The impact of a decentralised orthopaedic service on tertiary referrals in Cape Town, South Africa.

BACKGROUND:In South Africa (SA), district hospitals (DHs) have limited capacity to manage the high burden of traumatic injuries. Scaling-up decentralised orthopaedic care could strengthen trauma systems and improve timely access to essential and emergency surgical care (EESC). Khayelitsha township in Cape Town, SA has the highest trauma burden of the Cape Metro East health district.   Objectives. The primary objectives of this study were to describe the impact of the Khayelitsha District Hospital (KDH) on acute orthopaedic services for the health district with a focus on the volume and type of orthopaedic services provided without tertiary referral.  Methods. This retrospective analysis described acute orthopaedic cases and their management from Khayelitsha township between 1 January 2018 to 31 December 2019. Orthopaedic resources and the proportion of cases referred to the tertiary hospital by all DHs in the Cape Metro East health district were described.  Results. In 2018-2019, KDH performed 2040 orthopaedic operations of which 91.3% were urgent or emergencies. KDH had the most orthopaedic resources and the lowest referral ratio (0.18) compared to other DHs (0.92-1.35). In the Khayelitsha township, 2402 acute orthopaedic cases presented to community health clinics. Trauma (86.1%) was the most common mechanism for acute orthopaedic referrals. 2229 (92.8%) clinic cases were referred to KDH and 173 (7.2%) directly to the tertiary hospital. The most common reason for direct tertiary referral was condition related (n=157, 90.8%).   Conclusions. This study outlines a successful example of a decentralised orthopaedic surgical service that increased EESC accessibility and alleviated the high burden of tertiary referrals compared to other DHs with fewer resources. Further research on the barriers to scaling-up orthopaedic DH capacity in SA is needed to improve equitable access to surgical care.