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Emergency Medicine Australasia (2012) 24, 430434

doi: 10.1111/j.1742-6723.2012.01554.x

INTERNATIONAL EMERGENCY MEDICINE

Initial resuscitation for Australasian Triage

Scale 2 patients in a Nepalese
emergency department
emm_1554

430..434

Bibhusan Basnet, Rabin Bhandari and Malcolm Moore*

Department of General Practice and Emergency Medicine, B.P. Koirala Institute of Health Sciences,
Dharan, Nepal

Abstract
Objectives:

Triage is recognized as important in providing timely care to emergency patients. However,

systematic triage is only practised in two EDs in Nepal. The first objective of this study
was to assess the performance of one of these departments in seeing triaged patients in a
timely fashion. Second, an epidemiological survey of patients presenting to the ED was
performed to describe the conditions seen and initial resuscitation undertaken.

Methods:

We performed a descriptive cross-sectional study in the ED of B.P. Koirala Institute of

Health Sciences, eastern Nepal where the Australasian Triage Scale (ATS) is used. One
hundred and sixty patients triaged as ATS 2 were recruited. The time taken for the duty
doctor to see the patient was noted. The presenting problems, vital signs and level of
consciousness were measured at presentation. The resuscitation measures were recorded.

Results:

The mean waiting time was 2.1 1.7 min with a range of 110 min, which meets the
benchmark for ATS 2. At triage, the most common presenting problems were circulatory
shock (23.1%), altered consciousness (21%), respiratory difficulty (16.9%) and poisoning
(15%). Oxygen, i.v. fluids and antibiotics were the most common therapies used in the
initial resuscitation of patients.

Conclusion:

Patients triaged as ATS 2 were seen in a timely fashion. Seriously ill patients requiring
resuscitation present commonly to this ED. This is a big challenge for junior doctors.
Improved training, treatment protocols and equipment are needed to help manage this
burden.

Key words:

emergency department, Nepal, resuscitation, triage.

Introduction
Triage systems in EDs help to ensure that patients
receive timely and appropriate care based on their
Correspondence:

clinical need and that departmental resources are most

usefully applied.1,2 This is particularly important in
a resource-constrained setting with inadequate staff
numbers. The initial assessment can be done by a

Dr Bibhusan Basnet, B.P. Koirala Institute of Health Sciences, Post Box no: 7053, Kathmandu Dharan, Nepal. Email:
bibhusan117@hotmail.com; Dr Rabin Bhandari, Department of General Practice and Emergency Medicine, B.P. Koirala
Institute of Health Sciences, Dharan, Nepal. E-mail: bhandari529@yahoo.com

Bibhusan Basnet, MBBS, Medical Officer; Rabin Bhandari, MD, Associate Professor; Malcolm Moore, MD, Associate Professor.
*Present address: Dr Malcolm Moore, University Department of Rural Health, PO Box 457, Broken Hill, NSW 2880, Australia. Email: malnepal@
hotmail.com
2012 The Authors
EMA 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Resuscitation in a Nepalese emergency department

well-trained nurse who can then alert the relevant

medical staff.2 Triage is the first step in the process of
planning and performing resuscitation and treatment.
The Australasian Triage Scale (ATS) is a tool
designed for use in hospital-based emergency services
throughout Australia and New Zealand. Although primarily a clinical tool for ensuring that patients are seen
in a timely manner, commensurate with their clinical
urgency, the ATS is also a useful measure of the severity of cases presenting to a department. For example, a
large proportion of ATS 1 and 2 cases presenting suggests a need to increase capacity for intensive initial
resuscitation.3
The Australasian College of Emergency Medicine has
set performance indicators for EDs using the ATS. Staff
and other resources should be deployed so that the
performance indicator thresholds are achieved progressively from ATS categories 1 to 5.3 The benchmark is
that 80% of ATS 2 patients are seen within 10 min.
The ATS was chosen for use in the establishment of
the ED at our study hospital. Nepal is a poorly
resourced and developed country. It ranks 157 of 187
countries in the Human Development Index (HDI 2011)
with a gross national income per capita of $1160
per year.4 This compares with a developed country,
such as Australia, which is ranked second in the
HDI with a gross national income per capita of $34 431.
Some health indicators for Nepal are instructive: maternal mortality 380 deaths per 100 000 live births (vs
Australia 8); under 5 mortality 51/1000 (vs Australia
6); and life expectancy 63 years (vs Australia 82).4
Prehospital as well as institutionalized ED care in Nepal
still has not received much attention. Triage systems
are non-existent except in two major medical centres,
where they are not the same.
This study was conducted at B.P. Koirala Institute of
Health Sciences (BPKIHS), a 700-bedded tertiary care
and teaching hospital in the eastern region of Nepal.
The ED receives around 80 patients per day.5 It has used
the ATS system since 2003, with the benchmark of ATS
2 patients being seen within 10 min. The ED is mainly
staffed by junior doctors and nurses who are supervised
by senior doctors from the Department of General Practice and Emergency Medicine.
Triaging is done by staff nurses who have been
trained by senior doctors. It takes place immediately
on arrival, even before the patient is registered. At the
triage station, ATS 1 and 2 patients are announced
over the public address system for immediate attention and early resuscitation. Patients are distributed
to the appropriate area of ED based on their triage

level according to local guidelines. The main resuscitation areas can accommodate 8 to 10 patients with
difficulty. The emergency nurse is involved with
initial measures like venous access, airway management, supplying oxygen and fluids and assisting
doctors with resuscitation. The doctor then organizes
subsequent treatment, including the ordering of
medication.
There are several issues that make good triage and
resuscitation difficult at BPKIHS. There are shortages
of trained staff, equipment, trolleys and space. The main
resuscitation bay has three ECG and two oxygen saturation monitors. Infusion pumps are not available.
Investigation results are slow to arrive and the tests,
drugs and equipment must be paid for by all but the
poorest patients. In addition, central venous pressure
catheters and arterial lines are not placed in the ED.
Patients are intubated, but there are no ventilators in the
ED bag and valve ventilation usually being performed
by relatives or friends. Overcrowding is worsened
because transfer to the ward is often delayed while
families gather the necessary funds.
There is growing awareness in this context of the
need for early aggressive resuscitation of acutely ill
patients. The work on early goal-directed therapy for
patients with septic shock6 and the time-critical nature
of addressing the sepsis six7 are examples of concepts
needing more recognition in Nepal. The circumstances
described above make their implementation difficult.
Molyneux et al. who studied emergency services for
sick children in Malawi mentioned similar problems,
common to many developing countries.8
There is one previous study on triage in Nepal, performed at the same hospital. This audit in 2003 found
that 23.3% of ED patients were classified as ATS 1 or 2
and 70.5% of these patients were seen within the benchmark time.9 We could not identify any studies on the
practice of resuscitation in a Nepalese ED.
There are two objectives to the current study. First, to
identify and assess the time taken for ATS 2 patients to
be seen by a doctor. Second, to describe the epidemiology of presenting problems, examination findings on
arrival and the treatment instituted in the ED within 6 h
of presentation.

Methods
This is a descriptive cross-sectional study conducted
between February and December 2010. A total of 160
patients labelled ATS 2 were included. A sample was

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EMA 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

431

B Basnet et al.

collected of the ATS 2 patients present in the department at the times the researcher was present. Patients
below the age of 12 months were excluded. The study
complied with institutional ethics requirements, consent
for collection of data being given by the patient or their
attendants.
The time the patient arrived and the time seen by
the doctor are both routinely recorded in the case notes.
At the time of arrival, the following parameters were
also noted: AVPU scale (A alert, V responds to
voice, P responds to pain, U unresponsive), mean
arterial pressure (MAP), pulse rate, respiratory rate
and oxygen saturation by pulse oximeter. MAP was
calculated as 2/3 diastolic blood pressure + 1/3 systolic
blood pressure. The case sheets used for the purpose
also recorded the time, presenting problem (as noted by
the triage nurse), drugs and other treatment, supportive measures and monitoring of vital parameters.
Observations were recorded and followed for 6 h for
the study purposes.
The researchers were involved in data collection and
reviewing case notes. The data collected were entered in
Microsoft Excel (Microsoft, Redmond, WA, USA) and
further analysed using SPSS 17.0 statistical software
(SPSS, Chicago, IL, USA). Measures of simple averages
of an outcome variable along with 95% confidence interval were calculated. Continuous variables have been
provided as mean (standard deviation). Categorical variables have been provided as frequency (percentage).

Results
A total of 160 patients triaged as ATS 2 were analysed,
with 89 (55.6%) men and 71 (44.4%) women. The mean
(standard deviation) age of patients was 42.0 (19.9) and
the median age was 43.5.
The mean waiting time after triage was 2.1 1.7 min
with a range of 110 min before being seen by a
doctor.
At triage station, the nurse identified the major presenting problems as shock in 23.1%, followed by altered
consciousness (21.3%), respiratory difficulty (16.9%),
poisoning (15%), chest pain (9.4%) and snake bite
(6.8%), respectively. Triage nurses designated patients
presenting with systolic blood pressure <90 mmHg as
having circulatory shock. Of the 160 cases, 25% were
traumatic and 75% were non-traumatic in origin. Of the
37 patients identified with circulatory shock, 16 had
suffered from some degree of trauma. The 24 poisoning
432

Table 1.

Measured values of vital signs at admission

Vital signs
SPO2
Pulse
MAP
RR
Temperature

Values at admission, mean (SD)

87.8 mmHg (13.4)
96.6 /min (28.3)
88.8 mmHg (23.1)
26.7 /min (9.5)
98.6F or 37C (1.2)

MAP, mean arterial pressure; RR, respiratory rate; SD,

standard deviation; SPO2, oxygen saturation.

cases contained 14 patients who had intentionally

ingested organophosphate pesticide, 3 benzodiazepine
ingestions and 7 unknown.
The mean values of the oxygen saturation, pulse,
MAP, respiratory rate and temperature along with their
standard deviations at admission are shown in Table 1.
It is noteworthy that nine of the patients underwent
endotracheal intubation and received bag and valve
ventilation during the course of resuscitation in the
initial 6 hours.
Oxygen and i.v. fluid administration were the most
common therapies in the initial resuscitation of the
patients. Antibiotics were also very commonly prescribed in the ED, being given to 75% of all ATS 2
patients. A breakdown of the common drugs used with
the presenting complaints is given in Table 2. It was
noted that, of the patients with altered level of consciousness, 82.4% received oxygen, 91.2% received
fluids, 32.4% received diazepam, 17.6% received nebulization and 73.5% received antibiotics within the 6 h of
initial resuscitation. Among patients designated as
shocked when triaged by the triage nurse, 94.6%
received oxygen and fluids, 35.1% received nebulization
and 35.1% were supported with inotropes. Of the 14
organophosphate poisoning patients, 12 required atropinization and 2 had trivial ingestions not requiring
medication. The majority who had taken large amounts
typically required 6080 ampoules of atropine infused
every 6 h, sometimes more.

Discussion
We looked at 160 ATS 2 cases and saw young patients
with a male predominance. Turkey, with an HDI of 92
and so a moderately developed country, has reported
similar age groups for ED attenders.10 Studies from
more developed countries have reported an older
population.1113 The average life expectancy in Nepal
is 63 years. In addition, as insurance coverage for

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EMA 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Resuscitation in a Nepalese emergency department

Table 2.

Subjects presenting problems (as noted by the triage nurse) along with common drugs used
Presenting problems

Oxygen
Nebulization
Inotropes
Fluids
Frusemide
Anti-snake venom
Diazepam
Antibiotics
Aspirin/clopidogrel
Total

Total

Altered
consciousness

Resp.
difficulty

Shock

Snake bite

Poisoning

Chest pain

Others

28 (82.4%)
6 (17.6%)
1 (2.9%)
31 (91.2%)
3 (8.8%)

26 (96.3%)
23 (85.2%)
4 (14.8%)
20 (74.1%)
11 (40.7%)

35 (94.6%)
6 (16.2%)
13 (35.1%)
35 (94.6%)

6 (54.5%)

13 (54.2%)
4 (16.7%)

3 (25.0%)

11 (100.0%)

21 (87.5%)

14 (93.3%)
7 (46.7%)
1 (6.7%)
6 (40.0%)
6 (40.0%)

1 (2.7%)

9 (81.8%)

11 (32.4%)
25 (73.5%)

1 (3.7%)
19 (70.4%)

8 (72.7%)

34

27

24 (64.9%)
2 (5.4%)
37

medical care is not available, people pay for emergency

care themselves. The economic vulnerability of the
frail elderly in Nepal might deter them from seeking
emergency care.14 The male predominance is usual in
the Nepalese setting. Males are more likely to suffer
traumatic injury and are also more likely to have
money spent on their medical treatment compared with
women.
We found that the benchmark for time to being seen
for ATS 2 patients was met in 100% of cases. This
compares favourably with 70.5% in the same hospital in
2003.9 There are several reasons for this change. All
ATS 1 and 2 patients are now announced over the
public address system. The resuscitation bay is within
metres of the main doctors area, which has an open
design. Nurses can directly access a doctor. It is also
possible that times were not always accurately recorded
in the notes.
The frequent identification of circulatory shock underlines the importance of measuring vital signs. The
common problems of altered consciousness, chest pain
and respiratory difficulty are similar to emergency
problems worldwide. Snake bite, common during the
monsoon, and organophosphate poisoning were also
common. These patients often presented challenging
airway management issues because of the neurological
effects of envenomation by cobra and krait, or the bronchorrhoea and bronchospasm of organophosphate ingestion. Patients present late because of distance, lack of
transport and lack of money. Junior doctors are presented
with therapeutic challenges with limited resources and
support.
The trauma cases received at BPKIHS have many
causes. Road traffic accidents are now common. Falls

11

12 (50.0%)
20 (83.3%)
24

12 (80.0%)
11 (73.3%)
15

8 (66.7%)

4 (33.3%)
12 (100.0%)
1 (8.3%)
12

125
46
19
132
20
10
28
120
14
160

and physical assault, often using traditional khukuri

knives, are also common. About a quarter of the
patients suffered some degree of trauma and 16 of them
presented with circulatory shock, so it is essential that
the emergency services are prepared to manage trauma
and its associated complications.
A high use of antibiotics is noted in our setting, which
might be because of difficulty in initial diagnosis and
reflects the trend of use of antibiotics in South Asia.15,16
It is also because of the high incidence of infectious
conditions and the late presentations of patients.
Patients are usually started on antibiotics on presentation on the presumption of high rates of sepsis. Further,
the lack of orientation of the first attendant doctor
towards judicious antibiotic coverage might also come
into play with a desire to provide blanket therapy in
most undiagnosed cases. It is noteworthy that 70% of
patients with snakebites and 83% of patients with poisoning were given antibiotics, which indicates that more
attention needs to be given to teaching their rational
use.
The limitations to the study included the following:
the assessment of triage and timely response depended
on accurate recording in the paper file; the classification
of problems depended on nurse assessment and final
diagnosis was not sought; and medium and long-term
outcomes were not identified.
There is great scope for future research into therapies
that are used for specific conditions. In particular, the
management of circulatory shock could be studied in
the light of evidence supporting goal-directed therapy.
Protocols could be tailored for a resource-poor setting
and efforts made to provide more equipment to support
appropriate therapies.

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EMA 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

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B Basnet et al.

Conclusion

References

This study documents an early stage of the development of triage and resuscitation in Nepal. It supports the
contention that nurse-led triage is achievable and can
lead to a timely medical response in this setting. There
are more improvements required. These are in the areas
of training, supervision and the supply of necessary
equipment. There can also be more effort to develop
protocols that can be implemented by relatively junior
staff. It will be difficult, in the resource-poor setting
described in this paper, to institute protocols, such as
early goal-directed therapy as outlined in the literature.
However, the early successes described in this paper
give hope for future changes.

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Acknowledgements
The authors would like to thank the patients who participated in the study and gave valuable data regarding
their treatment. We are also thankful to Binaytara Foundation, Illinois, USA for funding the study. Also, special
thanks to Dr Surya Niroula, Associate Professor,
BPKIHS for his valuable analysis and advice on statistics and verifying the whole manuscript.

Author contributions
BB conceived, designed and collected the data for the
study, prepared the first draft of the manuscript and
assisted in preparing the final manuscript. RB helped in
carrying out the study, analysis and interpretation of
data and helped in drafting the manuscript. MM
assisted in design, interpretation of results, drafting the
manuscript and critically evaluated earlier drafts of the
manuscript. All authors read and approved the final
manuscript.

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Competing interests
None declared.
Accepted 12 February 2011

434

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EMA 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

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