Identifying barriers and facilitators to implementing triage systems in low- and middle-income countries: A scoping review

More than 50% of mortality and one-third of disabilities associated with a range of medical and surgical conditions may be prevented by a well-established Emergency Care System (ECS). The World Health Organization (WHO) has developed a framework that defines the essential ECS functions, including facility-based triage. This scoping review aims to identify the barriers and facilitators to facility-based triage implementation in low- and middle-income countries (LMICs) within peer-reviewed literature and map them to the Consolidated Framework for Implementation Research (CFIR). We searched Scopus, Web of Science-Core Collection, Ovid MEDLINE, Embase, Cochrane CENTRAL, CINAHL, AfricaWide, and Global Health for original research articles, with one or more barriers or facilitators to triage implementation in an LMIC facility. Two reviewers independently screened studies in Covidence. A third reviewer resolved conflicts at each stage. Data was extracted in Covidence by one reviewer and verified by a second. We conducted thematic content analysis of barriers and facilitators and mapped them to the Consolidated Framework for Implementation Research (CFIR). We also conducted quality appraisals of each study using Joanna-Briggs Institute (JBI) tools and the Mixed Method Appraisal tool (MMAT). Our search yielded 1,586 articles, including 839 unique articles. After applying inclusion/exclusion criteria, we included 57 studies. 42 (73.7%) studies were mapped to the Innovation domain; 19 (33.3%) studies were mapped to the Outer Setting domain; 50 (87.8%) studies were mapped to the Inner Setting domain; 51 (89.5%) studies were mapped to the Characteristics of Individuals domain; 53 (93.0%) studies were mapped to the Implementation Process domain. Several barriers and facilitators to triage implementation in LMIC settings are reported in the literature. Our analysis provides a comprehensive framework for emergency care leaders planning to implement or scale triage implementation in LMICs.