Introduction of systematic triage in the emergency room at Dhulikhel Hospital, Nepal: Evaluation of a quality improvement project
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Introduction: Correct use of systematic triage has been shown to provide the sickest patients essential care first and to increase survival. As a validated tool for both adults and children, and an established system at St. Olavs Hospital, RETTS (Rapid Emergency Triage and Treatment System) was chosen to be introduced in the Emergency Room (ER) at Dhulikhel Hospital (DH), Nepal. Our study aims to describe the implementation of a triage system in a low-resource setting and analyse adherence to the system after introduction. This quality improvement project evaluation was done one year after the implementation. Materials and methods: All patients presenting to the ER at DH from the 1st of February to the 30th of September 2015 were included in the study. Data including age, gender, if the patients had been triaged or not, color-code of triage and time of admission from 8499 handwritten records were collected and registered. Qualitative observations, semi-structured interviews and a questionnaire among the staff were performed. We made a statistical process control chart to control the percentage of patients with triage. The results from the remaining data collection and from the questionnaire were analysed and presented. Results: During our study period two large earthquakes struck Nepal, and this natural disaster affected our results considerably. The documented triage percentage was at 30% before the earthquake-period and at 71% after. There were 23% patients in the most severe triage categories red or orange. The yellow category constituted 36% of the patients and 42% were categorized as green. There were 6158 (82%) adult patients (>16 years) and 1281 (17%) children (0-15 years). Triage category were given in 51% of the adult population, while only 37% of the children had a registered triage category. The triage categories were also distributed differently among the pediatric and adult population, in particular it was fewer children in the most severe categories. No use of the triage room and also the lack of using ESS (an important part of the RETTS) was observed. Most of the doctors who was interviewed highlighted that high turnover of staff in the ER is a challenge to continuity and that frequent training is important. From the questionnaire it emerged that nearly half of the triage-staff do not think the triage system is easy to use. Close to 100% of the staff think it is meaningful to continue doing triage in the future. Conclusion: The implementation of triage some months in advance seem to have had a positive impact on the way the staff at DH handled the earthquake. One year after implementation, triage percentage is about to reach the goal at a stable 80%. However, several errors in performing RETTS were identified. It is possible that the RETTS is too complex and time-consuming for the Nepali setting. To improve and maintain triage skills, further training is essential, in particular towards pediatric patients. Relocation of the triage room would probably increase the share of triaged cases. Another possible solution is to implement an easier and more context-friendly triage system, like the South African Triage Scale (SATS).