Triage is a relatively new concept in many African emergency centres. Although it had been broadly implemented across EDs in high income nations [5,6,7,8], it has yet to be systematically implemented and evaluated in LMICs for provision of quality emergency care. To the best of our knowledge this is the first study conducted to explore the triage system and identify barriers in its application in hospitals in Sudan. Our study demonstrates that Sudan lacks a formal and standardized triage system. This finding, is no surprise, as a previous study conducted back in 2001 involving seven developing countries revealed that 14 of 21 hospitals lacked an adequate system for emergency triage and also showed that methods for initial patient assessment led to delayed treatment [18, 19]. Our study determined the proportion of the assessed hospitals that had an established triage protocol in Khartoum State, the two hospital namely, Ibrahim Malik and Omdurman use the Sudan Triage Tool and IITT, respectively. Despite the fact that the evidence on triaging in LMICs is limited, the value of simple and context-specific approaches is widely recognized [16]. The key to improvement of the triage system is to reach a consensus on a single standardized system that allows nurses and other health care providers to use something that is simple yet consistent. This can be readily achieved by implementing an already developed and validated triage scale, an effective strategy that could be useful in ensuring uniform application of triage across EDs, as there is little evidence to back up the validity and reliability of the existing triage tools in LMICs [10]. The four-tier SATS is the most extensively researched of the small number of tools specifically designed for resource-limited settings [12, 16]. Although the tool has been shown to have adequate validity and reliability in a number of countries and contexts, it is also been noted to be too complicated for some settings, necessitating provider capacity that isn't always available [16].However, tools utilising three categories such as IITT are well-suited to developing EDs because they are intuitive and efficient [15, 16]. Furthermore, it fits to the three-level profile established by the Sudanese Ministry of Health in certain hospitals [17], and it would be a simpler system to teach to nurses and possibly nursing assistants in rural or understaffed smaller hospitals, since the IITT does not require calculation of a triage early warning score unlike the SATS. [12, 16]. Moreover, the training of the staff in a single specific triage system is essential to tackle the disparities in the perspectives of hospital staff on the existence of a well -functioning and efficient triage system at the hospitals they work at as demonstrated by a significant association (at a p-value of 0.007).
62.7% of our respondents agreed that there is a need for substantial capital expenditure and adequate provision of resources to the ED. This was coincident with the findings of a study conducted in Ghana with the purpose of assessing the capacity for care of emergency patients [20]. This capital should be invested in the standardization of the triage process and its implementation, particularly at the site of the triage station. The triage station should be accessible to the patients at their first point of contact with the health care provider in order to promote adherence to evidence-based guidelines [4]. It also should easily catch emergency medical service and ambulatory patients as they enter the ED. More so, basic equipment (such as personal protective equipment, a pulse oximeter, and so forth) should be available. In addition, the triage area should be spacious, ensure the privacy of the patient and the safety of the ED staff [8, 12]. Moreover, some of the capital should also be utilised in the training of the front line staff on dealing with challenging behavior on part of the patients and their relatives. Protocols should be implemented to provide a safe environment for the staff and patients which is crucial to ensure an efficient ER triage [6]. As demonstrated by an internal survey of emergency nurses and patient care assistants, violence is a continuing problem within the ED [21], and in another study one of the challenges related to emergency management was the inadequacy of the security section in the triage area [22]. Our study concluded a significant association between both pillars of the safety at triage area (minimisation-of-aggression training and protocols and procedures for dealing with challenging behaviour) and the staffs’ perception of a well-functioning triage (both had a p-value of 0.000 and 0.003, respectively). Interestingly, staff that described the triage as inefficient, also reported the lack of proper safety measures provided at the EDs.
Training ER staff on correct means of triage has the potential to improve efficiency and the delivery of emergency medical services and reducing overall mortality and morbidity. The importance of training can be exemplified by the results of our study where 48.6% of the participants asserted the necessity of adequately training the staff on means of performing an effective triage. Moreover, this study highlighted a gap on the knowledge on how triage is performed by several participants at their respective hospitals. Once more emphasizing on the importance of triage training. The closest we found to our results were those of several studies that emphasized the importance of training and educating the staff [2, 23, 24]. According to various triage guidelines it was found that patients should be immediately triaged upon arrival and the assessment time should take about 2 to 5 min as this is the most critical period spent in the ER [5,6,7,8, 12]. Fortunately, 81.0% of our staff reported that the patient is immediately triaged upon his arrival to the ED which is consistent with the findings of a study conducted in Sweden [25]. A significant association had been found between the staff perspective of assessment time (p-value of 0.000) and their perception of a well-functioning triage, similar to an audit conducted in Australia (p-value of 0.005) [4]. Overall, 46.7% of the participants reported that the triage assessment normally took 2 to 5 min. The lowest percentages among all the hospitals were 40.0% and 33.3%, these were obtained from Ibrahim Malik Hospital and Alban Jadeed Hospital respectively, where respondents reported that it takes place in the ideal time. In retrospect, the range of triage time was found to be 0.5–11.1 min in a study conducted at a trauma center [26]. The assessment of the adequacy of clinical care provided for the patient requires high quality of documentation. In addition, it can assist in producing evidence for legal purposes. However, nearly a third of our respondents stated that documentation is inadequate. Previous studies have indicated that missing data is common in emergency medicine [27]. Therefore, prior to adopting the triage role, the triage personnel should receive adequate training on triage prerequisites including proper documentation. This can be readily accomplished by enrolling the staff in the Médecins Sans Frontières (MSF) tembo training which offers an IITT educational course [28]. The staff that have received the MSF training can then serve as future triage trainers in Sudan.
Moreover, the respondents also emphazised on the cruciality of raising awareness of the ED staff on the correct means of application of the triage guidelines (28.1% of the responses). In the two hospitals with a triage scale, namely Ibrahim Malik Hospital and Omdurman hospital, only, 72.0% and 50.0% were aware of the presence of a scale in their hospitals, respectively. Only 50.0% from those were adherent to the guidelines in the former and 80.0% were adherent in the latter. Likewise, it was stated by a systemic review that triage wasn’t performed by the staff at all in some instances [9]. As for the rest of the hospitals in our study there was no objective triage or a triage scale in first place for the staff to follow which was also reported in a study conducted in Iran [21]. Thus, an efficient triage can be achieved by the improvement of the clinical competency of triage nurses, their encouragement to be motivated and the implementation of specific policies and instructions for the triage of patients.
The most important barrier to a well functioning triage reported by most of the participants of our study (78.4%) was the role played by the administration and legislative measures taken by authorities, as they agreed that proper administration is of essence in improving the triage system. Several studies described that improving access to emergency care in Africa calls for careful examination of the processes of governance. There is a need for legislation in order to provide a legal assurance of access to emergency services irrespective of the capacity to pay. The potential effect of legislative assurances of access to emergency care in Africa is demonstrated by constitutional and statutory rules and other governance frameworks [9,10,11, 24]. Therefore, the success of a triage demands undertaking a holistic integral approach in order to improve the system. The heart of this approach is a reformation in administration. Legal and infrastructure frameworks are required to approve the system’s operation and ensure that it is properly performed. In the context of LMICs, triage can necessitate additional equipment and space in the ER, hence requiring adequate resource allocation by administrations. Emergency administrators can also improve the quality of triaging patients by empowering triage nurses since they should have professional capabilities, including adequate knowledge about how to triage patients. These reforms are vital in improving patient survival and other health-related outcomes as well as gaining patient satisfaction. Moreover, it reduces overall health related expenditure. In addition, collaboration with the Ministry of Health is needed to ensure legislative measures are taken to improve the triage system. Measures that protect health care providers from violence and threats should be included in these legislations.
Further research is needed in this field once common standards of triaging have been established, primarily to answer questions about the impact, effectiveness and limitations of the triage system. Moreover, future studies will be required for evaluation of triage tools, impact of triage on waiting times, resource utilization, and patient satisfaction.
The study had certain limitations. One of which is the modest sample size of participants as data was not collected from 15/200 (7.50%) of ED staff who refused to participate in the study, which may have underpowered this study for the detection of additional associations. The methods were designed to identify an association, but not a direct causative effect, between the dependent and independent variables. The study was based on what participants viewed as hindrances to an effective triage, further studies are required for identifying specific causes. Other limitations included interviewer effect which was minimized by using a standard set of questions, as well as confounding bias associated with using a cross-sectional study design.
