Exploring emergency department visits: factors influencing individuals’ decisions, knowledge of triage systems and waiting times, and experiences during visits to a tertiary hospital in Saudi Arabia

In recent years, there has been an increase in the utilization of emergency departments (EDs) in many countries, including Saudi Arabia, as the number of patients keeps rising [1, 2]. Such an issue can be partly attributed to non-urgent presentations, which comprised approximately 50% of all ED cases in Saudi Arabia and Australia [3, 4]. In Saudi Arabia, non-urgent patients reported multiple reasons for visiting the ED including the lack of a regular primary healthcare provider, convenience and quick access, and the perception that they will receive better care [5]. In addition, major delays in delivering care to patients in EDs have been reported in Riyadh (the capital city of Saudi Arabia) [6]. All these factors can lead to ED overcrowding with consequences such as increased waiting time, impaired patient-centered care, and disrupted evaluation and treatment [7].

Another component of this issue is triage, which is the assignment of priority to patients based on the level of urgency attached to their case [7]. The main goal of triage is not to increase or decrease general waiting times, but to provide immediate care for those in most need [8]. Therefore, triage leads to decreased waiting time for all patients except those in the lowest priority category [9]. Long waiting times are not only associated with poor satisfaction, but can also negatively impact patients’ perception of information, instructions, and the overall treatment [10, 11]. Decreasing waiting times is not an easily achievable aim; however, factors such as improving patient knowledge of how the assignment procedure works and communication of estimated waiting times can increase patients’ satisfaction during ED visits [10, 12, 13].

Additionally, patients’ expectations regarding waiting times for laboratory or imaging results (conducted in the ED) appear to vary greatly. In one study, the interquartile range (IQR) for patients’ time expectation for computed tomography (CT) scan results, for example, was 30 to 94 min [14]. This variation could be attributed to a general lack of knowledge regarding such procedures.

A review of the literature revealed some studies that addressed patient awareness of ED triage. For example, Adeniji et al. reported that patients lack a good understanding of the triage [15]. Meek et al. reached a similar conclusion and added that patients wanted to know more about the process [16]. Additionally, Seibert (2014) found that only 33% of patients were aware of the definition of triage [14].

To our knowledge, no studies have yet been conducted to evaluate ED patients’ knowledge of triage in Saudi Arabia or the Middle East. Therefore, in this study, we aimed to assess ED visitors’ knowledge of triage, to understand the factors influencing individuals’ decisions to visit an ED and to explore the experiences of ED visitors to a tertiary hospital in Riyadh, Saudi Arabia.

Knowledge of triage systems among patients is not a widely investigated topic in the literature. The importance of addressing this issue lies in the fact that increased knowledge of triage systems is associated with increased patient satisfaction [10, 12, 13]. Consequently, it is important to gain an understanding of patient satisfaction as well as the level of ED visitors’ knowledge of the triage system and other factors that influence their experience during ED visits.

In this study, 61% of participants reported understanding why some patients are seen before others; of these participants, 83.6% where able to provide a correct explanation for their answers, while 16.4% failed to do so. These results are consistent with the findings of Seibert et al., who reported 68% of participants reported understanding this issue, of which 87% provided a correct explanation [14]. Those who understood why some patients are seen before others were more likely to consider this situation to be fair, an association that was also reported to be significant by Seibert et al. [14] After explaining triage to the participants, respondents in the study be Meek et al. reported a score of 6 on a 7-point scale for fairness [15]. Furthermore, 24% of participants reported an understanding of the triage process, with 45% of these participants were able to provide a correct explanation; thus, only 11% of participants were able to define triage correctly. This number is much lower than the 33% reported in the USA and the 50% reported in Australia [14, 15]. These results indicate that the population in Saudi Arabia is as likely as those of other counties to know why some patients are seen before others in the ED, yet less likely to be able to correctly define triage. Furthermore, our findings indicate that patient satisfaction in directly related to their level of knowledge about triage.

Although the services provided by EDs have undergone improvements, some variations have been noted. Such variations may prompt some patients to choose one ED and avoid another. For instance, distance from the ED and presumed waiting time were the most influential factors in dictating patients’ choice of ED [17]; however, in this study, excellence of care and having regular care in an ED were the main reasons that influenced patients’ decisions. Nearly 75% of patients stated the importance of receiving periodic updates about waiting time, with 69% of these preferring updates every 30 min. While 30 min was the shortest interval offered as an option in the present survey, the survey used by Cooke et al. included a 15-min interval option [18]. A greater proportion of respondents in that study still preferred updates every 30 min (55%) compared with every 15 min (21%). More than 80% of participants viewed the provision of information about health education topics (e.g., diabetes, stroke) during the waiting time as important, which is consistent with the findings of a study conducted in the Boston [19]. Lastly, 61% of participants wanted more information on how the ED operates, with 50% of these preferring the information to be delivered by a video playing in the waiting room. Educational videos during ED visits have been reported to be associated with increased patient satisfaction [20].

Primary health care (PHC) plays an integral role in the quality of every sector in the health care system, including EDs. Overall health in communities, reduction in mortality, and health inequalities can be improved by providing high-quality primary care services [21]. Accessing well-established PHC reduces ED’s visits by approximately 50% and referrals to specialty care by 30% [22]. Lack of regular access to PCPs is one of the reasons for ED overcrowding worldwide [23, 24]. An international study conducted by van den Berg et al. to investigate how the likelihood of attending an ED is related to accessibility of primary care showed the percentages of participants not having PCP in the following countries: 7.8% in Denmark, 10.7% in Belgium, 16.6% in Finland, 20.5% in England, 23.8% in Australia, 25.7% in Canada, 29% in Germany, 41% in Norway and Slovenia, 51.9% in Czech Republic, and 73.6% in Slovakia [25]. Those percentages, not surprisingly, were below that identified in this study in Saudi Arabia, with almost 84% of ED visitors reporting a lack of access to PHC. Moreover, only half of those who had PCPs in this study attempted to communicate with their doctor prior to attending the ED. This finding is not accordance with the study by Afilalo et al. showing that 22% of ED patients had tried to contact their PCPs before attending the ED [26]. Such apparent inconsistencies may be explained by variation in the health care systems in different countries. In Saudi Arabia, PHC was not a priority for the leading personalities in the health sector, which results in ED overcrowding. However, in 2016, the Saudi government announced a new plan (2030 vision) to encourage citizens to make use of PHC as a first step and by increasing family medicine residency training program opportunities all over the country [27].

The mean time patients expected to wait for test results reported by participants in this study did not vary significantly from that of other studies, although different approaches were used to assess this variable. In this study, after excluding outliers, the mean times patients expected to wait for the results of laboratory tests, X-rays, and CT scans were 69, 47, and 61 min, respectively, whereas Seibert et al. reported 60 min for laboratory test results, 35 min for X-rays, and 60 min for CT scans [15]. It is worth mentioning that the latter study reported the median expected times. In another study, 58% of patients reported expecting to receive their test results within 1 h [18].

In this study, we used a convenient sample of ED visitors at a one tertiary hospital in Riyadh. Therefore, our study population cannot be representative of all ED visitors in Saudi Arabia or the Middle East. Moreover, non-Arabic speakers were not asked to participate in this study, which further limits the generalizability of our findings. Furthermore, variations in the work pressure and patient flow in the ED with time might influence our findings. However, the data were collected during different shifts (morning, evening, and night) on weekdays and weekends. Furthermore, the results could be skewed by the response rate of 80% and differences in patient waiting times during which the DCF was filled.

In conclusion, our population is not aware of triage. Efforts should be made to promote knowledge of triage. Additionally, only a small percentage of respondents said they have a primary care provider. It is important to provide access to primary care to community members. Finally, respondents in this study wanted more information regarding their visit and general information about health. These expectations should be met either by public health campaigns or educating material within the ED.