Quality and Clinical Appropriateness of Pediatric Referrals to the Emergency Pediatric Unit at Edward Francis Small Teaching Hospital, The Gambia: A Cross-Sectional Study

Background: Effective referral systems are essential for continuity of pediatric care, yet referral documentation in low-resource settings is often incomplete. This study assessed the quality, completeness, and communication gaps of pediatric referrals to the Emergency Pediatric Unit (EPU) at Edward Francis Small Teaching Hospital (EFSTH) and evaluated their association with early clinical outcomes. Methods: A descriptive cross-sectional study of 100 pediatric referrals received at the EPU between April and June 2025 was conducted. A seven-point scoring system assessed referral completeness and appropriateness across seven domains: patient details, clinical information, investigations, treatment given, facility details, justification, and correctness of destination. Outcomes within 24 hours (admission, discharge, death) were analyzed alongside communication gaps, facility level, referring personnel, and patient condition on arrival. Statistical significance was set at p < 0.05. Results: The mean referral quality score was 4.05 ± 1.29. Only 13% of referrals were of good quality, 56% were fair, and 31% were poor; none were fully complete. Although 96% provided a clear reason for referral, major documentation gaps included missing investigations (75%) and incomplete clinical information (54%). Secondary facilities contributed most referrals and had the highest rate of missing investigations (81.3%, p = 0.005). Referral quality differed significantly by referring personnel (p = 0.048), with paediatric consultants providing the best-quality referrals. Lack of instructions from referring facilities (p = 0.023) and missing referral timing (p = 0.001) were both significantly associated with poorer outcomes. Level of consciousness on arrival strongly predicted outcomes (p = 0.006). Conclusion: Pediatric referral quality to the EPU was generally suboptimal, with critical documentation and communication gaps across all facility levels. Although overall referral quality was not directly associated with 24-hour outcomes, specific gaps—including missing instructions and poor referral timing—were linked to worse outcomes. Strengthening referral systems, standardizing forms, enhancing communication, and improving training for all healthcare cadres are urgently needed.