Nigerian Journal of Paediatrics

4Current referral practices and adolescent transition to Adult clinic Setting an agenda

Niger J Paediatr 2016; 43 (2): 83 – 87

ORIGINAL

John C

Current referral practices and

Ocheke IE

Okpe ES

adolescent transition to Adult

Ige OO

clinic: Setting an agenda

Yilgwan C

Ejeliogu E

DOI:http://dx.doi.org/10.4314/njp.v43i2.4

Accepted: 2nd February 2016

Abstract : Background: The goal

Inter-departmental referral/transfer

of adolescent transition from child

was through use of referral notes

John C

(

)

to adult care services is to provide

(96.8%), or involved one-on-one

Department of Paediatrics,

uninterrupted, coordinated and

discussion (81.0%). Most referred

University of Jos,

Jos, Nigeria

developmentally

appropriate

patients are managed independ-

Email: cchibunkem@yahoo.com

health care as transfers are made

ently (64.2%), or may involve

from paediatric to adult clinics.

clinical conference (30.8%) and

Ocheke IE, Okpe ES, Ige OO

Adolescent transition practices are

grand rounds (31.2%).

Yilgwan C, Ejeliogu E

available but not in Nigeria.

Adolescent referral is through re-

Department of Paediatrics,

This study was carried out to de-

ferral notes (92.3%) with formal

Jos University Teaching Hospital,

termine current practice of patient

discharge (81.6%). Discussions

Jos, Nigeria

referral and adolescent transition

before transfer with the adolescent,

practice.

and the relatives, occur frequently

Methodology: The study was a

(91.6% & 92%). Discussions with

cross sectional studies among

the receiving physician, adoles-

paediatricians attending the an-

cents and caregivers occurs much

nual paediatric conference, using

less (37.8%). No written referral

a self-administered questionnaire.

policies were available (86.1%)

Result: A total of 80 respondents,

and no existing policy with adoles-

33 consultants and 47 paediatric

cents

transfer

was

available

residents were involved. Females

(66.2%). Mean age of transfer was

were 41 (51.2%) and 39 (48.8%)

16.8±1.8years (range 12-20years);

were males. Mean duration of

this was determined by hospital

practice was 12.5±0.75 (range 2-

(72.9%) or department (71.9%).

20years). Most respondents prac-

Informed consent usually re-

tice in urban centre, 91.2%; in

quested before transfer(90.7%).

public hospitals (96.2%) and

Most respondents, (97%), see re-

many attend to adolescents (80%).

fused transfer or returning clients.

Most practice intra-departmental

Possible reasons for refusal of

referral (96%) done through ver-

transfer are fear (90%); difficulty

bal communication (46.4%); re-

with new treatment relationship

ferral notes (92.8%); or through

(89.1%); and physician attitude

clinical

conference

(21.9%).

(61.7%).

Feedbacks

were

occasional

Conclusion: Little or no guidelines

(76.7%) or maybe verbally given

exist and a robust adolescent tran-

(61.4%).

sition protocol is required.

Introduction

with the healthcare system and providers can be particu-

larly problematic for those with serious chronic diseases.

Transition has been defined as the “purposeful, planned

The fate of older adolescent patients in paediatric clinics

movement of adolescents with chronic medical condi-

is either one of transfer to adult services, long term

tions from child-centered to adult- oriented health care.”

retention in the paediatric clinic, or discharge from

medical supervision, either voluntarily or by neglect .

The goal of transition is to provide health care that is

uninterrupted, coordinated, and developmentally appro-

Most patients need an efficient and gradual transition

priate and psychologically sound before and throughout

from paediatric to adult services. Change from paediat-

the transfer of youth into the adult system . For young

ric to adult healthcare systems is difficult not only for

people, poor adherence with treatment and disaffection

those with chronic disease but even for normal young

people.

sition to adult care policies and programme as we pay

As management capabilities improve, more adolescents

greater emphasis on adolescent medicine in Nigeria.

with chronic illnesses are surviving longer and ulti-

mately transiting to adult care.

While paediatric care is family focused, relies on devel-

opmentally appropriate care with significant parental

Methodology

involvement in decision-making and care provided with

in a multidisciplinary team, adult care is patient focused

The study was cross sectional and descriptive among

and investigational, requiring autonomous, independent

paediatric consultants and residents. A self-administered

consumer skills without many interdisciplinary re-

semi structured questionnaire was used in data collec-

sources.

tion. Information collected included age, sex, years of

practice, place of practice, subspecialty and designation.

A concerted effort therefore, must be made by the pae-

Current practice of referral and adolescent transition

diatrician based on prevailing circumstance to offer the

care was assessed using YES or NO question format and

most beneficial and appropriate method to the transiting

a few fill in the blanks.

adolescent. Transition must be individualised, designed

according to the illness the child is being managed for

Study Area and Population

and should include close collaboration with the adult

physician.

Study area was Nigeria paediatric care practice. All con-

senting paediatric consultants and resident doctors in

Adult health care differs significantly from paediatric

Nigerian hospitals as well as visiting paediatrician from

care in the type and level of support, decision-making,

other countries attending Paediatric Association of

consent processes and family involvement. These factors

Nigerian Conference (PANCONF) 2014 formed the

may play a role in the decrease follow- up visits by ado-

study population.

lescent patients after transfer to the adult care system.

Some authors believe that this decline is, in part, attrib-

Sample size

uted to the lack of transition planning and insufficient

coordination with adult services

All consecutively returned forms from participants at the

2014 PAN AGSM in Calabar Cross River state were

Some countries and paediatric associations have made

included.

deliberate effort at defining and putting in place meas-

ures to ease transition. In 2002, the American Academy

Data collection and analysis

of Pediatrics (AAP), the American Academy of Family

Physicians (AAFP), and the American College of Physi-

Data collected was entered into excel sheet and analysed

cians (ACP) issued a joint statement that defined spe-

using Stata 12SE statistical software. Frequency distri-

cific steps for ensuring an effective transition. These

bution tables were generated for the entries.

include having a primary care provider with responsibil-

A p value of <0.05 was considered statistically signifi-

ity for transition planning, incorporating the necessary

cant.

knowledge and skills to provide developmentally appro-

priate health care transition services, maintaining an up-

to-date portable medical summary, creating a written

health care transition plan by age 14, implementing rec-

Result

ommended preventive service guidelines, and ensuring

General characteristics

continuous health insurance coverage.

A transition programme can only succeed with the ac-

Eighty questionnaires were filled and returned out of

tive participation and interest of the staff in the adult

200 sent out. Of these 33 (41.2%) were consultants and

clinic, which face the challenge of matching the level of

47 (51.8%) were paediatric residents. There were 41

family support and rapid staff response that are features

(51.2%) females and 39 (48.8%) males. Mean duration

of most paediatric services. The paediatrician would be

of practice was 12.5±0.75years with a range of 2-20

the anchor man in such a process.

years. Consultants have mean years of practice of

16.9±6.0years while the residents have 9.4±5. 2 years.

Young people who require continuing healthcare into

Most of the respondents, 91.2% (73/80), practice in ur-

adulthood have generally been transferred from paediat-

ban setting. The rest have their practice in rural/

ric services at a time of great change in their lives, both

suburban places. Of the respondents, 96.2% (77/80) are

physical and emotional. While in some climes, effective

in public practice while 3.8% (3/80) are in private

transfer policies have been put in place with transition

practice.

processes beginning as early as 13years. There is no

known documented report of transition care services in

Out of the 80 respondents, 61.2% (49/80) work in

any Nigerian hospital or institution.

Teaching Hospitals, 26.2% (21/80) in specialist hospi-

It is therefore the objective of this paper to review the

tals, 6.2% (5/80) general hospital and the remaining

current practice of patient referral and adolescent transi-

work in private hospitals, federal agencies and non-

tion care and set a template for the development of tran-

governmental organisation.

Over 80% of the respondents see adolescent patients in

Table 1: Relevance of SOP

their practice. Percentage of adolescents seen range from

Relevance of SOP

Agree

Disagree

Total

2-70% of patients seen. Nearly all (98.8%) have co-

(%)

managed patients with other specialities and subspecial-

Minimize lost to follow up

69 (97.2)

2 (2.8)

71 (100)

ties.

Ensures continuity of care

73 (98.6)

1 (1.4)

74 (100)

Addresses psychosocial challenges

65 (97.0)

2 (3.0)

67 (100)

Affords all inclusive care

67 (97.1)

2 (2.9)

69 (100)

Patient referral practices

Window of opportunity for further

61 (93.8)

4 (6.2)

65 (100)

input

Intra-departmental patient referral and feedback

Most respondents, 96%, are involved in patient referral

Age at referral to adult clinic and reason for choice

within the department. Patient referral is done either by

verbal communication with the desired subspecialty in

Mean age at transfer to adult clinic was 16.8±1.8years,

46.4% (26/56), relayed information to caregivers 55.8%

range 12-20years. Male physicians refer at slightly later

(30/56), written note to the new team, 92.8% while

age

than

female

physicians

17.2±1.8years

and

21.9% of respondents will have a clinical conference

16.5±2.0years respectively, p=0.12.

with the new team.

The age at transfer is determined by the either hospital

Feedback during such referral is received verbally in

practice (72.9%) or departmental policy (71.9%). This is

61.4%. Significant numbers of responders (76.7%) says

shown in Table 2

feedback maybe occasional.

Table 2: Determinant of age of transfer to adult clinic

Inter-departmental referral and co-management

Determinant of transfer

Yes (%)

No (%)

Total (%)

Most respondents (96.8%) stated referral was done

Hospital policy

43 (72.9)

16 (27.1)

59 (100)

through written notes. One on one discussion takes place

Departmental policy

41 (71.9)

16 (28.1)

57 (100)

significantly (81.0%) during referral. Referred patient

WHO/UNICEF

26 (49.2)

28 (51.8)

54 (100)

are however managed independently in 64.2% of cases

Body size

4 (8.3)

44 (91.7)

48 (100)

Inadequate manpower

4 (8.7)

46 (91.3)

50 (100)

while regular clinical conference occurs in 30.8% of

Infrastructural need

10 (21.3)

47 (78.7)

57 (100)

clinical scenario and ground rounds occur in about

31.2% of cases.

Informed consent prior to referral and refusal of

referrals

Transition to adult clinic

Adolescent referral to adult clinic

Most (90.7%, 59/65) will request consent from the ado-

lescent before referral. A few (29.2%, 14/48) will make

Written notes are utilized during transfer to adult clinic

do with parental consent. Consent may not be sought for

by 92.3% (48/52) of respondents and formal discharge

by 21.7% (10/46) of respondents while 26.8% (11/41) of

from originating department occurs greatly, 81.6%

respondents may take a unilateral decision to refer.

(40/49). Formal/informal discussion with patient rela-

Most respondents (97% 53/57) have seen adolescents

tives occurs frequently 92% (47/51). In the same vein,

who refused referral to adult clinic or returned after re-

91.6% (44/48) of respondents will discuss with the ado-

ferral. The reasons for this are as shown in the table 3

lescents and his caregivers before referral. Only 37.8%

below.

of physicians will engage all parties (caregivers, patient

and receiving clinicians) in a discussion before referral

Table 3: Reasons for refusal of referral to adult clinic

and 50% of the attending clinicians may discuss with

only the adolescent. A few (11.9%, 5/42) may make no

Reasons given

Yes (%)

No (%)

Total (%)

formal input before referral.

Fear of the unknown

47 (90)

3 (10)

50 (100)

Adult Physician attitude

29 (61.7)

18 (38.3)

47 (100)

Transfer policy and standard operating procedures

Uncertain of level of care

42 (85.7)

7 (14.3)

49 (100)

Inadequate preparation

23 (54.8)

19 (45.2)

42 (100)

Inability to start new care

41 (89.1)

5 (10.9)

46 (100)

Among the physician respondents 86.1% (62/72), there

relationship

is no written policy on patient transfer. Of those with

Inconvenient appointment

15 (38.5)

24 (61.5)

39 (100)

written policy 90% are in teaching hospitals.

days

For adolescent referrals, there are no written policy

(66.2%) for referral and no standard operating proce-

dures (SOP). Most agree on the relevance of SOP

(98.6%).

The relevance of SOP agreed to by respondents is as

Discussion

shown in table 1. Most agree on its usefulness.

This study highlights the current practice of paediatri-

cians with patient referral both within and outside the

department. It also highlights the current mode of ado-

lescent to adult care transition practice.

Practically all respondents do intra-departmental refer

ral, a practice that engenders better patient management,

the same process of referral using referral notes and

allowing experts to bring to bear their experience and

most are formally discharged. The process also involves

skills in the management of the index patient. Ringberg

some discussion with the adolescent but not in all cases

et al, noted that referring a patient to secondary care in

of referral. In this study, it was observed that not all par-

order not to overlook anything is a common and legiti-

ties such as the primary care givers and receiving physi-

mate reason for referral. High referrers report that about

cians are involved in a discussion before a referral proc-

one-third of their referrals were carried out to avoid

ess begins. Exclusion of the adolescent from referral talk

overlooking anything, compared with only 11.9%

may make it much difficult for the adolescent to form

among low referrers. The results revealed a reduced

long lasting clinical relationship with his/her new man-

agement team.

tolerance for uncertainty among high referrers. This is in

keeping with best practices in patient management.

The mode of referral observed in this study varies

This study shows that there are no guiding policies or

among physicians with some referral been done via ver-

standard operating procedures for adolescent transfer to

bal communication but significantly via written notes.

adult clinic. This is different from what is obtained in

other climes where guidelines exist. Most respondents

Traditionally, referring clinicians obtained input from

specialists by either sending patients for in-person refer-

agree on the necessity of such policies or SOP. The

rals or through “curbside consultations”— that is, con-

SOPs are thought to be an avenue to minimize lost to

versations that occurred between the two physicians

follow up in adult clinic, ensuring continuity of care,

about patients when they met in the hospital hallway or

addressing psychosocial challenges and providing for an

cafeteria, or by telephone. Curbside consultations is

all-inclusive care processes. It is believed that a well-

initiated for a variety of reasons, including the perceived

executed transitions can improve outcomes and patient

reliability of an expert's opinion, urgency, cost, timeli-

satisfaction, decrease costs, and ensure that patients un-

derstand how, when, and where to seek help.

ness, accessibility, convenience, fear of malpractice liti-

gation, reassurance, desire for an academic discussion,

and autonomy . Referral notes are common practice but

The necessity of a SOP is further strengthened when the

may be marred by inadequacies such as inadequate con-

varying age of referral to adult clinic is considered. In

tent and lack of timeliness.

the present study, adolescent referral age ranges from 12

-20years with a mean age of 17years. This is close to the

There are few clinical conference/inter-departmental

16years age of referral adopted by the Royal Children’s

meetings taking place during referral as observed in this

hospital, although a consideration is in place for an offi-

cial cut off age of 19years. The age of transfer in our

study. This kind of meetings enable both teams to

clearly understand the purpose of the referral, define

observation was governed by departmental as well as

expectations and clear grey areas/differences if need be.

hospital policies while in few instances infrastructural

This practice underscores important components of the

deficiencies influenced the process. The timing of trans-

models of team health care practices especially the coor-

fer depends on physical and psychological factors and

18, 20

dinated, multidisciplinary and interdisciplinary mod-

the developmental readiness of the adolescent

and

els . This practices may be occurring in our settings but

not by undefined criteria. For speciality clinics without

they are not clearly defined. Work schedule and time

transition programmes, transfer of patients often hap-

maybe a particular hindrance to achieving this mode of

pens in a haphazard and idiosyncratic fashion. Common

communication in patient management. A clinical meet-

precipitants for transfer are leaving school, crises such

as pregnancy or a suicide attempt.

ing involving the patient/caregiver and management

team will be beneficial for continuity of care.

Many physicians do not understand why a patient is

The problem with poorly planned transfer is the high

referred but will be able to do so if clear communication

rate of lost to care and return of transferred patients

among others. Most paediatricians have encountered

takes place. An effective referral requires feedback.

This however seems not to be the case as our findings in

children who refused or returned after transfer. Some of

this study show, with a significant number of physicians

the reasons for this ‘failed’ transfer include fear, uncer-

stating they do not get feedback or that feedback is only

tainty, attitude of doctors, difficulty with starting new

relationship and poor preparation. While this is the

occasionally received. This poor feedback practices is

not peculiar to Nigeria as other studies in Saudi Arabia

finding in this study; difficulties exist with transferring

adolescents with special health care need.

showed. Abdelwahid et al noted that 53% of consult-

ants gave incomplete and poor feedback while Jarallah

For adolescents with chronic diseases, transition is a

observed that 81% of the feedback were inappropriate.

very important period requiring not only medical, but

Although a referred patient may no longer return to the

also psychological and social support, which should

primary physician, the outcome of the referral is cer-

begin on the day of diagnosis. Lack of coordination be-

tainly useful for improved care of patients with similar

tween paediatric and adult units, resistance of the ado-

problems.

lescents and their families, and lack of planning and

institutional support as well as receive conflicting advice

Adolescent care services

regarding chronic illness management are some of the

hardships that can be encountered during transition.

20, 23

Over 80% of respondents encounter adolescent patients

ranging from 2-70%. Most adolescents are referred in

Conclusion

lescents with chronic disorders need to take up this

challenge and develop working guidelines and docu-

In conclusion, it is obvious that we have no transition

ments to make adolescent transition to adult care centres

care practice in place and no guidelines to the establish-

smooth and without burden to the adolescents and his

ment of such practice. This therefore requires concerted

caregivers.

effort by paediatricians to interface with their adult

physicians to develop such a framework within the con-

Conflict of interest: None

text of existing best practices and institutional capabili-

Funding: None

ties. Various subspecialties in paediatrics managing ado-

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