Emergency department triage in Saudi Arabia : towards a standardised national triage system

More than 16 million patients are presenting for care in emergency departments (ED) in the Kingdom of Saudi Arabia (KSA) annually and this number is increasing. It is therefore essential that EDs utilise a systemic way to prioritise patients’ care based on clinical urgency. Despite the increase in demand for ED services, a formalised triage system is not common practice in most of the public EDs in Saudi Arabia. Consequently, this thesis aimed to develop a national triage system for the KSA; this was achieved in three stages. This thesis explores and describes current triage practice in public EDs in Saudi Arabia and investigates the support that is provided for the implementation of ED triage, including triage policy and procedures and education programmes. In addition, this thesis developed a national standardised 5-level triage system that is clinically and culturally appropriate for Saudi public EDs. To achieve these aims, 3 studies were conducted separately. The first and second studies focused on current triage practice, while the third study was concerned with the future of triage in public EDs in the KSA. The first study was a quantitative comparative descriptive study that utilised previously validated simulation scenarios. This study explored current triage practice in public EDs in the KSA. Further, it described and compared the concordance and accuracy in triage decisions among 105 ED nurses and physicians working in Saudi public EDs. The second study was a qualitative document analysis. It explored current triage policy and procedure as well as educations programmes that currently support ED triage practice in both public and non-public EDs in Saudi Arabia. Triage policy and procedures as well as educations programme documents were collected from the Ministry of Health (MOH) and three non-public hospitals. The findings of Studies 1 and 2 illustrate that triage is not well organised or practiced in public EDs in Saudi Arabia. More than 50 per cent of the study participants believed that formal triage does not exist in their EDs. The findings also showed lack of agreement between triage policies and procedures in regard to the clinician responsible for triage, the qualification of the triage clinician, the triage scale used and the education preparation for the triage role. Against international recommendations, the MOH triage policy recommended a three-level triage scale. Moreover, agreement in triage ratings among the ED clinicians was only fair (unweighted kappa = .25). The third study employed a two-stage modified Delphi methodology. The aim of this study was to develop a Saudi national triage system that is clinically and culturally appropriate for public EDs. A panel of 31 ED nurses and physicians participated. Consensus was reached on a five-level triage scale. In addition, the panel members agreed on a list of clinical descriptors to be used with the new triage system. Moreover, the panel members identified a list of potential barriers and cultural issues that may influence the implementation of the new triage system. In conclusion, current triage practice in public EDs in the KSA is ad hoc, and implementation is reliant on local interest. In light of the limited reliability and validity of the three-level triage system recommended by the MOH triage policy, it seems that public EDs do not adhere well to the policy. This study developed a five-level triage system to replace the current system