Awareness of importance of triaging in emergency department in Kingdom of Saudi Arabia

1. Introduction

The emergency department (ED) is one of the most important compartments of the health delivery system [1]. EDs are thus a significant department in many hospitals [2]. The coexistence of non-urgent walk-in patients and acute emergencies nonetheless poses challenges, as delivering prompt treatment for the latter can result in a decline in the quality of emergency services for the former, alongside increases in overall costs [3]. Recently, in most hospitals the ED is the most crowded department and this creates accessibility issues for most patients [4].

Triage is the process of categorizing patients in the ED according to their need for medical care, regardless of their order of arrival, alongside other factors such as age, gender, insurance, socioeconomic status, nationality, race, religion or residential status. Triage involves the assessment of prioritized ED patients needing immediate care in accordance with times urgency and clinical severity, compared with patients with non-urgent diseases who can wait longer to be seen or those who need a referral to more appropriate healthcare settings [5].

Research indicates most ED visits are non-urgent cases, which leads to unnecessary costs and many adverse consequences. For example, in three Ministry of Health hospitals located in Saudi Arabia, a study discovered more than half (53%) the patients who visited the ED did not require urgent care. Furthermore, 68.5% of these non-urgent cases visited the ED three to four times yearly [6]. The utilization of EDs by patients who do not require urgent medical attention has emerged as a significant public health concern both on a local and global scale [7].

Increased numbers of patients visiting the ED results in long waiting times, overcrowding and poorer patient satisfaction [2]. Reducing ED wait times nonetheless presents a significant challenge. However, explaining how the process of providing health services works and interacting with short waiting times may help boost patient satisfaction. This is why improving patient education is essential [8]. There is however a lack of studies assessing the knowledge and awareness of patients about the importance of the triage system in EDs in Saudi Arabia, which was the rationale for this study.

2. Subjects and methods

3. Results

The 2056 participants provided demographic information like age, gender, education level, current employment, nationality, place of residence and income. The data is shown in Table 1.

The participants were asked about their last visit to the ED. The major causes of ED visits were abdominal pain (26.4%), headaches (14.4%), and chest pain (11.1%). Other health problems are shown in Table 2.

Data concerning the circumstances of the ED visit, when the health problem started, who was the patient, the type of hospital, along with other variables, are shown in Table 3. The largest proportion of participants reported that the health problem started the same day as the ED visit (47.6%), that the patients were the participants themselves (56.3%), and that a government hospital was where they attended (71.7%). Most participants did not try to visit a PHC facility (72.3%).

Just over half of the cases were not classified as critical (50.7%), though at the same time just under a quarter of study participants did not know how their case was categorized (22.9%). The major causes are in turn shown in Table 4. The most reported causes were being too sick, so needed the ED (64.8%), along with close to where they live or work (46.2%). The other causes rated less than 30%.

Table 5 presents the reasons for heading directly to a certain emergency department. The most reported causes were hospital resources (63.6%) and other causes (59.8%).

Participants’ knowledge about the triage system was investigated through ten questions. The results are shown in Table 6.

The difference in knowledge was evaluated regarding different variables. There was no significant difference in the level of knowledge (p = 0.1). There was also no significant difference between the mean score of knowledge regarding gender (p = 0.6). However, significant differences in the mean score of knowledge were found for educational level (p < 0.001), current job (p = 0.001), and residence (p < 0.001). The mean score of knowledge did not vary between different incomes (p = 0.2) or nationality (p = 0.3), all these information shown in Table 7.

There were five questions used to assess the importance of information in the ED. Each question has four answers, either not important at all, not important, important or very important (Table 8). Both medical conditions (42.3%) and updates about the delays (41%) were considered very important. The highest proportion of participants reported that common illness (43.2%) and the healthcare system (43%) were important.

The time taken for some procedures was investigated. The procedures included laboratory results, X-rays, computed tomography (CT) scans, consultation with another doctor, and getting a bed (Table 9). The most reported time was less than half an hour for X-rays (48.5%), consultation with another doctor (42.5%) and getting a bed (46.5%). This was followed by half an hour to one hour for laboratory results (36.3%) and a CT-scan (31.1%).

The attitude of participants in respect how to improve primary healthcare to prevent overutilization of the ED was assessed via four questions (Table 10). The absence of a specialized doctor was the main cause of going to the ED directly, as reported by most participants (80.1%). A large majority (89.3%) agreed that having a PHC center with an emergency doctor and expert nursing staff, along with an ambulance, would save time and effort in accessing health services. The majority agreed that the opening time of PHC centers must be 16–24 hours/day (80.8%). The majority (82.9%) also agreed that increasing the working hours of the PHC centers would reduce the crowdedness in the ED.

4. Discussion

The ED is a crucial component of the healthcare delivery system, with triage an important part of the ED. In the current study, however, only 55.7% of participants knew about triage, although 77.3% knew why some patients were admitted to the ER before others. This may mean many people know about the triage system, just not the specific term. By contrast, a study based in Opole, Poland, showed that 90% of participants knew what triage is [10]. This proportion is much higher compared with our study.

Triage helps prioritize treatment based on acute clinical need, however it can lead to long waiting times for some patients with non-urgent conditions, which may in turn affect the patient’s satisfaction along with the quality of service delivered. In one study from Saudi Arabia, it was found that waiting time was a significant modifiable risk factor for patient satisfaction [11]. Therefore, it is necessary to understand and assess the knowledge of patients about the triage system, to know if the ED waiting time is a major factor affecting patient decisions about what health care facility to visit in emergency situations. As there is a lack of studies focusing on this subject in a Saudi Arabian setting, this study was conducted.

It can be inferred that one strategy to improve the burden on emergency departments is to reduce waiting times for patients with non-emergency conditions. This can also be achieved through the implementation of measures to streamline the screening process and ensure that patients receive appropriate care in a timely manner.

In our study, the mean level of knowledge was low (8.79%). Regarding each aspect of knowledge assessed, the highest level of participant knowledge was found in respect why it is fair for some patients to be taken to the emergency room (ER) before others (83.1%). In a previous study conducted on the Saudi population to assess their knowledge regarding triage in the ED during the COVID-19 pandemic, it was found that the majority of participants (80%) knew the reason that some patients are taken to the ER before others; moreover, 85.3% thought this was fair [9].

Similar to our findings, Seibert et al. [12] revealed that 51.2% of patients correctly reported the definition of triage. Worse findings compared with ours were reported by Alhabdan et al. [8], who demonstrated that the knowledge of the triage system in a single hospital in Riyadh, Saudi Arabia, was just 24%. Another Saudi study conducted on 389 participants who visited an ED revealed that 66.2% have no knowledge about triage [2]. These findings were thus lower than our studies.

In the current study, most participants (73.7%) wanted to know how long other patients had been waiting. In a previous Saudi study of ED patients, a lower proportion (57%) of participants wanted to know how long other patients had waited [2]. In another study, the factors affecting the decision of patients to visit a specific ED were investigated. It was found that, of 634 participants, 44% reported distance was the major reason for choosing that ED over other facilities, whereas 9.3% cited waiting time [13]. The study found that the primary reason for directing patients to the ED was their urgent need for medical attention (64.8%). Hospital resources and the speed of care were the primary factors in directing patients to a specific ED, while distance ranked third. Of those who reported a reason for proximity, 46.2% cited the ED being located near to their place of work or residence.

Other studies showed that high proportions of patients reported the cause of visiting the ED was the urgency of their conditions, even if triage classified them as non-urgent [14]. More than half our study participants were not classified as critical cases. Moreover, many patients complain of ED delays due to reasons such as hospital equipment, physicians or transportation. Sometimes, the delay is due to waiting for the pharmacy to provide medication or required supplies [15]. Patients also often wait for a long time before they meet the physician and must wait even longer to be transferred to a hospital bed. This, in turn, results in a deterioration of the overall outcomes of the patients [9].

In our study, 42.5% of participants reported that consultation with another doctor takes less than half an hour. In another study, the expectations of patients regarding waiting times for laboratory and imaging results varied significantly, and the expectation of patients for a CT-scan was 30–94 minutes [12]. In the current study, regarding CT-scans, the largest proportion (34.1%) reported a half an hour to one hour, which was similar to a previous study [12]. Moreover, the largest proportion (36.3%) regarding laboratory results reported 30–90 minutes.

5. Limitations

Because of the nature of the study, recall bias is one of the limitations, as the participants attempt to remember their last ED visit to complete the questionnaire. Moreover, as the research was conducted through an electronic questionnaire, social-desirability bias is another limitation.

6. Conclusions

In conclusion, the triage process is essential for the operation of EDs, since it helps distinguish between patients who need immediate attention and those who can wait. Long wait periods, however, can cause dissatisfaction among patients and degrade the quality of the care given.

55.7% of participants in our study indicated that they were aware of the triage system, indicating that patients are not especially well-informed about it. It was discovered that knowledge was influenced by place of residence, present employment and education level. Patient expectations on the length of time they should expect to wait for doctor consultations as well as results from lab and imaging tests were also evaluated, with mixed findings found.

To increase patient happiness and overall outcomes, healthcare practitioners must aim to better inform patients about the triage system and to shorten wait times. Future research is required to examine additional elements that may influence Saudi Arabian patients’ expectations and knowledge of ED visits.

Availability of data and materials

The data used to support the findings of this study are included in the article.

Author contributions

KSA and FHA—conceptualization, supervision; JAA—methodology, visualization; FHA—software, resources; SAA—validation, formal analysis, writing–original draft preparation; KSA and SAA—investigation; JAA and KFA—data curation; KFA—writing–review and editing; KSA, JAA and KFA—project administration. All authors have read and agreed to the published version of the manuscript.

Ethics approval and consent to participate

The College of Medicine’s Committee of Scientific Research and Conferences at the University of Ha’il (H-2023-385) evaluated the research protocol and granted ethical approval for the study titled “Awareness of importance of triaging in emergency department in Kingdom of Saudi Arabia”. The participants have been provided with a clear understanding of the research objectives and, on an informed basis, voluntarily consented to participate in the study.

Acknowledgment

The author acknowledges the Deanship of Scientific Research, Ha’il University for providing support for the publication of this research project.

Funding

This research received no external funding.

Conflict of interest

The authors declare no conflict of interest.