngeal edema
10. Corrosive poisoning
11. Foreign bodies of oral cavity, oropharynx or hypopharynx
with abscess formation or impending airway compromise
12. Foreign bodies of oesophagus
13. Foreign bodies of bronchus
14. Penetrating neck injuries
15. Cases requiring micro-laryngeal surgery
16. Cases with trismus of spondylotic changes which necessitate
fiberoptic scopies
17. Laryngeal injuries with fracture of cartilages or airway
compromise
18. Nasopharyngeal angiofibroma
19. Pharyngeal pouch
20. Cases requiring oesophagoscopy
21. All malignancies of oral cavity larynx and pharynx requiring
surgery
22. Benign or malignant tumors of the parotid
23. Unilateral or bilateral vocal cord paralysis – traumatic or
otherwise
24. Thyroid malignancies
25. Benign and malignant parotid diseases
26. All malignant neck swellings including lymph nodes which
require surgery
27. Unknown primary for detailed investigation
39
(All diseases of the throat are potential threat to airway; either the disease
itself or the interventional surgery. This has to be anticipated and referral
made at the earliest if facilities for airway management are not available)

40
 B.6.Obstetrics & Gynecology:
Reference guidelines special to maternity referral: Maternity (Obstetric)
referrals are more complex and the decision making window is narrow.
Maternity referral is based on the concerned Obstetrician’s clinical judgment
depending on the nature of obstetric condition and proximity to the health
care facility.
There are essentially two types of references: Elective (Planned referral) and
emergency referrals.
As the obstetricians experience and availability of supporting specialist
services differ, across institutions, the individual practitioner can take
decision according to the merit of individual case and what is given is only
general guidelines.
The following are the conditions for referral

· Patient should be preferably seen by a gynaecologist before elective

referral.
· Emergency referrals can be done by the duty doctor after discussion
with the gynaecologist.
· Medico legal cases should be seen by a gynaecologist wherever
available.
· Medico-legal cases: The medico-legal case where gynecologist is not
available on duty is sometimes referred unnecessarily for examination
by gynecologists. The case should be attended by on call duty
gynecologist and facility for transport should be made available by the
hospital administration. This can avoid unnecessary referral.

41
 · Stabilizing the patient before referral: All possible efforts should be
taken for this and steps like starting an intravenous drip,
administration of drugs like oxytocin in the case of hemorrhage,
terbutalin in the case of pre-term labor etc. should be undertaken
along with referral.
· All High risk cases need to be referred to tertiary care facility.

· Elective antenatal references:

Risk assessment should be done at the first visit at all centers and
early referral to be ensured.
Any high risk factor identified should be referred after first visit
Pregnancy with Heart Disease: If known case of cardiac case or first
detected heart lesion, first refer to a cardiologist for assessment of risk. If
found to be low risk cardiac lesion (Like MVP or mild MR) then the
pregnancy can be managed at secondary level .
Hypertensive disorders
Mild gestational hyper tension that is if BP is controlled with one drug and
no other complications can be managed at the secondary level and other
cases can be referred to a tertiary centre sufficiently early.

Diabetes
Gestational diabetes mellitus(GDM) without complications can be managed
at the secondary level, Pre-gestational diabetes and complicated GDM cases
should be referred to tertiary centre sufficiently early.
Multiple drug allergies should be referred to a tertiary centre

42
Thyroid disorders can be managed in consultation with a physician.
Uncontrolled cases can be referred.

Systemic lupus erythematosis and auto immune disorders should be

referred to tertiary centre.

Anaemia – Severe anaemia in late pregnancy should be referred to a tertiary

care centre.

Jaundice complicating pregnancy: All cases should be referred.

Fever – follow the fever protocol in all cases and refer appropriately*.

Seizure disorders with pregnancy can be referred

Psychiatric cases after consultation with a physician or psychiatrist can be

referred.

All cases with anticipated anaesthesia complications like severe obesity can
be referred. Under weight cases (< 40 kg) and over weight (> 90 kg) can be
referred.

*Short Febrile Illness including ILI Management guidelines: Public Health

Division, Directorate of Health Services, Kerala, 2012.

Obstetric complications

1. All previous obstetric adverse outcomes should be referred to a

tertiary care centre for evaluation.
2. Hyperemesis – Majority of Hyperemesis can be managed at
secondary level and non- responding cases can be referred to a
tertiary centre.
3. Previous caesarean where complications are anticipated like
previous CS with placenta previa, anomalies, IUD and
complications during previous LSCS should be referred
sufficiently early.
4. Mal- presentation can be managed at the secondary level.
5. Multiple pregnancies with any complications should be
referred.

43
 6. All ante partum hemorrhage cases should be referred. Placenta
previa cases diagnosed after 28 weeks can be referred.
7. IUGR: Growth restriction severe enough requiring neonatal
care in can be referred.

Emergency Referral
1. It is better not to refer ruptured ectopic, cord prolapse, failed
induction and incomplete abortion if facilities for immediate
intervention are available.
2. Pre- term labour and PPROM can be referred to tertiary centre
for neonatal care.
3. PPH and third stage complications can be referred in time after
first aid measures like IV crystlloids, condom tamponade,
continuous bladder drainage and oxytocin drip.
4. Eclampsia can be referred after giving 1st dose of Magnesium
sulphate with proper documentation.
5. Post operative complications. Any acute or severe post
operative complications can be referred if the treating
gynaecologist feels necessary.
6. Re laparotomy should be avoided in the periphery as far as
possible.
7. Postnatal reference – Details of mother’s treatment and
investigations should be furnished in the reference card even if
the mother is referred for baby sake.
8. Acute abdomen in pregnancy – Any case of acute abdomen in
pregnancy can be referred.

Conditions not to be referred– just because the case is

having only the specified condition and otherwise no
added risk.
1. HbsAg, HIV
2. Chicken pox
3. Un complicated IUD

Gynaecology Reference
1. All cases of suspected malignancy

44
 2. Any gynaecological condition with significant medical or surgical
co morbidities and drug allergy.

· All reference letters should contain the details of the patients

with treatment given and other relevant investigation
findings.

45
 B.7. Pediatrics

REFERRAL PROTOCOL FOR NEWBORNS, INFANTS AND

CHILDREN

NEWBORNS
In newborns, whenever a cannula is put, a sample of blood should be drawn
for relevant investigations if needed and then only sent.

Refer
• Preterm < 32 wks , IUGR < 1.8 kg

• Major congenital malformations

eg. TOF, choanal atresia, diaphragmatic hernia, ruptured

meningo-myelocele, ectopiavesicae
• Central cyanosis

• Any bleeding manifestation in spite of Vitamin K administration

• Bulging anterior fontanelle

• Blood in stools

• Pathological abdominal distension / bilious vomiting

• Initially normal, by 3-28 days, cannot suck and has stiffness/ muscle
spasm

• Not gaining weight as expected

Respiratory distress or respiratory rate > 60 per minute with cyanosis /

grunt / severe chest retractions/ indrawing

Think of hyaline membrane disease, surgical conditions, sepsis, pneumonia

and asphyxia. Assess Downes score and if more than 3, refer with free flow
oxygen.

46
Downes score
Score 0 1 2
Respiratory rate <60 60-80 >80/ apnea
Cyanosis none In air In 40% oxygen
Grunt none Audible with Audible without
steth steth
Retraction none mild severe
Air entry good diminished Barely audible

Poor feeding/ poor activity

Act
• Hypoglycemia
• Hypothermia • If RBS <40mg/dL
• Sepsis • 10 % D 2ml/kg • Not better in
• Continue with 3 hrs
• Asphyxia appropriate fluids
• Intracranial bleed • Rewarm, breast feed REFER
Think

Apnea

Think of hypoglycemia, hypothermia, sepsis, intracranial bleed, anemia and

apnea of prematurity. Immediate actions include stimulation of the baby,
positioning the neck and suctioning
suction mouth & nose.Bag
.Bag and mask ventilation

47
may be given if needed. 10 % D and warmth may be provided if
hypoglycemic or hypothermic. If not improving wi
with
th these measures, baby
should be referred.

Convulsions

Act

• Draw blood for

RBS,Ca++
• Hypoglycemia • If not
• 10 % D 2ml/kg, if not
• Hypocalcemia improving
• Sepsis controlled,
• IV 10% Calcium
• Asphyxia
gluconate 2 ml/ kg
REFER
• IC bleed
• If not controlled,
Think IV pheno 20 mg/kg
over 20 min

Failure
ailure to pass meconium in 24 hrs

48
 • Anorectal Act
malformations
• Intestinal
Obstruction • Check patency & position of • If found
• Hirschsprung anus
disease abnormal
• W/F abdominal distension
• Congenital • W/F bilious vomiting
hypothyroidism
• AXR erect
REFER
Think

Failure to pass urine in 48 hrs

Think of genitourinary
urinary malformations. Review antenatal ultrasound records
(oligamnios, fetal kidneys) , look for palpable bladder & kidneys, assess
lactation and put intravenous fluids. Refer if any abnormality is found or no
urination occurs after a challenge with intravenous fluids.
Neonatal Jaundice –
Do serum bilirubin, Hb and blood grouping. Refer if serum erum bilirubin in
indefinite/ exchange range, serum bilirubin in phototherapy range but has
no facility, baby is sick – poor feeding / activity, excess cry, convulsions
and jaundice
aundice > 2weeks with clay colored stools
stools.
Guidelines for exchange transfusion in neonatal hyperbilirubinemia
hyperbilirubinemia-
FIMNCI 2009

49
In case of indirect hyperbilirubinemia in phototherapy range in a newborn
who isnot sick, phototherapy is to be started if facility is available.
Encourage breast feeds and give intravenous fluids if needed for hydration.
Repeat serum bilirubin after 6 h and if values have not come down or rising,
baby should be referred.
Guidelines for initiating phototherapy in neonatal hyperbilirubinemia -
FIMNCI 2009

50
INFANTS AND CHILDREN

Acute short febrile illness

Control fever before your clinical examination as a child with high grade
fever will appear sick. Once fever is controlled, do a clinical examination
and decide whether the child is sick or not sick. Arrive at a provisional
diagnosis and do investigations as required. Clinical examination includes
vital signs, capillary filling time, the feel of extremities, sensorium,
appearance whether toxic or not, pallor, icterus, lymphadenopathy, ear nose,
throat, chest, anterior fontanelle in small children and meningeal signs in
older children, abdomen and skin.
Treat but refer if not improving in case of viral fevers, measles without
complications, dengue without warning signs, uncomplicated malaria, ear,
throat & other URI, ALRI, ADD as per algorithm,uncomplicated UTI (
culture facility present) and uncomplicated skin infections.

51
Refer in case of sick child with danger signs eg. Shock, altered sensorium,
bleeds etc, severe dengue, measles with severe complications, CNS
infections (if CSF study & culture facility not available), complicated UTI,
complicated malaria and ALRI, ADD as per algorithm.
Pyrexia of Unknown Origin
Defer antibiotics if not sick. Investigation includes urine & blood C&S. In
enteric fever not responding to treatment or with any complications, referral
should be done. Leptospirosis with complications should also be referred.
Pneumonia
Classify severity of pneumonia based on age, presence of danger signs (not
able to feed, drowsiness, cyanosis, stridor in a calm child, convulsions,
severe palmar pallor, severe malnutrition and severe dehydration). ALRI,
very severe illness without tertiary care facility for management, ALRI, very
severe illness, tertiary care facility available but not responding to treatment
in 24 hrs , presence of complications ( empyema, pneumothorax, pleural
effusion), rapidly progressing pneumonia (staph, viral) and associated
congenital heart diseases, immunodeficiency, nephrotic syndrome,
malignancy and on immunosuppressive therapy should be referred. Pre
referral actions include taking a chest X-ray, administration of first dose
antibiotic and free flow oxygen. The latter should be continued during
transport also.

52
Malnutrition

Act

• SAM (6 – 60mo ) • Hypoglycemia <54mg%

• Wt for ht < 70% or • Asymptomatic-
• MUAC < 11.5 cm or oral/ NG 10% D 50ml
• Edema both feet • Symptomatic-
10% D 5ml/kg REFER
• Age < 6 mo
• Warmth
• First dose antibiotic
• Vit A
Think • ORS SOS

Bronchial asthma

Child should be referred if there is no improvement with 3 doses of

nebulization with short acting beta 2 agonists (SABA), SPO2 after 3 doses
of nebulization with SABA < 92%, on maximum dose steroids, past history
of ventilatory management, ICU admission oorr life threatening episode and
history of sibling death due to asthma
asthma.
Acute diarrheal disease

Classify dehydration. In severe dehydration, give 30 ml/kg of intravenous

RL or NS over 30 min in an older child and over 1 hr in an infant. 70 ml/kg
of the fluid should be continued over 2 ½ hrs in an older child and over in
5hrs in an infant. ORS may be given if possible. Give oxygen if in shock. In

53
case, shock is not corrected with this management, child should be
transferred with intravenous fluid and oxygen to a higher centre. Associated
severe acute malnutrition and suspected sepsis are other indications for
referral.

Fever with convulsions

Act

• Unstable vitals
• ABC
• Uncontrolled
• Febrile fits • Paracetamol 15 mg/kg PR seizures
• Tepid sponging • Drowsy > 30min
• Meningitis • FND
• IV Lorazepam 0.1 mg/kg OR
• Epilepsy PR Diazepam 0.5 mg/kg • Atypical
Maximum 3 doses seizures
Think • B&M should be available
• Meningeal signs

REFER

Anemia

Refer if Hb< 7 g/ dl, in suspected

uspected hemolytic anemia
anemia/ hypoplastic anemia/
anemia
malignancy, iron
ron deficiency anemia not responding to oral therapy in 3 mo
and associated chronic heart/ respiratory/ hepatic/ renal disease
disease.
Acute nephritis

In case of urine output < 1 ml / kg / hhr, hypertension

ypertension with complications,
complications
rising blood urea levels,, rrenal
enal failure requiring peritoneal dialysis and
seizures,, patient should be referred. Indications for peritoneal dialysis

54
include blood urea > 150mg/dl, serum creatinine> 4 mg/dl, serum
potassium> 6meq/l.

Acute hepatitis

Signs of hepatic failure including flap, altered sensorium, altered PT and

sudden shrinkage of liver span are indications for referral.
Acute abdomen & acute scrotum

All cases should be referred to a surgeon or a higher centre

Snake bite

Presence of local reaction, systemic reaction, prolonged CT and abnormal

vital signs are indications for referral.

Care of newborn /child during transport

• Provide warmth- covering should include scalp & extremities in

newborns

• Appropriate fluids if hypoglycemic/ dehydrated

• Oxygen if in respiratory distress or has tachypnea / cyanosis

• Inform the higher centre beforehand over phone if possible

55
 C Appendix
C.1. Definitions of terms
Referral systems: Referral can be defined as a process in which a health
professional at a one level of health system having insufficient resources
(equipments/drugs/skills) to manage a clinical condition seeks the
assistance of a better or differently resourced facility at the same or
higher level to assist in or take over the management of the client’s case.

Referring facility: The initiating facility from where the decision to refer
is made
Referral receiving facility: The institution where a referred patient is
received and managed.
Directory of services: The list of specialists or special procedures or
investigations available in each facility. This facilitates the search for
appropriate service provider.
Back referral: Back referral means referring the patient back to the
lower and referred out facility for further follow up and care.
Referral card: The letter to accompany the outward referral from the
initiating facility
Referral Register: A maintaining list of all outward and inward referrals
for one facility or service provider. Information includes who referred,
where referred, when and why and the appropriateness of referral
Levels of care: In a three tired health system model the three levels of
care are a) primary (Primary health centers and sub-centers b) secondary

56
 (Talukhead quarters hospitals, FRUs and CHCs) c) tertiary (District
hospitals, general hospitals and medical hospitals, regional institutes)
Appropriateness of referral: This is decided based on the preconditions
1) Timeliness i.e. neither too early nor too late as
decided by the referring physician as well as the
receiving physician and depending upon the
patient’s clinical condition noted by them
respectively.
2) Effectiveness: Whether the objectives of referral
achieved or not (a) to get expert opinion b) to get
an additional skill oriented service example
surgery c) to get admitted and managed at a higher
level centre d0 to get a diagnostic investigation
done
3) Cost effectiveness i.e. the benefits exceed and
justify the costs

57
 C.2. REFERRAL CARD

Name of the Patient & address: Special comments if any

Age in years: Sex: M/F

Date & Time of Reference

Total monthly income for the

family:

APL/BPL if BPL No:

Brief on Illness

Investigations done

Working diagnosis

Treatment given

Reasons for reference

Referred to

Any additional information or comments

Signature
Name & Designation of Doctor
Phone No,
email Optional)
Name of
Hospital

58