Ethical considerations

University of Nairobi/Kenyatta National Hospital Ethics and Research Committee granted ethical approval (ERC No: P852/10/2021). Administrative approval was also granted by KNH Medical Research Department and KNH Orthopaedics Department.

Study design

This was descriptive qualitative study design.

Study area

KNH Orthopaedic Wards. KNH is the national teaching and referral hospital based in Upperhill, Nairobi, the Capital city of Kenya.

Data collection

Data collection was done through chart abstractions and Key Informant Interviews (KIIs).

a) Chart abstractions. Study period. Data was abstracted from patients’ charts covering 1^st February to 31^st December 2021. The data abstraction was done from 1^st January to 31^st March 2022 during the data collection period.

Study population. KNH Orthopaedic inpatient caseload admitted from 1^st February to 31^st December 2021.

Sample size. 905 chart reviews. A systematic sampling technique was used. This was part of a study that sought to determine the patterns of orthopaedic and trauma admissions at Kenyatta National Hospital.

Pilot testing. Pilot testing was done to assess the feasibility and appropriateness of the data abstraction tool to collect the data required to answer the study objective.

Data collection procedures. Data abstraction form was used to extract data from the patient files. Three (3) research assistants (2 females and 1 male) were recruited, trained on data abstraction process from the patients’ charts. The data collection was done at KNH Health Information Office. The principal investigator did data quality checks for all the abstracted data before and after data entry.

Data management, analysis. Quantitative data was analysed using Statistical Package for Social Sciences (SPSS) version 21.0 using frequencies. The qualitative data obtained from the chart abstractions were entered into excel spreadsheets and were subjected to thematic analysis using NVIVO 12 Pro. The research questions and responses from excel spreadsheets were reviewed for the identification of themes and patterns and a coding framework was developed. The coding framework and excel spreadsheet were then imported directly into NVIVO for coding. The coding process entailed going through the texts on the excel spreadsheet, dragging and dropping into correct nodes. Some codes were modified and new ones created as they came up while reviewing more spreadsheets entries. By analyzing the content of each code to check if they are correctly placed, those related to the objective of the study were noted down for summary report.

b) Key Informant Interviews (KIIs). Study period. Key Informant Interviews were done in January 2022 and the respondents shared their experiences and observations dating back from 1^st February to 31^st December 2021 period.

Study population. Key Orthopaedic and trauma staff from the 10 (ten) health facilities namely KNH, Mama Lucy Kibaki Hospital, Mbagathi Hospital, Machakos County Hospital, Mwingi County Hospital, Thika Level 5 Hospital, Ngong Sub- County Hospital, St Peters Orthopaedic Specialist Hospital, St Francis Community Hospital and Arthi River Shalom Community Hospital.

Sample size. 10 (ten) KIIs were conducted. These were purposively sampled. These were the health facilities that referred majority of patients to KNH during the study period.

Pilot testing. Pilot testing was done to assess the feasibility and appropriateness of the KII guide to collect the data required to answer the study objective.

Data collection procedures. The interviewees were medical officers and orthopaedic consultants responsible for patient orthopaedic and trauma referrals at the sampled health facilities. The interviews were interviewer-administered. The Principal Investigator (male) who is an orthopaedic surgeon conducted the interviews. The interviewees were briefed on the purpose of the study. They reviewed the participant information consent form prior to giving their written informed consent to participate in the study. The interviews were done at the sampled health facilities referral office/desk. KII interview guide was used to guide the Key Informant Interviews. The focus of the interviews was on common orthopaedic and trauma referrals to KNH, reasons for referrals to KNH, challenges, lessons learnt and their recommendations with a focus to improve orthopaedic and trauma care at their respective health facilities. The interviews lasted about 30 to 45 mins. Audio recordings were taken for each interview session and later transcribed into transcripts by one transcriber. The principal investigator went through the 10 audio recordings and the transcripts to ensure they were in verbatim and verified the accuracy of the transcription process.

Data management, analysis

Audio recordings were transcribed and subjected to content analysis using NVIVO 12 Pro. The research questions and responses from transcripts were reviewed for the identification of themes and patterns and a coding framework was developed. The coding framework and transcripts were then imported directly into NVIVO for coding. The coding process entailed going through the texts on the transcripts, dragging and dropping into correct nodes. Some codes were modified and new ones created as they came up while reviewing more transcripts. By analyzing the content of each code to check if they are correctly placed, those related to the objective of the study were noted down for summary report.

Study limitations

1. Incomplete and missing records–this was addressed by making phone calls to patients to access the required data;
2. All admissions were reviewed and therefore not necessarily focussing on admissions appropriate to KNH as a national referral health facility.
3. Recall bias–the interviewees were to recall the reasons for referrals to KNH during the review period, February to December, 2022.

Sample characteristics

The mean age was 33.8 years (SD 16.5) with range of 1–93 years. Majority 600 (66.3%) were between 25–64 years with those above 65 years being 40 (4.4%). About 453 (50.1%) were facility referrals while 452 (49.9%) were walk-ins. Majority of orthopaedic and traumatic admissions were through Accident and Emergency Department 707 (78.1%) followed by Corporate Outpatient Centre 135 (14.9%) and Orthopaedic Clinic 63 (7.0%). Of the 905 admissions 712 (78.7%) were emergency admissions while 188 (20.8%) were elective admissions (Table 1).

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Table 1. Sample characteristics (N = 905).

https://doi.org/10.1371/journal.pgph.0002323.t001

About 405 (44.8%) were casual workers, 183 (20.2%) unemployed. With regard to education level 308 (34.0%) had primary education, 317 (35.0%) had secondary education (Table 1).

The facility and patient related factors to the orthopaedic and trauma admissions at the KNH included human resource capacity and availability, health facility infrastructure, Orthopaedic equipment’s and implants availability, patient’s preference, unaccompanied patients and financial considerations among others (Table 2).

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Table 2. Table showing the frequency distribution of the major facility and patient related factors to the orthopaedic and trauma admissions at the KNH.

https://doi.org/10.1371/journal.pgph.0002323.t002

1. Human resource capacity and availability

Human resource for health is a critical pillar in WHO health system strengthening and a key component in access to health care. Quantity and quality of human resource for health determines the quality of care received. This study showed that most of the admissions to KNH were due to need for specialized orthopaedic and trauma surgeons to handle orthopaedic (spine and pelvic injuries) and other injuries including polytrauma patients. This compares with studies done on reasons for inter-hospital transfer of trauma patients that revealed that severely injured trauma patients and those with pelvic injuries are likely to be transferred to advanced trauma centres for management and for better outcomes [9–12]. The advanced centres are presumed to have well trained personnel with relevant experience to handle complicated cases. This reinforces studies that revealed limited staff capacity at the peripheral facilities necessitates surgical referrals in low- and middle-income countries [13–18]. Most of these polytrauma patients require multidisciplinary team for effective management and this is usually not available at the peripheral facilities.

2. Patients’ preferences

Patients’ preferences refer to patients’ values, beliefs, expectations and health goals that influences their health choices and health facility choices as well. This study did reveal the role of family, friends and the society at large in health seeking behaviour of orthopaedic admissions.

The study did show that some patients, their families, relatives and friends opted to go to KNH or be referred to KNH from other health facilities due to personal reasons, and preferences. For some patients, either themselves or their relatives have been treated at KNH before and had good experience and outcome and ended up encouraging their loved ones and friends to seek services at KNH. This compares favourably with a study done in Israel indicated that about 33% of patients seek second opinion on recommendation of a relative and/or friend [18, 19]. However, this contradicts a review done in Northern Tanzania that showed patients preference accounts for about 1% of surgical patient’s referral to a Tertiary health facility [18]. A systematic review of factors patients consider in choice of a surgeon reveal that hospital reputation, rather than surgeon’s reputation, was of primary importance and most patients relied on word-on-mouth and physician preference to decide the hospital of choice [20].

3. Financial constraints

Personal finance is key factor in the choice of a hospital with patients of high socio-economic status and with insurance cover opting for high -end private health facilities while patients of low-socio-economic status and mostly with no insurance cover opting to seek services in government health facilities.

This study did show that for a significant number of admissions, the referral was done because of financial constraints since they could ill afford the private health facilities, they were in. In addition, most of the private health facilities would require additional financial top ups in addition to the NHIF cover while others would outrightly reject the NHIF cover due to its low financial allocations for orthopaedic procedures. A number of private orthopaedic patients were advised by their doctors to seek care at KNH because of their relative affordability and ability to make use of the NHIF cover to sort their medical bills, given that most of the admissions are not well-endowed financially.

4. Orthopaedic equipment and implants availability

Equipments, supplies are another WHO building block for effective health service delivery. Orthopaedic equipment’s, sets and implants are generally costly and require significant capital outlays. Availability of Orthopaedic equipment’s, sets and implants are key to management of orthopaedic patients. Given the level and the nature of health care financing in Kenya, most health facilities—both government and private—are not able to acquire and maintain these equipment’s.

KNH being a premier referral facility in the country is believed to be well resourced and therefore best equipped in this regard including CT scans, MRI and X-rays to manage diverse and complicated orthopaedic conditions compared to the peripheral health facilities. This compares with a qualitative study done in Uganda that revealed unavailability, non-functional or intermittent functioning of imaging facilities like CT scan, MRI that hindered surgical service provision [14, 18]. This also compares with a study done in Muhimbili National Hospital in Tanzania that revealed lack of equipment as the main reason for referral to the Tertiary facility [21]. Similar studies done in Kenya, Uganda, Tanzania, Rwanda and Ghana revealed infrastructure gap at the peripheral health facilities necessitated referrals to tertiary health facilities [22].

5. Health infrastructure

Health Infrastructure is one of the WHO pillars of health system strengthening and provides the structural framework for provision of health care. It refers to availability of health amenities, adequate ward, theatre rooms, physiotherapy, occupational therapy spaces for Orthopaedic and Trauma and Rehabilitation service provisions. Poor infrastructure means compromised health service delivery.

Orthopaedic patients were also referred or self-referred to KNH because of the unavailability of bed space and poor facilities to handle and perform orthopaedic operations. This compares with a prospective study done in Aga Khan University Hospital in Kenya that revealed bed availability was one of the commonest reasons cited for referral [23]. Similar studies in Uganda, Rwanda have shown inadequate health infrastructure with limited ward and theatre capacity hinders provision and access to surgical services [14–16, 18]. The operating rooms are shared by other surgical specialities and most often overburdened by urgent obstetric cases that often lead to planned orthopaedic operations delayed or postponed due to the urgent obstetric procedures. This effectively means reduced operative capacity for orthopaedic procedures. Some of these public health facilities in addition to limited operative capacities also lacked ICU or HDU capacities to handle polytrauma patients with neurosurgical complications.

7. Proximity to KNH

Geographical distance is a key consideration for choice of a hospital. Long distance travel has financial implications but also it is not convenient for friends, relatives and family of the patients who seek to visit and take care of them seek ones.

A number of admissions were either brought or came to KNH because it was the nearest facility from their residence or from the scene of the accident; the paramedics decided to rush them to KNH being the nearest government hospital that’s is affordable. For some, they had relatives in Nairobi and so it was easier for the relatives to monitor them. This compares favourably with a systematic review of factors patients consider in choice of health provider that revealed hospital distance was of primary importance in choosing facility of choice [20, 24].

8. Unaccompanied

Unaccompanied means that these are admissions that were brought in by good Samaritans or police officers and not relatives as unconscious and not much was known about them at the time of admission. They were victims of road traffic accidents, assaults or mentally ill patients that sustained orthopaedic related injuries. The polices officers, the good Samaritans are normally the first responders at the scene of accident and most of them make the decision to refer the patients to KNH either due to financial considerations given KNH is a government facility or due to proximity to KNH given that majority of the RTAs occur within Nairobi County. The unaccompanied and unconscious patients at the scene of accident are deemed to have serious injuries. This compares with studies that showed Police officers are usually the first responders at the scene of accident [26, 27]. Similarly a study done on post-crash emergency care in India showed good Samaritans and police officers referred about 90% post-crash victims to government hospitals as the first contact health facility [28].

6.2.1 Recommendations to County Government

1. Ensure availability of accessible and high-quality orthopedic and trauma health services at the lower tier health facilities;
2. Provide regular supportive supervision and capacity building of county health facilities on the referral system;
3. Allocate more resources to human resource for health for recruitment of more orthopaedic and trauma surgeons and also fund training for more specialized orthopaedic speciality including pelvic and spine specialities;
4. Improve the health infrastructure and operative capacity of peripheral facilities to be able to handle orthopaedic and trauma cases;
5. The high cost of Orthopaedic sets and implants is an impediment to orthopaedic care. The government to consider subsiding the cost of orthopaedic equipment’s, sets and implants to reduce the overall cost of orthopaedic procedures and make it more affordable and accessible;