To the best of our knowledge this is the first study conducted to assess the triage system and identify barriers in its application in hospitals in Sudan. Our study clearly demonstrated that Sudan has a deficient formal 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 [28, 29]. In comparison to high income countries, where triage had been broadly implemented across EDs ever since the 1990s [4, 5] and in Sudan, the system was only introduced in 2001 .
Nurses made up most of the participants in our study (30.3%). It is widely accepted that the triage is generally done by a triage nurse but it can also be performed by physicians and receptionists [30–33]. Nurses and registrars had the most positive perception amongst the staff while specialists, consultants and matrons had a negative perception on the triage system in the hospital they work at, this might be justified by the fact their perception is quite likely to be based on their years of experience and their comparison to prior practice.
A significant association was found between the staffs’ residence and their perception of a well functioning triage system, where the residents of Omdurman expressed the most positive perception of the triage system in the hospitals they were working in. This finding can be explained by the fact that the where they reside might determine the hospital they are employed at and this coincides with the positive association this study has found in accordance to the perception of the healthcare workers of the hospitals within the vicinity of Omdurman locality (i.e.: Al-Nau hospital).
All the staff working at Ibrahim Malik hospital believed that there was an existing triage system at their hospital of employment. Meanwhile the percentages of staff that shared a similar view were 90% from Al-Nau, 80% from Omdurman, 64% from both Khartoum North and Al-Tamayouz, 36% from Alban Jadeed, 4% (1 participant) from the Turkish Hospital and none from Ombada. Furthermore, a significant association had been found between the hospital the staff worked at and their perspective of a well-functioning and efficient triage (at a p-value of 0.007) in chi-square analysis. This may be explained by the fact that staff from different hospitals had different perspectives on what a triage system should constitute based on their knowledge and experience at other hospitals. Staff at Al-Nau hospital (77.8%) mentioned that the triage system is well-functioning while it might have not been competent, one explanation is that they might have worked at a less qualified hospital and they considered their ED triage as sophisticated. While those at Khartoum North hospital (75.0%) perceived it as poorly functioning and this is perhaps due to the fact that they worked at a more advanced hospital. This might also be due to the differences in the hierarchy of administration, capacity of the hospitals, funding and the tools used in each hospital.
A significant association was found between the staffs’ perception of a well-functioning triage with certain hindrances to the application/improvement of the triage system on chi-square analysis. The most important barrier being the role played by the administration and legislative measures taken by authorities (p-value of: 0.026), which was supported by a significant association on logistic regression (p-value of: 0.020). This is because most of the participants of this study (78.8%) 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 [20–22, 31].
Other barriers were the need for substantial capital expenditure and adequate provision of resources (p-value of: 0.026), adequate training of the staff on means to performing an effective triage (p-value of: 0.017) and raising their awareness on the importance of the correct application of triage guidelines (p-value of: 0.007). In regards to the other barriers, up to 63.0% of our respondents stated 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. It stated that emergency treatment, given the growing burden of medical, surgical and traumatic emergency conditions, is an integral component of health systems and is of increasing significance. This burden is inappropriately highest in low-and middle-income countries (LMICs), which are least equipped to assess and treat emergency situations due to organizational and planning failures, skilled staff and physical resources . Another study conducted in Australia suggests adjusting the triage area to make triage agents more accessible and at the first point of contact would promote adherence to evidence-based guidelines. Nevertheless, they stated that this requires substantial capital expenditure .
Lastly, the participants in our study asserted the necessity of adequately training the staff on means of performing an effective triage (48.9% of the responses) and raising their awareness on the importance of the correct application of triage guidelines (28.3% of the responses). This was highlighted in our study by the fact that several participants lacked the knowledge of how triaging is performed at their respective hospitals. The closest we found to our results were those of several studies that emphasized the importance of training and educating the staff. In Malaysia, paramedic medical officer assistants and registered nurses, both of whom have completed 3 years of training, become eligible to perform triage roles in the ED . Meanwhile, in Iran, the various performance challenges that were identified affecting the quality of triage units in ED were the lack of clinical competency of the triage nurses, encouragement to motivate staff by the administration, specific instructions and policies for triage patients and specialist training workshops to motivate triage nurses .
In another study exploring the emergency nurses' assessment of the triage, it was identified that the lack of trained and experienced staff compromises decision making at the initial patient encounter . A review that evaluated literature from Saudi Arabia and the Eastern Mediterranean Region on triage, emphasized on capacity-building and recruitment of nurses. It stated that the initial issue of implementing triage can be solved by hiring professional nurses with advanced expertise in triage and yielding them in the education of other nurses . In a randomized control trial that was conducted in Malaysia that identifies the effect of training triage officers on the accuracy of triaging adult trauma patients, concerning the accuracy of triage decisions, the effect was significantly different between the control group and the intervention group (p < 0.001). It was concluded that the triage training improved the skills of the participants and the accuracy of triaging .
On assessment of the performance of the triage it was found that as per existing guidelines patients should be immediately triaged upon arrival and the assessment time should take about 2 to 5 minutes [23–27]. 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 . A significant association had been found between immediate assessment (p-value of 0.000) in chi-square analysis and (p-value of 0.005) by logistic regression and staffs’ perception of a well-functioning triage, similar to an audit conducted in Australia (p-value of 0.005) . Overall, 46.7% of the participants reported that the triage assessment normally took 2 to 5 minutes. 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 minutes in a study conducted at a trauma center . Upon arrival to the ED the patient has to be assessed immediately as this is the most critical period spent in the ER.
Mis-triaging was reported to be a very likely outcome by approximately two thirds (60%) of the participants in our study. On the contrary to these findings, only 5.8% of patients were judged to have been mis-triaged by expert review in a study conducted in Ghana . This might indicate that it has a better triage system, although the system has been implemented around the same time, Ghana is now more advanced. Incorrect assignment of triage codes can lead to adverse consequences on patient outcome. An experienced triage officer that uses a consistent triage scale should be present at the triage desk. This can ensure better outcomes, less adverse events, reduced overcrowding and increase patients’ satisfaction.
In the two hospitals with a triage scale, namely Ibrahim Malik Hospital and Omdurman hospital, 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 85.7% were adherent in the latter. Likewise, it was stated by a systemic review stated that triage wasn’t performed by the staff at all in some instances .
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 .
Nearly a third of our respondents stated that documentation is inadequate. Previous studies have indicated that missing data is common in emergency medicine . Maintaining a high quality of documentation can assist in producing evidence for legal purposes and assessing the adequacy of clinical care provided for the patients.
As demonstrated by an internal survey of emergency nurses and patient care assistants, violence is a continuing problem within the ED . According to the Australasian College of Emergency Medicine guidelines for triage  the front line staff should be trained on dealing with challenging behavior on part of the patients and their relatives and protocols should be implemented to provide a safe environment for the staff and patients which is crucial to ensure an efficient ER triage. Our study concluded that there is 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. In another study one of the challenges related to emergency management was the inadequacy of the security section in the triage area .
More than half of the participants stated that the average length of stay exceeds four hours regardless of the presence of a triage system; and may often extend up to 24 hours. This is beyond the four hour target for the maximum length of stay at the ED that mandates discharge or admission of 98% of patients within 4 hours of arrival. Following the introduction of a four-hour target strategy, a reduction in waiting time had been achieved in England. Similar waiting time targets have been set in Australia (4 h) and New Zealand (6 h) with some beneficial effects observed on patient outcomes [17, 18].
In some cases triage offers a moderate decrease in the LOS at EDs which was seen in a hospital with a triage system where the daily mean length of stay during the entire study period was approximately, 4 hours . In Canada in a hospital that implemented the CTAS, the mean ED LOS was approximately, 4.5 hours . However, the four hour target is still exceeded sometimes. Hence, implementing a triage on its own is not sufficient to decrease the LOS and further measures should be taken. This is supported by a study done in a university hospital in America, where patients categorized without faculty triage had a mean LOS of approximately, 7.4 hours while patients categorized with faculty triage had a mean LOS of approximately, 6 hours. Mean difference in LOS was only 82 minutes . In the Netherlands, the total LOS did not differ prior to and after the implementation of the triage system; with the minimum LOS being 0.04 hours and the maximum LOS 12.55 hours .
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.
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. The mean length of stay is an imperfect measure as it was an estimation by the ED staff. 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 which was controlled by running a multiple logistic regression.