At each level of health care infrastructure,

there is need for support from higher level of

infrastructure and also from secondary &
tertiary level hospitals to strengthen and
promote credibility of primary health care
system
 “Referral system is defined as a system of
transferring cases which are beyond the
technical competence of one infrastructure to a
higher level infrastructure/ institution having
technical competency and all other resources to
provide desired health services”
 The referral system is vertical in nature. • The
cases can be referred from village health post to
SC/PHC, from SC to PHC/CHC and from
PHC to CHC/secondary or tertiary level
hospital and from CHC to secondary or tertiary
level hospital.

 Provision is made for bypassing 1 or 2 level
depending upon the nature and seriousness of
cases so that required medical and nursing care
can be given on time to the case and mortality
and morbidity can be prevented and
controlled.
 SUPERSPECIALIST HOSP

TEACHING HOSPITAL

DISTRICT HOSPITAL

CHC

PHC

SUB CENTER

CHW (ANM, ASHA,VHG etc.)

 • To provide need based comprehensive care
within the technical competencies & resources
at each level of primary health care
infrastructure efficiently and effectively.
 • To help people avail specialized services
available at higher level institution which are
beyond their reach.
 • To streamline the appropriate use of PHC
infrastructure and specialized services in order
to prevent overloading of specialized
institution by direct uses.
 • Well trained required number of
professionals, medical equipment & supplies,
organization structure etc.
 • Continuing training, guidance & supervision
of community health workers.
 • Guidance on sanitary measures & to
disseminate information on disease control
methods.
 • Conduct health education sessions.
 • Provide logistic supports in terms of
equipment & supplies required at PHC.
 • Establish liaison & functional relation with
other sectors involved in social and economic
development.
 • Organize transportation facilities for cases to
be referred.
 THE REFERRAL HOSPITAL AT SECONDARY
& TERTIARY LEVEL NEED TO:
 • Provide specialized clinical outpatient &
inpatient care continuously.
 • Back up primary health care system by
providing PH care messages/teaching.
 • Discourage people attending OPD’s directly
i.e. to attend OPD when they have referral
card/letter or a genuine emergency.
 Act as teaching centre for health professionals
including community health workers.
 • The very serious patient requiring immediate
medical care & treatment.
 • Patients presenting serious signs &
symptoms. He/she may not be sick but
requires immediate referral.
 • When special diagnostic procedures are
required for diagnosis.
CASES REQUIRING IMMEDIATE CARE THE
CASES WHO MAY REQUIRE IMMEDIATE
REFERRAL ARE AS UNDER:
 • Cases presenting any problem which cannot
be handled during pregnancy, labor and post
natal period.
 • Severe diarrhea with dehydration or not
responding to treatment.
 • Pain in abdomen and vomiting with or
without presence of bowel sounds.
 • Heart burn, dyspepsia, dysphagia,
haemetemesis and maleana etc.
 • Continuous cough with or without sputum,
haemoptysis.
 • Fever with stiff neck.
 • Fever not responding to treatment.
 • Fever with severe joints pain, rashes,
bleeding under the skin.
 • Breathing difficulty while walking, sleeping,
doing physical work.
 • Chest pain with/without pain in the left arm,
restlessness and vomiting.
 • Jaundice, loss of appetite.
 • Convulsions with fever.
 • Coma, paralysis, fracture, severe injury,
hemorrhage, poison etc.
 • Beneficial to patients because they receive effective
care at the primary level which is near to their home.
 • Beneficial to health workers because they are able to
take care of patients which are within their level of
competence and are not frightened to handle difficult
cases because they can refer them to higher level
centers and referral units.
 Beneficial to management because it is economical as
highly trained and highly paid doctors, nurses and
other professionals take care of patients with serious
and complex problems at higher level referral unit and
patients with simple and minor problems are taken
care at much low cost by health workers at lower level.
 • Observe and collect information about the
illness, trauma, related situation, factors etc.
 • Identifies the nature of illness/emergency
and its seriousness.
 • Provides immediate treatment care within
her competence, standing orders and resources
available.
 • Assures the casualty/family members/ any
other person accompanying.
 • Explains about the seriousness of the
problem situation and need for reference to the
casualty.
 • Fills up the referral form as desired and
hands over the same with related documents to
be given to health professionals in referred
health center.
 • Arranges for transport of the patient
according to feasibility as soon as possible.
 • May do the telephonic consultation or
provide information to referred health center.
 • May accompany the casualty/patient if
required and feasible.
 • Maintains the records and reports.
 • Provides follow up care as per treatment and
instructions prescribed by the referral unit.