Abstract

Despite advances in BEmONC and CEmONC services in Cambodia, referral of women and children suffering from emergencies is often significantly delayed due to systemic barriers.  These shortfalls disproportionately impact poor and rural patients.

In 2014, Stanford Emergency Medicine International partnered with University Research Co. in the 5-year, USAID funded Quality Health Services Project to improve maternal and child health outcomes in nine Cambodian provinces.

Working closely with the Ministry of Health (MOH), gaps in the current referral system were identified and capacity building interventions were crafted to address them.  Implementation and follow up was also done in conjunction with government partners to maximize uptake and long term sustainability.

Recognition of sick patients:

A simple, Cambodia specific triage system was effected at referral hospitals to help providers rapidly identify and prioritize sick patients. Emergency care and referral guidelines were also distributed to hospital providers to assist them in recognizing critical patients and administering evidence based treatments.

Enhanced communication:

A standardized, MOH approved, referral slip was implemented to communicate clinical data between treating providers at each level of care.  Provincial referral hotlines were established at all referral hospitals, streamlining the referral process and facilitating real time communication between providers at referring health centers or hospitals and higher level receiving hospitals.  An ambulance Patient Care Report form was also created to relay ambulance care information.

Education, quality improvement and feedback:

Utilizing a quality improvement approach, quarterly education and feedback forums were established, assembling providers from each level of the referral system to analyze referral data, discuss difficult cases, provide feedback and address systems challenges.  Prehospital care training was also given to previously untrained ambulance providers to enhance their transports care skills. 

Impact metrics related to these efforts are 1) the number of complicated deliveries referred to a higher level of care and 2) the number of newborn complications referred to a higher level of care.  Gains are being made, however progress has been gradual.  Incorporating proposed changes into institutional culture has been a challenge.  Thus, project partners are restructuring reinforcement strategies to better align with provider values and facility goals.