Is the Triage System Welcomed in the Tertiary Hospital of the Limpopo Province? A Qualitative Study on Patient’s Perceptions

Round 1

Reviewer 1 Report

Dear authors,

 

It was a pleasure to read your paper. I am not a clinician, but I do have a background in healthcare management, particularly management control, and qualitative methods. This is a very interesting study that explores patient perceptions of a triage system and practice in a hospital. Speaking generally, I can see that the paper, as is exists contributes to the literature although in a rather minor way. I would suggest several issues to be addressed before re-submission to develop that contribution and have a strong impact.

 

1.     Motivation: It seems to me that the paper needs to do more to explain why it is important to explore patient perceptions of triage practice. Is this a matter of effectiveness or are there other reasons to understand these perceptions to be useful?

2.     Triage model or proactive: Closely connected with the question of motivation is that question of what you are intending to study. The study articulates the model as the focus of evaluation, but then the empirics focus on questions related to implementation, communication, etc. These appear to be (important) aspects of triage practice, but largely independent of the actual model that is being used. I wonder, in other words, if the study intends to investigate patient perceptions of a triage model, or patient perceptions of triage practice in a hospital. Another minor related point: SATS is used before the full name is introduced.

3.     Purposive sampling. I didn’t know enough about the object of study to be convinced that the sample selection was robust. Selection seems to drive by classification, but why not demographic, diagnosis, etc.? Why, moreover, are red patient excluded as presumably they are affected by the triage process? This issue relates to point 1 and 2 above: without a clearer articulation of the motivation for the study and the specific object of investigation, it is hard to justify the sample selection. Whether the sample is enough to be generalizable, likewise, depends on your ability to clarify the object.

4.     Benner’s theory: It seems to me that this should be introduced before the methodology section to be able to understand the references to Benner in that section. Given that you also develop the use of Benner’s theory as a contribution of the study, it should take a greater prominence in the front of the paper. This issue again relates to point 1: a clearer understanding of the theoretical relevance of clinical wisdom in nursing practice for triage effectiveness needs to be articulated.

5.     Table 1: While relevant, I am not able to really evaluate its meaning. Clearly the sample is not large enough to make inferences about age or gender and perceptions. So, why is this information relevant? Perhaps a bit more hypothesis development would allow us to make sense of this descriptive information.

6.     Presentation of section 4.2: More could be done to organize your findings in each sub-section. The very long paragraphs make it hard to understand the development of an argument. Many sub-sections end with summary recommendations. Perhaps these can become separate concluding paragraphs under each sub-section to bring consistency to your analysis.

7.     Analysis of findings: These are several instances in which normative statements are made which exceed what is presented empirically. One extreme example in section 4.2.4 states “This study revealed that the triage system is not good because one will have to wait a very long time before one can be attended”. This seems wildly simplistic given that triage is explicitly designed to increase the wait of some patients so that patient welfare collectively can be maximized. There are several other statements such as these that seem quite unsubstantiated. To avoid this, I think it would be useful to separate your empirical findings—what patients say about the triage system as they experience it—more clearly from your analysis of the implications of those findings—what you understand the meaning of these statements to be for the operation of triage. This analysis could come as a separate paragraph at the end of each sub-section. Such analysis will require you to take a more explicit stand on how you are thinking about the value and relevance of patient perceptions (see point 1 above).

8.     Recommendations. These feel rather shallow and only loosely related to the empirical findings. They can be enhanced if you address point 1 above.

 

I hope that these recommendations will prove valuable as your advance this study. It may be, given my unfamiliarity with the journal, that all these comments are not equally relevant—and I would hope the editor can direct your attention to those that are most relevant—but I think addressing them all would make the paper more readable and impactful.

Author Response

Thank you for the valuable comments. Comments were effected as suggested, Please see the attached correction for reviewer 1

Author Response File: Author Response.docx

Reviewer 2 Report

This is a qualitative study of patients' perceptions on the use a triage system in an emergency department of a tertiary hospital in South Africa.

It is a comprehensive well-conducted study that has managed to highlight some of the difficulties in applying a triage system in a hospital emergency department.

However the manuscript could be improved by enriching the introduction with some additional information on how the SATS work and specifically to define after how long the patients initially classified yellow and green are being re-assessed in the emergency department and to clarify if this is actually something that the system entails.

Moreover, some re-arranging of the paragraphs will help the flow of text for the reader. For example lines 61-67 should be mover to line 78 to make more sense.

Also in the text there is use of both acronyms SATS and SAST (lines 71, 103, 130

In fact in line 130 it is written SAST triage system which is overstatement as both words triage and system are supposedly included in the acronym.

The 7 domains described for the first time int he paper in lines 235-241 should also be mentioned in the Methods section (in line 166 for example)  to give the reader a clearer idea earlier in the text.

Also in the Methods section, please state the time period when the interviews took place.

Line 69 to effectively sorts and categorizes, CORRECT sort and categorize

Line 121 in triage nor received in-service TRAINING (add training in the end)

In Table 1 correct Age 18-2

Line 444 to ensure order and void confusion. Do you mean AVOID?

Recommendations "Constant communication with patient triaged is vital to reas-486 sure them." This final phrase is very essential and links with the way the triage system is designed and operates (see my comment about enriching  the introduction), so please elaborate on this point a bit further especially on how constant communication can be achieved.

  

Author Response

Thank you for the valuable comments. Comments were effected as suggested. Please see the attached correction for reviewer 2

Author Response File: Author Response.docx

Reviewer 3 Report

1. abstract: Please add the duration of the interview.

 

2. In the first paragraph of the introduction(line 41-45, line 46-48), the main sentences are described by mentioning the names of the researchers, but it is recommended to add references at the end of the sentence rather than mentioning the names of the researchers in the introduction.

 

3. Was the interview conducted only once per participants? Please add how many sessions were conducted per participants.

 

4. Please add the main research question used for the in-depth interview.

 

5. It seems necessary to add a discussion on the contents of the six areas revealed through qualitative research.

Author Response

Thank you for the valuable comments. Comments were effected as follows: Please see the attached correction for reviewer 3

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

I believe it is sufficiently improved for publication.