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

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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. Pediatric referrals documentation quality emergency care inter-facility transfer communication gaps The Gambia Introduction Efficient referral systems are critical for timely, appropriate healthcare delivery, especially in low-resource settings where tertiary hospitals serve as hubs for critically ill patients( 1 , 2 ). A functional system ensures patients are treated at the correct level of care, facilitates continuity through accurate documentation and clear communication between providers, and enables timely transfer with essential clinical information( 1 , 3 ). In The Gambia, the healthcare system operates at three tiers—primary, secondary, and tertiary care( 4 )—with EFSTH in Banjul serving as the national tertiary referral center for pediatric emergencies. Referrals to EFSTH’s EPU originate from primary health centers, district hospitals, and private clinics( 5 ). Many of these facilities, especially in rural and peri-urban areas, face shortages of specialized staff, equipment, and resources, which can compromise pre-referral stabilization and documentation quality( 6 ). Referral letters remain the standard tool for transferring patient information between facilities. A complete referral should include patient identifiers, details of the referring provider, the reason for referral, relevant history, examination findings, and results of investigations already performed. The World Health Organization (WHO) recommends that referral forms clearly outline the patient’s clinical status, treatment provided, and the names of both the sending and receiving facilities, and that referral registers be maintained for traceability( 6 ). Counter-referrals are equally important, ensuring feedback to the referring facility for follow-up care( 7 ). However, in many low-resource settings, referral quality is undermined by incomplete documentation, lack of pre-transfer communication, inadequate stabilization, and unreliable transport. Studies from India and other countries have shown that pediatric referrals frequently arrive without prior notification, proper records, or appropriate pre-transfer care, leading to treatment delays and adverse outcomes( 8 ). Globally, general practitioners—often the first point of contact for children—face referral decision challenges influenced by time pressure, limited pediatric training, and parental expectations( 9 ). Rising demand on emergency departments has intensified the need to evaluate referral appropriateness and strengthen referral pathways( 10 ). Despite EFSTH’s central role in pediatric emergency care, there is limited evidence on the quality and completeness of referrals it receives. This study evaluates the completeness, appropriateness, and timeliness of pediatric referrals to the EPU, identifies factors influencing referral quality, and examines their association with short-term patient outcomes. Findings aim to inform targeted interventions to strengthen referral protocols, improve inter-facility communication, and enhance pediatric emergency care in The Gambia. METHODOLOGY Study Design A descriptive cross-sectional study was conducted. Study Setting The study took place at the Emergency Pediatric Unit (EPU) of Edward Francis Small Teaching Hospital (EFSTH), the main tertiary referral hospital in Banjul, The Gambia, from April to June 2025. Study Population The study included all pediatric patients aged 1 month to 15 years who were referred to the EPU from other healthcare facilities during the study period. Inclusion Criteria Referred patients arriving at the EPU with a referral form or documented referral information. Patients aged 1 month to 15 years. Exclusion Criteria Patients presenting directly without a referral. Patients aged less than 1 month. Sample Size and Sampling Technique The sample size was calculated based on the estimated number of pediatric referrals during the study period. A convenient sampling method was used to select referred cases for review. Data Collection Data were collected using three approaches: Referral form and hospital record review – to assess completeness and appropriateness. Caregiver interviews – to determine referral delays and challenges encountered. Key informant interviews – with healthcare providers at referring facilities to identify barriers to effective referrals. Referral forms were assessed using a structured seven-point scoring system covering key documentation and appropriateness domains. Data Analysis Data were entered and analyzed using SPSS version 20. Descriptive statistics summarized findings, including the proportion of complete versus incomplete referrals. Referral appropriateness was assessed based on predefined clinical criteria. Associations between referral quality and short-term patient outcomes were examined using chi-square tests and logistic regression, with a significance threshold set at p < 0.05. RESULTS A total of 100 referral cases to the Paediatric Emergency Unit (EPU) at Edward Francis Small Teaching Hospital (EFSTH) were analyzed. A seven-point scoring system assessed referral quality based on completeness and appropriateness of the following: (1) patient details, (2) clinical information, (3) investigations, (4) treatment before referral, (5) referral facility details, (6) justification of referral based on clinical findings, and (7) appropriateness of referral destination. Quality and Completeness of Referrals The overall mean referral quality score was 4.05 ± 1.29, with scores ranging from 1 to 6. Among the referrals, 13 (13%) were classified as good quality (score 6–7), 56 (56%) as fair (score 4–5), and 31 (31%) as poor (score 0–3). Notably, all referrals (100%) were considered incomplete in documentation. The referral reason was clearly stated and justified in 96 (96%) cases, while 4 (4%) lacked clarity or justification. Referral Quality and Outcome within 24 Hours Within 24 hours of arrival, 91 (91%) patients were admitted, 6 (6%) discharged, and 3 (3%) died. The mean referral quality score was highest among admitted patients (4.12 ± 1.30), compared to discharged (3.33 ± 1.21) and deceased patients (3.33 ± 0.58). This difference was not statistically significant (p = 0.219). Duration of Referral and Quality Most referrals (81%) arrived within 1–4 hours, with a mean quality score of 4.09 ± 1.28. Referrals arriving in 4–8 hours (15%) had a mean score of 4.07 ± 1.10. Referrals with unspecified duration (4%) had a lower mean score (3.25 ± 2.22). These differences were not statistically significant (p = 0.453) Level of Referring Facility Most referrals came from secondary facilities (74%), which had a mean quality score of 4.09 ± 1.14. Tertiary-level referrals had the lowest mean score (3.80 ± 1.87), while private clinics had the highest (4.80 ± 0.84). Differences were not statistically significant (p = 0.354) Referring Personnel Doctors accounted for 83% of referrals, with a mean referral quality score of 4.14 ± 1.26. Paediatric consultants (3%) had the highest quality scores (4.67 ± 0.58), while assistant physicians (2%) scored lowest (3.50 ± 0.71). The difference was statistically significant (p = 0.048). Communication Gaps and Clinical Outcome The most frequent communication gaps were missing investigations (75%), incomplete clinical history or vitals (54%), and poor road access (93%). Absence of referral timing (23%) was significantly associated with discharge within 24 hours (p = 0.001), while lack of instructions from the referring facility (38%) correlated with poorer outcomes (p = 0.023) (Table 1). Table 1: Communication Gaps and 24-hour Outcomes Communication Gap N % Admitted (%) Died (%) Discharged (%) P-value Incomplete history/vitals 54 54 85.2 5.6 9.3 0.079 Missing investigations 75 75 88.0 4.0 8.0 0.192 Lack of referral timing 23 23 0 0 100 0.001 Language barrier 1 1 100 0 0 0.951 Lack of instructions 38 38 81.6 7.9 10.4 0.023 Poor roads 93 93 90.3 3.2 6.5 0.689 Communication Gaps by Facility Level Missing investigations were most common in secondary facilities (81.3%), with a significant association (p = 0.005). Other gaps showed no significant differences across facility levels (Table 2). Table 2: Communication Gaps by Referral Facility Communication Gap N % Primary (%) Private (%) Secondary (%) Tertiary (%) P-value Incomplete history/vitals 54 54 14.9 3.7 70.4 11.1 0.512 Missing investigations 75 75 8.0 1.3 81.3 9.3 0.005 Lack of referral timing 23 23 21.7 0 73.9 4.3 0.248 Language barrier 1 1 0 0 100 0 0.949 Lack of instructions 38 38 13.2 5.3 76.3 5.3 0.640 Poor roads 93 93 10.8 4.3 75.3 9.7 0.615 Level of Consciousness and Outcome At arrival, 40% of children were alert, with 92.5% admitted and none deceased. Among lethargic patients (36%), all were admitted with zero mortality. Comatose children (24%) had worse outcomes, with 75% admitted, 12.5% mortality, and 12.5% discharged. Level of consciousness was significantly associated with 24-hour outcome (p = 0.006) (Table 3). Table 3: Level of Consciousness on Arrival and 24-hour Outcome Consciousness Level N % Admitted (%) Died (%) Discharged (%) P-value Alert 40 40 92.5 0 7.5 0.006 Lethargic 36 36 100 0 0 Comatose 24 24 75 12.5 12.5 Discussion This study reveals moderate overall referral quality but pervasive documentation gaps in pediatric referrals to the Emergency Pediatric Unit (EPU) at EFSTH. The predominance of fair-quality referrals (56%) and the fact that 87% did not meet the threshold for “good” quality underscore an urgent need for improvement. Similar deficiencies have been documented elsewhere. For example, Agrawal N. et al. (2024) reported that 80% of referral forms were less than 75% complete ( 8 , 11 ), while Ezhumalai et al. found that nearly all pediatric referral letters lacked essential clinical details ( 12 ). In Rwanda, average completeness ranged from 46% to 58%, further highlighting widespread documentation deficits across low-resource health systems ( 13 ). The fact that 100% of referral forms in our study were incomplete reflects an even more pronounced gap compared to studies in other settings. The systematic absence of basic clinical information—vital signs, physical examination findings, and investigation results—mirrors global concerns that unstructured, handwritten referrals often omit critical data ( 13 ). Our use of a structured questionnaire did not eliminate these gaps, emphasizing that merely having referral forms is insufficient unless they are consistently and thoroughly completed. In contrast to some reports citing unclear reasons for referral, 96% of our referrals contained a clear, justified reason. This aligns with earlier studies reporting 88–100% documentation of referral motives ( 12 ). However, this strength was overshadowed by deficiencies in other domains: 75% of referrals lacked investigation results and 54% lacked complete clinical histories. These omissions have been similarly reported in South African studies where only 8.3% of general practitioner referrals included laboratory results ( 14 – 16 ). Referral quality varied significantly across referring personnel. Physicians authored most referrals and attained the highest average quality scores, consistent with findings from Wahlberg et al. in Norway, where board-certified physicians produced significantly higher-quality referral letters compared to less experienced clinicians ( 17 ). In our context, pediatric consultants had the highest-quality referrals (mean score 4.67), likely reflecting specialized training, while referrals signed by “unknown” personnel were the poorest. This pattern suggests a pressing need for targeted training for all cadres involved in pediatric referral decisions. Although most referrals originated from secondary-level facilities (74%), no statistically significant difference in referral quality was found by level of facility. Private clinics, despite contributing only 5% of referrals, achieved the highest mean score (4.80) and recorded no poor-quality referrals. This may indicate better standardization, closer supervision, or more selective referral practices in private settings. Conversely, 50% of referrals from the tertiary outpatient department were poor, pointing to potential gaps in internal handover practices ( 15 ). The association between referral quality and 24-hour patient outcomes was mixed. While admitted patients tended to have slightly higher-quality referrals, the overall association was not statistically significant. Notably, none of the discharged or deceased patients had good-quality referrals, suggesting that incomplete documentation may undermine pre-transfer preparation or timely clinical interventions. Literature directly linking referral completeness to immediate pediatric outcomes remains limited. However, concerns about referral delays and associated morbidity have been documented in pediatric trauma and emergency care ( 18 – 22 ). Communication gaps were widespread. Missing laboratory investigations (75%) and incomplete history or vital signs (54%) were the most prevalent gaps, consistent with findings from Ezhumalai et al. and others who reported frequent omission of treatment and examination details ( 23 ). Missing lab results were especially common among referrals from secondary hospitals (81.3%), suggesting either limited diagnostic capacity or poor transmission of results ( 24 , 25 ). Poor referral timing (23%) and lack of instructions from the referring facility (38%) were significant issues, with the latter associated with poorer outcomes (p = 0.023). This aligns with earlier reports that highlight how unclear or absent referral instructions can delay appropriate management ( 26 , 27 ). Although 93% of referrals experienced traffic-related delays, this factor did not significantly impact outcomes, possibly due to similar transit challenges across most referrals or rapid initiation of emergency care upon arrival. Language barriers were rare and not associated with outcomes. Level of consciousness on arrival emerged as a strong predictor of outcome. Comatose children experienced the highest mortality (12.5%), consistent with pediatric critical care studies showing that depressed Glasgow Coma Scale scores on admission strongly predict worse outcomes ( 28 , 29 ). Although lethargic children in our study had no mortality, their universal admission underscores the need for urgent referral and stabilization when consciousness is impaired. Overall, this study highlights a fragmented referral system characterized by inconsistent documentation, communication failures, and variable provider capacity. These gaps pose substantial risks to continuity of care and timely clinical management, reinforcing the need for systemic improvements in referral processes across all levels of care in The Gambia. Conclusion This study highlights critical deficiencies in the quality of pediatric referrals received at the EPU at EFSTH. Despite most referrals being clinically justified, none were complete, and the majority were of fair or poor quality, reflecting systemic challenges in documentation, communication, and referral decision-making. Secondary facilities contributed most cases and were notably associated with missing investigations, indicating potential resource or procedural gaps. Referring personnel influenced referral quality, with physicians providing better documentation than nurses or assistant physicians. While overall referral quality did not show a statistically significant relationship with 24-hour patient outcomes, poor referral timing and lack of instructions were significantly linked to suboptimal outcomes. These findings suggest that incomplete or poorly timed referrals may delay appropriate interventions, especially in critically ill patients. Recommendations Standardize Referral Forms Develop and implement a nationally standardized referral form with clearly defined mandatory fields including patient demographics, clinical findings, vital signs, investigations, treatments, and reasons for referral to improve completeness and uniformity. Capacity Building and Training Conduct regular, structured training programs for healthcare workers at all facility levels focusing on clinical documentation, effective referral writing, and timely identification of emergency cases requiring transfer. Referral Quality Monitoring and Feedback Establish an audit and feedback system at tertiary referral centers to monitor referral quality and provide regular feedback to referring facilities, promoting continuous quality improvement and accountability. Strengthen Inter-Facility Communication Encourage direct pre-referral communication between referring and receiving teams through hotlines or digital platforms to ensure critical information is conveyed before patient arrival. Policy Development and Enforcement Formulate national guidelines on minimum referral standards and timing with mechanisms for supervision and enforcement. Policies should emphasize timely referral, especially for critical conditions, and foster a culture of accountability in inter-facility transfers. Declarations Ethics Approval and Consent to Participate Ethical approval for this study was obtained from the Research and Ethics Committee of the Edward Francis Small Teaching Hospital (EFSTH), Banjul, The Gambia. All components of the research adhered to the ethical principles outlined in the Declaration of Helsinki . For the review of referral forms and hospital records, the Ethics Committee granted a waiver of individual consent because the study involved minimal risk and used routinely collected clinical data. For caregiver interviews, written informed consent was obtained from parents or legal guardians after providing a clear explanation of the study purpose, procedures, risks, and benefits in a language they understood. Participation was voluntary and participants were informed of their right to withdraw at any time without consequences. Availability of Data and Materials The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request, in accordance with institutional data-sharing policies. Competing Interests The authors declare that they have no competing interests. Funding This study received no external funding . All costs were covered by the research team. Authors’ Contributions OM: Conceptualization, study design, data collection, analysis, manuscript drafting. MM: Data analysis, interpretation of findings, critical revision of the manuscript. SL: Supervision, manuscript review and editing LM:Conceptualization, Supervision, methodology oversight, manuscript review and editing. All authors read and approved the final manuscript. Acknowledgements The authors express sincere appreciation to the staff of the Emergency Pediatric Unit and the Medical Records Department of EFSTH for their support during data collection. We also extend gratitude to the caregivers who participated in the interviews and to the healthcare workers at referring facilities who provided valuable insights during the study. References Daniels AA, Abuosi A. Improving emergency obstetric referral systems in low and middle income countries: a qualitative study in a tertiary health facility in Ghana. 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13:28:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":927589,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8272720/v1/b770b69e-8470-4517-9cb0-8aeab075b7f9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Quality and Clinical Appropriateness of Pediatric Referrals to the Emergency Pediatric Unit at Edward Francis Small Teaching Hospital, The Gambia: A Cross-Sectional Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEfficient referral systems are critical for timely, appropriate healthcare delivery, especially in low-resource settings where tertiary hospitals serve as hubs for critically ill patients(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). A functional system ensures patients are treated at the correct level of care, facilitates continuity through accurate documentation and clear communication between providers, and enables timely transfer with essential clinical information(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn The Gambia, the healthcare system operates at three tiers\u0026mdash;primary, secondary, and tertiary care(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u0026mdash;with EFSTH in Banjul serving as the national tertiary referral center for pediatric emergencies. Referrals to EFSTH\u0026rsquo;s EPU originate from primary health centers, district hospitals, and private clinics(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Many of these facilities, especially in rural and peri-urban areas, face shortages of specialized staff, equipment, and resources, which can compromise pre-referral stabilization and documentation quality(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eReferral letters remain the standard tool for transferring patient information between facilities. A complete referral should include patient identifiers, details of the referring provider, the reason for referral, relevant history, examination findings, and results of investigations already performed. The World Health Organization (WHO) recommends that referral forms clearly outline the patient\u0026rsquo;s clinical status, treatment provided, and the names of both the sending and receiving facilities, and that referral registers be maintained for traceability(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Counter-referrals are equally important, ensuring feedback to the referring facility for follow-up care(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, in many low-resource settings, referral quality is undermined by incomplete documentation, lack of pre-transfer communication, inadequate stabilization, and unreliable transport. Studies from India and other countries have shown that pediatric referrals frequently arrive without prior notification, proper records, or appropriate pre-transfer care, leading to treatment delays and adverse outcomes(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Globally, general practitioners\u0026mdash;often the first point of contact for children\u0026mdash;face referral decision challenges influenced by time pressure, limited pediatric training, and parental expectations(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Rising demand on emergency departments has intensified the need to evaluate referral appropriateness and strengthen referral pathways(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite EFSTH\u0026rsquo;s central role in pediatric emergency care, there is limited evidence on the quality and completeness of referrals it receives. This study evaluates the completeness, appropriateness, and timeliness of pediatric referrals to the EPU, identifies factors influencing referral quality, and examines their association with short-term patient outcomes. Findings aim to inform targeted interventions to strengthen referral protocols, improve inter-facility communication, and enhance pediatric emergency care in The Gambia.\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA descriptive cross-sectional study was conducted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study took place at the Emergency Pediatric Unit (EPU) of Edward Francis Small Teaching Hospital (EFSTH), the main tertiary referral hospital in Banjul, The Gambia, from April to June 2025.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study included all pediatric patients aged 1 month to 15 years who were referred to the EPU from other healthcare facilities during the study period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eReferred patients arriving at the EPU with a referral form or documented referral information.\u003c/li\u003e\n \u003cli\u003ePatients aged 1 month to 15 years.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003ePatients presenting directly without a referral.\u003c/li\u003e\n \u003cli\u003ePatients aged less than 1 month.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eSample Size and Sampling Technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample size was calculated based on the estimated number of pediatric referrals during the study period. A convenient \u0026nbsp;sampling method was used to select referred cases for review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected using three approaches:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003e\u003cstrong\u003eReferral form and hospital record review\u003c/strong\u003e \u0026ndash; to assess completeness and appropriateness.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCaregiver interviews\u003c/strong\u003e \u0026ndash; to determine referral delays and challenges encountered.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eKey informant interviews\u003c/strong\u003e \u0026ndash; with healthcare providers at referring facilities to identify barriers to effective referrals.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eReferral forms were assessed using a structured seven-point scoring system covering key documentation and appropriateness domains.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were entered and analyzed using SPSS version 20. Descriptive statistics summarized findings, including the proportion of complete versus incomplete referrals. Referral appropriateness was assessed based on \u003cu\u003epredefined clinical criteria.\u003c/u\u003e Associations between referral quality and short-term patient outcomes were examined using chi-square tests and logistic regression, with a significance threshold set at p \u0026lt; 0.05.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 100 referral cases to the Paediatric Emergency Unit (EPU) at Edward Francis Small Teaching Hospital (EFSTH) were analyzed. A seven-point scoring system assessed referral quality based on completeness and appropriateness of the following: (1) patient details, (2) clinical information, (3) investigations, (4) treatment before referral, (5) referral facility details, (6) justification of referral based on clinical findings, and (7) appropriateness of referral destination.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality and Completeness of Referrals\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe overall mean referral quality score was 4.05 \u0026plusmn; 1.29, with scores ranging from 1 to 6. Among the referrals, 13 (13%) were classified as good quality (score 6\u0026ndash;7), 56 (56%) as fair (score 4\u0026ndash;5), and 31 (31%) as poor (score 0\u0026ndash;3). Notably, all referrals (100%) were considered incomplete in documentation.\u003c/p\u003e\n\u003cp\u003eThe referral reason was clearly stated and justified in 96 (96%) cases, while 4 (4%) lacked clarity or justification.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReferral Quality and Outcome within 24 Hours\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWithin 24 hours of arrival, 91 (91%) patients were admitted, 6 (6%) discharged, and 3 (3%) died. The mean referral quality score was highest among admitted patients (4.12 \u0026plusmn; 1.30), compared to discharged (3.33 \u0026plusmn; 1.21) and deceased patients (3.33 \u0026plusmn; 0.58). This difference was not statistically significant (p = 0.219).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDuration of Referral and Quality\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost referrals (81%) arrived within 1\u0026ndash;4 hours, with a mean quality score of 4.09 \u0026plusmn; 1.28. Referrals arriving in 4\u0026ndash;8 hours (15%) had a mean score of 4.07 \u0026plusmn; 1.10. Referrals with unspecified duration (4%) had a lower mean score (3.25 \u0026plusmn; 2.22). These differences were not statistically significant (p = 0.453)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of Referring Facility\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost referrals came from secondary facilities (74%), which had a mean quality score of 4.09 \u0026plusmn; 1.14. Tertiary-level referrals had the lowest mean score (3.80 \u0026plusmn; 1.87), while private clinics had the highest (4.80 \u0026plusmn; 0.84). Differences were not statistically significant (p = 0.354) \u003cstrong\u003eReferring Personnel\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDoctors accounted for 83% of referrals, with a mean referral quality score of 4.14 \u0026plusmn; 1.26. Paediatric consultants (3%) had the highest quality scores (4.67 \u0026plusmn; 0.58), while assistant physicians (2%) scored lowest (3.50 \u0026plusmn; 0.71). The difference was statistically significant (p = 0.048).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunication Gaps and Clinical Outcome\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe most frequent communication gaps were missing investigations (75%), incomplete clinical history or vitals (54%), and poor road access (93%). Absence of referral timing (23%) was significantly associated with discharge within 24 hours (p = 0.001), while lack of instructions from the referring facility (38%) correlated with poorer outcomes (p = 0.023) (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Communication Gaps and 24-hour Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunication Gap\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdmitted (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDied (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDischarged (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIncomplete history/vitals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e85.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.079\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMissing investigations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e88.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.192\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLack of referral timing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLanguage barrier\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.951\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLack of instructions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e81.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePoor roads\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e90.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.689\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eCommunication Gaps by Facility Level\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMissing investigations were most common in secondary facilities (81.3%), with a significant association (p = 0.005). Other gaps showed no significant differences across facility levels (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Communication Gaps by Referral Facility\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunication Gap\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrivate (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecondary (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTertiary (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIncomplete history/vitals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e70.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.512\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMissing investigations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e81.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLack of referral timing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e73.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.248\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLanguage barrier\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.949\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLack of instructions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e76.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.640\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePoor roads\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e75.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.615\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of Consciousness and Outcome\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt arrival, 40% of children were alert, with 92.5% admitted and none deceased. Among lethargic patients (36%), all were admitted with zero mortality. Comatose children (24%) had worse outcomes, with 75% admitted, 12.5% mortality, and 12.5% discharged. Level of consciousness was significantly associated with 24-hour outcome (p = 0.006) (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Level of Consciousness on Arrival and 24-hour Outcome\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eConsciousness Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdmitted (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDied (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDischarged (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAlert\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e92.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLethargic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eComatose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study reveals moderate overall referral quality but pervasive documentation gaps in pediatric referrals to the Emergency Pediatric Unit (EPU) at EFSTH. The predominance of fair-quality referrals (56%) and the fact that 87% did not meet the threshold for \u0026ldquo;good\u0026rdquo; quality underscore an urgent need for improvement. Similar deficiencies have been documented elsewhere. For example, Agrawal N. et al. (2024) reported that 80% of referral forms were less than 75% complete (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), while Ezhumalai et al. found that nearly all pediatric referral letters lacked essential clinical details (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In Rwanda, average completeness ranged from 46% to 58%, further highlighting widespread documentation deficits across low-resource health systems (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The fact that 100% of referral forms in our study were incomplete reflects an even more pronounced gap compared to studies in other settings.\u003c/p\u003e \u003cp\u003eThe systematic absence of basic clinical information\u0026mdash;vital signs, physical examination findings, and investigation results\u0026mdash;mirrors global concerns that unstructured, handwritten referrals often omit critical data (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Our use of a structured questionnaire did not eliminate these gaps, emphasizing that merely having referral forms is insufficient unless they are consistently and thoroughly completed.\u003c/p\u003e \u003cp\u003eIn contrast to some reports citing unclear reasons for referral, 96% of our referrals contained a clear, justified reason. This aligns with earlier studies reporting 88\u0026ndash;100% documentation of referral motives (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). However, this strength was overshadowed by deficiencies in other domains: 75% of referrals lacked investigation results and 54% lacked complete clinical histories. These omissions have been similarly reported in South African studies where only 8.3% of general practitioner referrals included laboratory results (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eReferral quality varied significantly across referring personnel. Physicians authored most referrals and attained the highest average quality scores, consistent with findings from Wahlberg et al. in Norway, where board-certified physicians produced significantly higher-quality referral letters compared to less experienced clinicians (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In our context, pediatric consultants had the highest-quality referrals (mean score 4.67), likely reflecting specialized training, while referrals signed by \u0026ldquo;unknown\u0026rdquo; personnel were the poorest. This pattern suggests a pressing need for targeted training for all cadres involved in pediatric referral decisions.\u003c/p\u003e \u003cp\u003eAlthough most referrals originated from secondary-level facilities (74%), no statistically significant difference in referral quality was found by level of facility. Private clinics, despite contributing only 5% of referrals, achieved the highest mean score (4.80) and recorded no poor-quality referrals. This may indicate better standardization, closer supervision, or more selective referral practices in private settings. Conversely, 50% of referrals from the tertiary outpatient department were poor, pointing to potential gaps in internal handover practices (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe association between referral quality and 24-hour patient outcomes was mixed. While admitted patients tended to have slightly higher-quality referrals, the overall association was not statistically significant. Notably, none of the discharged or deceased patients had good-quality referrals, suggesting that incomplete documentation may undermine pre-transfer preparation or timely clinical interventions. Literature directly linking referral completeness to immediate pediatric outcomes remains limited. However, concerns about referral delays and associated morbidity have been documented in pediatric trauma and emergency care (\u003cspan additionalcitationids=\"CR19 CR20 CR21\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCommunication gaps were widespread. Missing laboratory investigations (75%) and incomplete history or vital signs (54%) were the most prevalent gaps, consistent with findings from Ezhumalai et al. and others who reported frequent omission of treatment and examination details (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Missing lab results were especially common among referrals from secondary hospitals (81.3%), suggesting either limited diagnostic capacity or poor transmission of results (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Poor referral timing (23%) and lack of instructions from the referring facility (38%) were significant issues, with the latter associated with poorer outcomes (p\u0026thinsp;=\u0026thinsp;0.023). This aligns with earlier reports that highlight how unclear or absent referral instructions can delay appropriate management (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough 93% of referrals experienced traffic-related delays, this factor did not significantly impact outcomes, possibly due to similar transit challenges across most referrals or rapid initiation of emergency care upon arrival. Language barriers were rare and not associated with outcomes.\u003c/p\u003e \u003cp\u003eLevel of consciousness on arrival emerged as a strong predictor of outcome. Comatose children experienced the highest mortality (12.5%), consistent with pediatric critical care studies showing that depressed Glasgow Coma Scale scores on admission strongly predict worse outcomes (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Although lethargic children in our study had no mortality, their universal admission underscores the need for urgent referral and stabilization when consciousness is impaired.\u003c/p\u003e \u003cp\u003eOverall, this study highlights a fragmented referral system characterized by inconsistent documentation, communication failures, and variable provider capacity. These gaps pose substantial risks to continuity of care and timely clinical management, reinforcing the need for systemic improvements in referral processes across all levels of care in The Gambia.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights critical deficiencies in the quality of pediatric referrals received at the EPU at EFSTH. Despite most referrals being clinically justified, none were complete, and the majority were of fair or poor quality, reflecting systemic challenges in documentation, communication, and referral decision-making. Secondary facilities contributed most cases and were notably associated with missing investigations, indicating potential resource or procedural gaps. Referring personnel influenced referral quality, with physicians providing better documentation than nurses or assistant physicians.\u003c/p\u003e\n\u003cp\u003eWhile overall referral quality did not show a statistically significant relationship with 24-hour patient outcomes, poor referral timing and lack of instructions were significantly linked to suboptimal outcomes. These findings suggest that incomplete or poorly timed referrals may delay appropriate interventions, especially in critically ill patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003e\u003cstrong\u003eStandardize Referral Forms\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Develop and implement a nationally standardized referral form with clearly defined mandatory fields including patient demographics, clinical findings, vital signs, investigations, treatments, and reasons for referral to improve completeness and uniformity.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCapacity Building and Training\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Conduct regular, structured training programs for healthcare workers at all facility levels focusing on clinical documentation, effective referral writing, and timely identification of emergency cases requiring transfer.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eReferral Quality Monitoring and Feedback\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Establish an audit and feedback system at tertiary referral centers to monitor referral quality and provide regular feedback to referring facilities, promoting continuous quality improvement and accountability.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eStrengthen Inter-Facility Communication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Encourage direct pre-referral communication between referring and receiving teams through hotlines or digital platforms to ensure critical information is conveyed before patient arrival.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePolicy Development and Enforcement\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Formulate national guidelines on minimum referral standards and timing with mechanisms for supervision and enforcement. Policies should emphasize timely referral, especially for critical conditions, and foster a culture of accountability in inter-facility transfers.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Declarations","content":"\u003ch3\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Research and Ethics Committee of the Edward Francis Small Teaching Hospital (EFSTH), Banjul, The Gambia. All components of the research adhered to the ethical principles outlined in the \u003cstrong\u003eDeclaration of Helsinki\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eFor the review of referral forms and hospital records, the Ethics Committee granted a waiver of individual consent because the study involved minimal risk and used routinely collected clinical data.\u003c/p\u003e\n\u003cp\u003eFor caregiver interviews, \u003cstrong\u003ewritten informed consent\u003c/strong\u003e was obtained from parents or legal guardians after providing a clear explanation of the study purpose, procedures, risks, and benefits in a language they understood. Participation was voluntary and participants were informed of their right to withdraw at any time without consequences.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request, in accordance with institutional data-sharing policies.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis study received \u003cstrong\u003eno external funding\u003c/strong\u003e. All costs were covered by the research team.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eOM: Conceptualization, study design, data collection, analysis, manuscript drafting.\u003c/p\u003e\n\u003cp\u003eMM: Data analysis, interpretation of findings, critical revision of the manuscript.\u003c/p\u003e\n\u003cp\u003eSL: Supervision, manuscript review and editing\u003c/p\u003e\n\u003cp\u003eLM:Conceptualization, Supervision, methodology oversight, manuscript review and editing.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors express sincere appreciation to the staff of the Emergency Pediatric Unit and the Medical Records Department of EFSTH for their support during data collection. We also extend gratitude to the caregivers who participated in the interviews and to the healthcare workers at referring facilities who provided valuable insights during the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDaniels AA, Abuosi A. Improving emergency obstetric referral systems in low and middle income countries: a qualitative study in a tertiary health facility in Ghana. BMC Health Serv Res. 2020 Jan 10;20:32. \u003c/li\u003e\n\u003cli\u003ePittalis C, Brugha R, Gajewski J. Surgical referral systems in low- and middle-income countries: A review of the evidence. PLoS ONE. 2019 Sep 27;14(9):e0223328. \u003c/li\u003e\n\u003cli\u003eFactors associated with delayed referrals of patients with sepsis from primary to tertiary healthcare in Blantyre, Malawi: a qualitative study | BMC Primary Care | Full Text [Internet]. [cited 2025 Nov 23]. Available from: https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-025-02708-1?utm_source=chatgpt.com\u003c/li\u003e\n\u003cli\u003ehmis_policy.pdf [Internet]. [cited 2025 Nov 23]. Available from: https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/gambia/hmis_policy.pdf?utm_source=chatgpt.com\u003c/li\u003e\n\u003cli\u003eEFSTH [Internet]. [cited 2025 Nov 23]. Available from: https://www.efsth.gm/?utm_source=chatgpt.com\u003c/li\u003e\n\u003cli\u003eThe20Gambia20PER20-20Report2028Final2920202005192020.x80726.pdf [Internet]. [cited 2025 Nov 23]. Available from: https://p4h.world/app/uploads/2023/02/The20Gambia20PER20-20Report2028Final2920202005192020.x80726.pdf?utm_source=chatgpt.com\u003c/li\u003e\n\u003cli\u003estandards-for-improving-quality-of-maternal-and-newborn-care-in-health-facilities.pdf [Internet]. [cited 2025 Nov 23]. Available from: https://platform.who.int/docs/default-source/mca-documents/qoc/quality-of-care/standards-for-improving-quality-of-maternal-and-newborn-care-in-health-facilities.pdf?utm_source=chatgpt.com\u003c/li\u003e\n\u003cli\u003eAgrawal N, Kumar R, Pandey S, Gupta A, Das K, Simalti A. Evaluation of referral documentation in pediatrics emergency transfers: A cross-sectional observational study. J Pediatr Crit Care. 2024 Dec;11(6):262. \u003c/li\u003e\n\u003cli\u003eConlon C, Nicholson E, Rodr\u0026iacute;guez-Martin B, O\u0026rsquo;Donovan R, De Br\u0026uacute;n A, McDonnell T, et al. Factors influencing general practitioners decisions to refer Paediatric patients to the emergency department: a systematic review and narrative synthesis. BMC Fam Pract. 2020 Oct 16;21:210. \u003c/li\u003e\n\u003cli\u003ePediatric Emergency Department Diagnostics: Global Challenges and Innovations | Current Treatment Options in Pediatrics [Internet]. [cited 2025 Nov 23]. Available from: https://link.springer.com/article/10.1007/s40746-025-00333-9?utm_source=chatgpt.com\u003c/li\u003e\n\u003cli\u003eAmeyaw EK, Amoah RM, Njue C, Tran NT, Dawson A. Audit of documentation accompanying referred maternity cases to a referral hospital in northern Ghana: a mixed-methods study. BMC Health Serv Res. 2022 Dec;22(1):347. \u003c/li\u003e\n\u003cli\u003eEzhumalai G, Jayashree M, Nallasamy K, Bansal A, Bharti B. Referrals to a pediatric emergency department of a tertiary care teaching hospital before and after introduction of a referral education module - a quality improvement study. BMC Health Serv Res. 2020 Dec;20(1):761. \u003c/li\u003e\n\u003cli\u003eKalume Z, Jansen B, Nyssen M, Cornelis J, Verbeke F, Niyoyita JP. Assessment of formats and completeness of paper-based referral letters among urban hospitals in Rwanda: a retrospective baseline study. BMC Health Serv Res. 2022 Nov 28;22(1):1436. \u003c/li\u003e\n\u003cli\u003e(PDF) The Challenges of Implementing a Health Referral System in South Africa: A Qualitative Study. ResearchGate [Internet]. [cited 2025 Nov 23]; Available from: https://www.researchgate.net/publication/379730971_The_Challenges_of_Implementing_a_Health_Referral_System_in_South_Africa_A_Qualitative_Study\u003c/li\u003e\n\u003cli\u003eHaeusler IL, Sajan M, Parrish A. Mind the message: Referral letter quality at a South African medical outpatient department. S Afr Med J. 2020 Apr 29;110(5):396. \u003c/li\u003e\n\u003cli\u003eVanker N, Faull NHB. Laboratory test result interpretation for primary care doctors in South Africa. Afr J Lab Med. 2017 Mar 24;6(1):453. \u003c/li\u003e\n\u003cli\u003eW\u0026aring;hlberg H, Valle PC, Malm S, Broderstad AR. Impact of referral templates on the quality of referrals from primary to secondary care: a cluster randomised trial. BMC Health Serv Res. 2015 Dec;15(1):353. \u003c/li\u003e\n\u003cli\u003eImpact of Delayed Trauma Unit Admission on Mortality and Disability in Traumatic Brain Injury Patients [Internet]. [cited 2025 Nov 23]. Available from: https://www.mdpi.com/1660-4601/22/10/1566?utm_source=chatgpt.com\u003c/li\u003e\n\u003cli\u003eHosseinpour H, Magnotti LJ, Bhogadi SK, Colosimo C, El-Qawaqzeh K, Spencer AL, et al. Interfacility transfer of pediatric trauma patients to higher levels of care: The effect of transfer time and level of receiving trauma center. J Trauma Acute Care Surg. 2023 Sep 1;95(3):383\u0026ndash;90. \u003c/li\u003e\n\u003cli\u003eLocke T, Rekman J, Brennan M, Nasr A. The impact of transfer on pediatric trauma outcomes. J Pediatr Surg. 2016 May;51(5):843\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eKumar S, Lee P, Chin B, Nasef H, Yates Z, Ford A, et al. Effect of Interfacility Transfer on Outcomes in Pediatric Severe Traumatic Brain Injury Patients. J Trauma Nurs Off J Soc Trauma Nurses. 2025 Oct 29; \u003c/li\u003e\n\u003cli\u003eGale HL, Staffa SJ, DePamphilis MA, Tsay S, Burns J, Sheridan R. Pediatric Burn Care for Burn Injury: Outcomes by Timing of Referral Using a U.S. Single-Center Retrospective Cohort, 2005-2019. Pediatr Crit Care Med J Soc Crit Care Med World Fed Pediatr Intensive Crit Care Soc. 2024 Dec 1;25(12):1150\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eNgoie KD, Jenkins L, Schoevers J. Evaluating referrals between rural district hospitals and a regional hospital in South Africa. Afr J Prim Health Care Fam Med. 2025 Jul 9;17(1):e1\u0026ndash;11. \u003c/li\u003e\n\u003cli\u003eA qualitative evaluation of access to essential laboratory services for communicable diseases at the primary health care level in the Western Pacific Region | Tropical Medicine and Health | Full Text [Internet]. [cited 2025 Nov 23]. Available from: https://tropmedhealth.biomedcentral.com/articles/10.1186/s41182-025-00797-3?utm_source=chatgpt.com\u003c/li\u003e\n\u003cli\u003eDas S, Patil S, Pathak S, Chakravarthy S, Fernandez A, Pantvaidya S, et al. Emergency obstetric referrals in public health facilities: A descriptive study from urban Maharashtra, India. Front Health Serv. 2023 Apr 17;3:1168277. \u003c/li\u003e\n\u003cli\u003eARTICLE_6_Effectiveness+of+Referral+Protocols+in+Improving+Obstetric+and+Neonatal+Emergency+Care.pdf. \u003c/li\u003e\n\u003cli\u003eBarriers to proper maternal referral system in selected health facilities in Eastern Ethiopia: a qualitative study | BMC Health Services Research | Full Text [Internet]. [cited 2025 Nov 23]. Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-024-10825-3?utm_source=chatgpt.com\u003c/li\u003e\n\u003cli\u003eCicero MX, Cross KP. Predictive value of initial Glasgow coma scale score in pediatric trauma patients. Pediatr Emerg Care. 2013 Jan;29(1):43\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eDuyu M, Karakaya Altun Z, Yildiz S. Nontraumatic coma in the pediatric intensive care unit: etiology, clinical characteristics and outcome. Turk J Med Sci. 2021 Feb 26;51(1):214\u0026ndash;23. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pediatric referrals, documentation quality, emergency care, inter-facility transfer, communication gaps, The Gambia","lastPublishedDoi":"10.21203/rs.3.rs-8272720/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8272720/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003cbr\u003e\nEffective 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003cbr\u003e\nA 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 \u0026lt; 0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003cbr\u003e\nThe 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).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003cbr\u003e\nPediatric 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.\u003c/p\u003e","manuscriptTitle":"Quality and Clinical Appropriateness of Pediatric Referrals to the Emergency Pediatric Unit at Edward Francis Small Teaching Hospital, The Gambia: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-17 07:29:07","doi":"10.21203/rs.3.rs-8272720/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1a6fcb14-c730-4518-bbc3-cdfde257b9ad","owner":[],"postedDate":"December 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-11T13:27:38+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-17 07:29:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8272720","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8272720","identity":"rs-8272720","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}