UNASSIGNED: In 2017, the Ministry of Health and Public Hygiene (MoH) of Burkina Faso designed and piloted a specimen transport system using the national courier services (La Poste BF) in 4 districts. Based on satisfactory performance indicators, the MoH set a vision aimed at scaling up this system to strengthen disease detection and surveillance of epidemic prone diseases across the country. This work describes the implementation process, performances, and lessons learned.
UNASSIGNED: This work describes the implementation process, performances, and lessons learned. Under the leadership of the Directorate of Population Health Protection within the MoH, a stepwise approach was used to bring together multiple partners across sectors to develop the first needed documents including a guide, an implementation plan, Standard Operating Procedures, and data collection tools. Then, the execution phase included equipment purchase, trainings, and consensus on a financing mechanism. Key indicators were defined to allow performance monitoring.
UNASSIGNED: The integrated biological specimen referral system (SITEB) was officially launched in January 2020 to transport human biological specimens of priority diseases including COVID-19 from district level to reference laboratories nationwide. As of December 31, 2022, La Poste BF transported 168,856 packages containing 206,314 specimens from all 13 regions. 99.66% of packages were delivered in <24 h as required, and 99.68% of specimens were in good condition at reception. COVID-19 specimens represented respectively 18% and 63% of samples transported in 2020 and 2021.
UNASSIGNED: The political will combined with the experience gained during the pilot phase and the commitment and support from all stakeholders laid to the foundation of the effective implementation of this system. Collaboration between two government entities (MoH and Minister of Transport, Urban Mobility, and Road Safety) to benefit public health has led to reasonable pricing for sustainability. Although all documents integrate the \"One Health\" approach, the system ensures the transport of only human samples for now. Despite security constraints, Burkina Faso has successfully set up a system using the national postal service to ensure the routine transport of specimens for all diseases under laboratory surveillance including laboratory tests for HIV and TB from the district level to reference laboratories nationwide. This system has also proved to be useful and efficient in managing public health emergency.

BACKGROUND: Inappropriate utilization of higher-level health facilities and ineffective management of referral processes in resource-limited settings are becoming increasingly a concern in health care management in developing countries. This is characterized by self-referral and frequent bypassing of the nearest health facilities coupled with low formal referral mechanisms. This scenario lends itself to a situation where uncomplicated medical conditions are unnecessarily managed in a high-cost health facility. On July 1, 2021, Kenyatta National Hospital (KNH) enforced the Kenya Health Sector Referral Implementation Guidelines, 2014, which required patients to receive approval from the KNH referral office and a formal referral letter to be admitted at KNH to reduce the number of walk-ins and allow KNH to function as a referral facility as envisioned by the Kenya 2010 Constitution and KNH legal statue of 1987.
OBJECTIVE: To determine the effect of enforcing the national referral guidelines on patterns of orthopaedic admissions to the KNH. This was a pre-post intervention study. Data abstraction was done for 459 and 446 charts before and after the enforcement of the national referral guidelines, respectively.
RESULTS: Enforcement of the national referral guidelines reduced the proportion of walk-in admissions from 54.9% to 45.1%, while the proportion of facility referrals increased from 46.6% to 53.4% (p = 0.013). The percentage of non-trauma orthopaedic admissions doubled from 12.0% to 22.4% (p<0.001). There was also an increase in admissions through the Outpatient Clinic and Corporate Outpatient Clinic. The proportion of emergency admissions declined, while that of elective admissions increased. The increase in elective cases was mainly driven by the increase in female admissions with active insurance cover, tertiary education, non-trauma-related conditions and older age groups. However, the use of official formal written referral letters did not change despite the enforcement of the national referral guidelines.
CONCLUSIONS: The enforcement of the national referral guidelines reduced the proportion of walk-ins\' admissions to KNH. While the enforcement of the national referral guidelines had no effect on the use of official formal written referral letters, it did limit access and utilization of inpatient orthopedic services for young male patients with no active insurance cover and in need of emergency orthopedic care.

BACKGROUND: Early childhood caries (ECC) is one of the most common childhood diseases affecting the primary teeth of children younger than 6 years of age. ECC progression can be reversed in the early stages although these lesions often go undetected. New approaches are needed to detect oral diseases at an early stage when they can be better controlled. The aim of the study is to assess the effectiveness of ECC tele-detection methods combined with referral pathways with and without user fee removal in controlling ECC.
METHODS: A randomized factorial trial will be used to compare two tele-dentistry detection methods for ECC (intraoral camera and smartphone camera) and two referral pathways (user fee removal versus conventional care). The study will recruit children younger than 6 years of age in marginalized communities in Alexandria, Egypt. The primary outcome is the percentage of teeth receiving indicated care, while the secondary outcomes are the oral health-related quality of life, acceptance of teledentistry by dentists, procedure time, and child cooperation. Two-way analysis of variance will be used to assess the effect of the two factors as between group variables on the outcomes after 6 and 12 months. The interaction between detection methods and referral pathways will also be assessed, and the effect of confounders will be controlled in a multivariable linear regression model.
CONCLUSIONS: The findings of this study have the potential to inform clinical practice and oral healthcare policies for ECC management. Successful tele-detection and referral pathways could be integrated into oral healthcare systems, leading to improved oral health outcomes for children.
BACKGROUND: The trial has been registered on ClinicalTrials.gov in August 2023 (initial release) ID: NCT06019884.

BACKGROUND: Implementation of the World Health Organization (WHO) recommended Advanced HIV Disease screening package, remains poor in most settings with limited resources. More than 50% of newly diagnosed-HIV clients are missed on screening as a result of implementation barriers. It is important to mitigate the existing barriers and leverage enablers\' inorder to maximize uptake of the advanced HIV disease screening. This study aimed to identify strategies for scaling up implementation of advanced HIV disease screening among newly HIV-diagnosed clients in pre-ART phase using a Consolidated Framework for Implementation Research-Expert Recommendation for Implementing Change (CFIR-ERIC) guiding tool.
METHODS: A qualitative study was conducted at Rumphi district hospital in Malawi (August - September, 2023). Two sessions of Focus group discussions (FDGs) involving key stakeholders were facilitated to identify specific strategies following the initial study on exploration of barriers and facilitators of advanced HIV disease screening package. Participants comprised healthcare providers, purposively selected from key hospital departments. A deductive approach was used to analyze FDG transcripts where emerging themes were mapped with ERIC list of strategies. CFIR-ERIC Matching tool version 1.0, was used to generate an output of the most to least expert-endorsed Level 1 and Level 2 strategies.
RESULTS: About 25 key healthcare workers participated in FDGs. Overall, 6 Level 1 strategies (≥ 50% expert endorsement score) and 4 Level 2 strategies (≥ 20%, ≤ 49% expert endorsement score) were identified, targeting barriers associated with availability of resources, intervention complexity, access to knowledge and information, communication; and implementation leads. Most of the reported strategies were cross-cutting and aimed at enhancing clinical knowledge of the intervention (distributing training materials, educational meetings), developing stakeholders\' interrelations (network weaving) as well as improving clinical workflow (environmental restructuring). Use of evaluative and iterative strategies such as monthly data collection for evaluation were also recommended as part of continuous improvement while an AHD coordinator was recommended to be formally appointed inorder to spearhead coordination of AHD screening services.
CONCLUSIONS: Through the involvement of key stakeholders and the use of CFIR-ERIC matching tool, this study has identified cross-cutting strategies that if well implemented, can help to mitigate contextual barriers and leverage enablers for an improved delivery of AHD screening package.

BACKGROUND: Little is known about the prevalence of dermatoses in \"skin-well\" geriatric Singaporeans. We aim to identify the prevalence of dermatoses and their associations within the geriatric population in Singapore, and to understand the distribution of dermatological encounters presenting to primary care physicians, and the resultant referral behaviour.
METHODS: A joint quantitative-qualitative study was performed across 8 months. Patients aged 65 years and above who visited a local polyclinic for management of non-dermatological chronic diseases were recruited. They were administered questionnaires, and underwent full skin examinations. Online surveys were disseminated to polyclinic physicians under the same healthcare cluster.
RESULTS: 201 patients and 53 physicians were recruited. The most common dermatoses identified in patients were benign tumours and cysts (97.5%), and asteatosis (81.6%). For every 1-year increase in age, the odds of having asteatosis increased by 13.5% (95% CI 3.4-24.7%, p = 0.008), and urticarial disorders by 14.6% (95% CI 0.3-30.9%, p = 0.045). Patients who used any form of topical preparations on a daily basis had higher odds of having eczema and inflammatory dermatoses (OR 2.51, 95% CI 1.38 to 4.56, p = 0.003). Physicians reported dermatological conditions involving 20% of all clinical encounters. Eczema represented the most commonly reported dermatosis within the first visit. 50% of dermatology referrals were done solely at the patient\'s own request.
CONCLUSIONS: The prevalence of dermatoses in the elderly in Singapore is high, especially asteatosis. Prompt recognition by the primary healthcare provider potentially prevents future morbidity. Outreach education for both primary care physicians and the general public will be key.
UNASSIGNED: National Healthcare group (NHG) Domain Specific Review Board (DSRB), Singapore, under Trial Registration Number 2020/00239, dated 11 August 2020.

BACKGROUND: The optimisation of patients in primary care is a prime opportunity to manage patient care within the community and reduce the burden of referrals on secondary care. This paper presents a quality improvement clinical programme taking place within an NHS Primary Care Network as part of the wider Leicester Leicestershire Rutland integrated chronic kidney disease programme.
METHODS: Patients are optimised to guidelines from the National Institute for Health and Care Excellence, by a primary care clinical team who are supported by nephrology consultants and nephrology pharmacists. Multidisciplinary team meetings take place with secondary care specialists and primary care staff. Learning is passed to the community clinicians for better patient treatment locally.
RESULTS: A total of 526 patients were reviewed under this project.The total number of referrals to secondary care which were discharged following first outpatient appointment, reduced from 42.9% to 10%. This reduction of 32.9% represents the optimisation of patient cases through this quality improvement project. Patients can be optimised and managed within the community, reducing the number of unnecessary referrals to secondary care.
CONCLUSIONS: This programme has the potential to offer significant improvement in patient outcomes when expanded to a larger patient base. Medicine management and the use of clinical staff are optimised in both primary and secondary care.

BACKGROUND: Considering the challenges of the referral system in the family physician program and the impact of COVID-19 pandemic on the performance of the relevant ministry\'s programs, it is necessary to assess the performance of the referral system. This study was conducted with the aim of investigating the performance of the family physician referral system before and during COVID-19 in Golestan province.
METHODS: The present repeated cross-sectional study was conducted on secondary data Recorded of 786,603 cases referred and cared by family physicians (including information on physicians\' and midwives\' visits, percentage of prescriptions and other information) in Golestan province from 2017 to 2022 in a census and retrospective manner. Data were collected using the reference ratio checklist and analyzed with SPSS 23 software at a significance level of less than 0.05.
RESULTS: Referral to 10 types of medical specialties and 10 indicators of family physicians referral before and during COVID-19 were investigated. The highest and lowest percentages of referrals by family physicians were belonged to the surgical (17.6%) and infectious (2%) specialists before COVID-19, and internal medicine (15.07%) and urology (3%) specialists during COVID-19, respectively. Referral due to physician\'s diagnosis increased by 19.3% compared to before Covid-19, target group increased by 0.86%, care decreased by 2.69% and reverse referral decreased by 36.1%. The amount of population covered by rural insurance, the amount of visits to midwives, the percentage of electronic appointments in the post-Covid-19 years have changed significantly compared to before.it (P-Value < 0.05).
CONCLUSIONS: The present study showed that the COVID-19 pandemic had a significant impact on family physician referral indicators, such as the process of referral to specialists, drug prescriptions, insurance coverage, one-time service population, and patient care, which can be used to eliminate the weaknesses and Strengthening the strengths of the programs being implemented in the face of possible pandemics is very useful and effective and can be used in the country. Finally, the results obtained from this research provide evidence to discuss the importance of the family physicians care and referral system in the face of special conditions for quality control in health policies.

OBJECTIVE: Ocular emergencies require immediate intervention to prevent rapid vision loss or functional impairment. The aim of this study was to determine the proportion of true ocular emergencies among patients who presented to the general emergency department with ocular complaints and were referred to the Eye Clinic.
METHODS: In a retrospective cross-sectional study in a tertiary hospital in Istanbul, patients aged 0-100 years who presented to the general emergency department with ocular complaints between January and December 2022 were included. Inconclusive diagnoses and incomplete records were excluded. Patients were divided into three groups: top eye emergencies (TE), relative eye emergencies (REE), and non-emergency eyes (NEE).
RESULTS: Among the 652,224 individuals seeking care, 9,982 (1.5%) were referred to the Eye Emergency Clinic. Of these, 2,788 (27.9%) were female, and 7,194 (72.1%) were male, with ages ranging from 0 to 98 years. TopEye Emergencies (TEE), Relative Eye Emergencies (REE), and Non-Eye Emergencies (NEE) accounted for 13%, 60%, and 27% of the cases, respectively. Common top-eye emergencies (TEE) include chemical injuries, orbital-preseptal cellulitis, and orbital fractures. Relative eye emergencies (REEs) commonly feature corneal foreign bodies, corneal erosion, and conjunctivitis. Nonemulsion eye (NEE) methods involve simple eye redness, trauma without eye involvement, and subconjunctival haemorrhage.
CONCLUSIONS: Consistent with the literature, 1.5% of patients presenting to the general emergency department had eye complaints.However, 27% of those referred to the ophthalmological clinic did not have an urgent eye condition. This is partly due to the high proportion of patients presenting to the emergency department with ocular complaints and the lack of knowledge of ophthalmological diseases by emergency physicians, leading to unnecessary referrals to the ophthalmology clinic, resulting in a loss of the workforce and reduced time allocated to patients with true ocular emergencies.

BACKGROUND: Psychiatric emergency assessment of minors can be a complex process, especially for professional staff who are not specifically trained in handling child and adolescent emergency patients. As minors cannot usually express their feelings and experiences as well as adults, it is difficult to form an accurate picture of their condition and to determine what kind of emergency care is needed, for instance whether or not a psychiatric emergency admission is necessary. We lack insight in what professionals at emergency departments need to adequately assess these minors and their families. The aim of this study was to explore staff members\' experiences with assessing minors and explore recommendations for improving their ability to provide appropriate support.
METHODS: Guided by a topic list with open-ended questions, we conducted 11 semi-structured interviews with staff working at psychiatric emergency services. Thematic analysis enabled us to identify five main themes: (1) young age and the crucial role of parents; (2) professionals\' feelings, especially uncertainty; (3) psychiatric emergency admissions and the alternatives to them; (4) regional differences in organization and tasks; and (5) options for improving care.
RESULTS: The staff interviewed all agreed that it was often complicated and time consuming to take full responsibility when assessing minors with serious and urgent psychiatric problems. Most found it difficult to determine which behaviors were and were not age-appropriate, and how to handle systemic problems during the assessment. When assessing minors and their families in crisis, this led to uncertainty. Professionals were especially insecure when assessing children under age 12 and their families, feeling they lacked the appropriate knowledge and routine.
CONCLUSIONS: Customized expertise development and improved regional embedding of the psychiatric emergency service in the child and adolescent services will reduce professionals\' uncertainty and improve psychiatric emergency care for minors.

BACKGROUND: The current Italian scenario of pediatric palliative care (PPC) services is characterized by inadequate coverage of the territory. Therefore, it is important to improve the referral of patients to the most appropriate setting (community care, general PPC, or specialized PPC) and to improve the delivery of PPC care.
METHODS: Aiming at obtaining information about the referrals to the Padua Pediatric Hospice that could help estimate the investments needed to improve the provision of care, a retrospective analysis has been carried out. The rate of proper referral and discharge, the number of patients followed at the hospice, the mortality rate, and the length of follow-up were analyzed, and, when possible, data were stratified by oncological and non-oncological diseases.
RESULTS: The analysis showed that of the 870 patients referred to the Padua Pediatric Hospice between 2008 and 2022, 76% were affected by non-oncological conditions. 82% of patients referred were taken in charge and most of the remaining patients have been inappropriately referred. The analysis showed a growing number of total referrals, which increased by 195% from 2008 to 2022. An increase in proper referrals and referrals of non-oncological patients was observed alongside a decrease in oncological patient referrals and a trend toward a decrease in discharge rates. A decreased mortality was observed in patients with non-oncological conditions, with only 6% of deceased patients in 2022. Moreover, a longer survival with a median follow-up length of 43 months was observed among patients with non-oncological conditions who were followed up at the Padua Pediatric Hospice for more than 12 months. Conversely, the short survival rate observed for oncological patients suggests that those patients should have been referred to PPC earlier to benefit from palliative care for longer periods.
CONCLUSIONS: Considering these data, it is expected that the number of patients needing PPC services will steadily increase in the next years. Hence, there is a need to invest resources to provide the best care delivery model encompassing specific pathways for the transition into adulthood, the establishment of networks within all the Italian regions, and an efficient referral to the more suitable setting of care.