Triage for resource-limited emergency care: why it matters

Mitchell, Richard

doi:10.1097/ec9.0000000000000082

Emerg Crit Care Med

2023

DOI: 10.1097/ec9.0000000000000082

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Triage for resource-limited emergency care: why it matters

Richard Mitchell

Abstract: Triage aims to identify and prioritize patients with time-sensitive health care needs. This process is particularly important when demand for emergency care exceeds the available resources.A small number of triage instruments have been purpose designed for low- and middle-income countries. Most recently, the World Health Organization, in collaboration with the International Committee of the Red Cross and Médecins Sans Frontières, has released the Interagency Integrated Triage Tool (IITT). Despite endorsement b… Show more

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Cited by 3 publications

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“…According to this guidance, one of the essential functions of emergency departments (EDs) is triage. This is broadly defined as the process of sorting patients according to the urgency of their presentation, such that those with time-critical care needs are prioritised for assessment and management [ 2 , 3 ].…”

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Triage implementation in resource-limited emergency departments: sharing tools and experience from the Pacific region

Mitchell,

White,

Elton

et al. 2024

Int J Emerg Med

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According to the World Health Organization’s (WHO) Emergency Care Systems Framework, triage is an essential function of emergency departments (EDs). This practice innovation article describes four strategies that have been used to support implementation of the WHO-endorsed Interagency Integrated Triage Tool (IITT) in the Pacific region, namely needs assessment, digital learning, public communications and electronic data management.Using a case study from Vila Central Hospital in Vanuatu, a Pacific Small Island Developing State, we reflect on lessons learned from IITT implementation in a resource-limited ED. In particular, we describe the value of a bespoke needs assessment tool for documenting triage and patient flow requirements; the challenges and opportunities presented by digital learning; the benefits of locally designed, public-facing communications materials; and the feasibility and impact of a low-cost electronic data registry system.Our experience of using these tools in Vanuatu and across the Pacific region will be of interest to other resource-limited EDs seeking to improve their triage practice and performance. Although the resources and strategies presented in this article are focussed on the IITT, the principles are equally relevant to other triage systems.

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confidence: 99%

Triage implementation in resource-limited emergency departments: sharing tools and experience from the Pacific region

Mitchell,

White,

Elton

et al. 2024

Int J Emerg Med

Self Cite

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Systematic review: What is the impact of triage implementation on clinical outcomes and process measures in low‐ and middle‐income country emergency departments?

Mitchell,

Fang,

Tee

et al. 2023

Academic Emergency Medicine

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IntroductionTriage is widely regarded as an essential function of emergency care systems, especially in resource‐limited settings. Through a systematic search and review of the literature, we investigated the effect of triage implementation on clinical outcomes and process measures in low‐ and middle‐income country (LMIC) emergency departments (EDs).MethodsStructured searches were conducted using MEDLINE, CENTRAL, EMBASE, CINAHL and Global Health. Eligible articles identified through screening and full‐text review underwent risk‐of‐bias assessment using the Newcastle‐Ottawa Scale. The quality of evidence for each effect measure was summarised using GRADE.ResultsAmong 10,394 articles identified through the search strategy, 58 underwent full‐text review and 16 were included in the final synthesis. All utilised pre‐post intervention methods and a majority were single‐centre. Effect measures included mortality, waiting time, length of stay, admission rate and patient satisfaction. Of these, ED mortality and time to clinician assessment were evaluated most frequently. The majority of studies using these outcomes identified a positive effect, namely a reduction in deaths and waiting time among patients presenting for emergency care. The quality of the evidence was moderate for these measures, but low or very low for all other outcomes and process indicators.ConclusionThere is moderate quality of evidence supporting an association between the introduction of triage and a reduction in deaths and waiting time. Although the available data support the value of triage in LMIC EDs, the risk of confounding and publication bias is significant. Future studies will benefit from more rigorous research methods.

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Triage processes in primary, secondary, and tertiary health care facilities in the Kathmandu Valley, Nepal: a mixed-methods study

Shrestha,

Adhikari,

Bajracharya

et al. 2024

BMC Emerg Med

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Background In healthcare facilities, an efficient triage system is critical to optimize patient care. The main objective of this study was to explore the triage processes and practices in three different tiers of healthcare facilities in the Kathmandu Valley, Nepal. Methods A mixed-methods approach in this study comprised observations and interviews in ten healthcare settings across primary care centers (PHC; n = 6), secondary care centers (SHC; n = 3), and tertiary care hospital ( n = 1). Data were collected from June to November 2023. Semi-structured interviews were conducted among patients ( n = 30) including survey questionnaires among 144 healthcare workers (HCWs) focused on triage. The qualitative data were analyzed using Interpretative Phenomenological Analysis and quantitative data were analyzed to explore the median score on the consistent practice of triage based on the Likert scale. Results PHCs had designated space for triage with less equipped emergency services and outpatient departments (OPDs) and received severely ill patients rarely. Although prioritizing critical patients and prompt care was part of the services, there was a lack of triage protocols with more than half of the HCWs (56.3%; 36/64) from the tertiary hospital reporting the availability of triage guidelines compared to SHCs (28.1%; 9/32) and PHCs (6.3%; 3/48). The majority of HCWs from the tertiary level recognized triage's effectiveness in reducing time lag, and prioritizing patients. Tertiary level had the consistent use of triage (94%; 60/64) compared to only around two-thirds in SHCs (66%; 19/29) and PHCs (62%; 28/45). Patients often attended PHC services for routine check-ups and were motivated by health insurance, affordability, free medicines, referral cards, and proximity. In the SHC, there was a well-equipped emergency department (ED) with specific guidelines, but its use was infrequent. Patients were unaware of the triage process and its utility. In all settings, while most HCWs had a basic knowledge of triage, some were not confident due to limited exposure to the triage process and training. Many HCWs reported the need for triage-related training and its’ consistent implementation. Conclusions Consistent utilization of triage protocols, coupled with improved infrastructure, resource allocation, and training for healthcare workers is critical for the optimization of triage processes in healthcare settings in the Kathmandu Valley, Nepal. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-024-01139-y.

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Triage for resource-limited emergency care: why it matters

Cited by 3 publications

References 31 publications

Triage implementation in resource-limited emergency departments: sharing tools and experience from the Pacific region

Triage implementation in resource-limited emergency departments: sharing tools and experience from the Pacific region

Systematic review: What is the impact of triage implementation on clinical outcomes and process measures in low‐ and middle‐income country emergency departments?

Triage processes in primary, secondary, and tertiary health care facilities in the Kathmandu Valley, Nepal: a mixed-methods study

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