Hrev_master Abstract This study aims to investigate patients’ knowledge of the triage system, utilization of primary healthcare resources, and expecta- tions for waiting times in Jordanian Emergency Departments (EDs). A descriptive, cross-sectional design was employed in the EDs in the largest public hospitals in Jordan. Convenient sampling resulted in 726 participants. A self-reported questionnaire included socio-demographic information and instruments assessing primary healthcare use, triage system awareness, and expected waiting times. Most participants (61.3%) lacked awareness of the triage system. The use of primary healthcare was influenced by age, edu- cation, marital status, current job, nationality, and location. Having a primary healthcare provider was associated with higher patient satisfaction. Significant variations in expected waiting times for diagnostic test results were noted based on gender, place of resi- dence, education, current job, and marital status. Addressing patient awareness of the triage system is crucial for optimizing healthcare accessibility and quality in Jordanian EDs. Improving patient education, communication, and primary care utilization can enhance patient outcomes, reduce ED burden, and contribute to a more efficient healthcare system. Introduction The Emergency Department (ED) uses a triage system where a nurse assesses the nature and severity of a patient’s illness.1,2 Patients are classified into five levels: immediate, emergent, urgent, less urgent, and not urgent.3 The open-door policy and easy access to the ED impact medical care. Dealing with non-urgent and urgent cases can lead to inefficiency and increased waiting times, causing stress and fatigue for healthcare providers.4-6 This can result in verbal and physical violence and lead to staff turnover, posing a threat to patient safety.7 The lack of patient awareness about the triage process can cause tension and unpredictability in patient care.8 Patients’ aware- ness about using primary healthcare resources is important to min- imize pressure on the ED and its staff.9 Understanding the patterns of patient engagement with primary healthcare facilities before resorting to ED visits is crucial for healthcare professionals and policymakers.10 Patients frequently start at primary care facilities before visiting the ED, and understanding this can help optimize the allocation of healthcare services.11 Despite primary healthcare facilities being widely available in Jordan, patients are still not properly aware of the triage system.12 High patient loads, crowding, and increased violence are sig- nificant challenges faced by EDs.13-15 Enhancing patient awareness can help allocate resources more efficiently and reduce wait times, resulting in better patient care and increased awareness of the Emergency Care Journal 2024; volume 20:12549 [Emergency Care Journal 2024; 20:12549] [page 87] Investigating primary healthcare resource utilization, triage system awareness, and time expectations among patients presenting at emergency departments in Jordan: a cross-sectional study Mohammad M. Alnaeem,1 Khaled H. Suleiman,1 Amal M. Ababneh,2 Nour Alrida3 1School of Nursing, Al-Zaytoonah University of Jordan, Amman; 2School of Nursing, Jerash University, Jerash; 3School of Nursing, Yarmouk University, Irbid, Jordan Correspondence: Mohammad M. Alnaeem, School of Nursing, Al-Zaytoonah University of Jordan, 11733 Amman, Jordan. E-mail: mmalnaeem33@gmail.com Key words: triage system, emergency departments, healthcare resource, patient awareness, wait times, Jordan. Contributions: MMA, KHS, AMA designed the research study; MMA, KHS performed the research; MMA, KHS, AMA, NA wrote the manuscript. All authors contributed to editorial changes in the manuscript, read and approved the final manuscript, and agreed to be held accountable for all aspects of the work. Conflict of interest: the authors declare no potential conflict of interest. Funding: none. Ethics approval and consent to participate: the study was approved by Al-Zaytoonah University of Jordan (No. 2024-2023/133/03) and the Ministry of Health (No. MOH/REC/2023/480). The researcher interviewed the head nurse in the Emergency Department to explain the purpose of the study, while patients were interviewed in the triage room. Participants who met the study criteria were given full description for the study purpose and the significant of the study. Informed consent: all participants were informed of their right to withdraw without consequences. The interested participants signed the consent form and completed the questionnaire. All filled ques- tionnaires were kept secure and anonymized. The researcher stored the completed questionnaires in a sealed envelope in the researcher's office, ensuring that only the researcher had access to the data. After data entry, analysis, and publication, the questionnaires will be dis- carded. Availability of data and material: all data generated during this study are included in this published article. Acknowledgments: the study participants are sincerely appreciated by the researchers for their important participation and contribu- tions. Our study has been greatly enhanced by your willingness to share your experiences and viewpoints. Received: 6 April 2024. Accepted: 11 July 2024. Early view: 23 July 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Emergency Care Journal 2024; 20:12549 doi:10.4081/ecj.2024.12549 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Non -co mmerc ial us e o nly triage system. Another factor related to their awareness is patients’ expectations of the length of time they would have to wait at the ED. Exploring patients’ expectations regarding the turnaround time for test results in primary healthcare settings is important.16,17 Delays in result communication can influence patients’ decisions to seek emergency care, increasing anxiety and uncertainty.9 Educating the public on the ED’s operations and patients’ rights and responsibilities is crucial to the ED’s operation and staff productivity.12,18 Optimizing healthcare accessibility and quality requires addressing patient awareness of the triage system in the ED.19,20 In Jordan, teaching people about the triage procedure is essential, as EDs frequently deal with a large number of patients seeking care.21 Raising patient knowledge of triage in Jordanian EDs is essential to enhancing both the effectiveness of care deliv- ery and the general patient experience in the medical system.12,22 Accordingly, this study aimed to investigate the patients’ knowl- edge about the triage system, using primary healthcare resources before ED visits, and the expected time for waiting for test results at EDs in Jordan. Materials and Methods Study design A descriptive, cross-sectional design was used to study the use of primary healthcare resources, awareness of the triage system, and time expectations among Jordanian patients visiting the ED. This study was carried out at the largest public hospital in Jordan, which provides care for 30-45% of the Jordanian population with various medical conditions. Sample and sampling A convenience sampling technique was used to select the par- ticipants who met the study criteria. Eligible participants included adult patients over 18 years old arriving at the ED and able to engage in the study. The study excluded critically ill patients clas- sified as level immediate or emergent triage categories, pediatric patients, and those with cognitive impairments. Study variables and measurements Data was collected using a self-reported questionnaire consist- ing of two parts. The first part is a socio-demographic question- naire including categories such as age, gender, education, current job, marital status, residence, nationality, and monthly income. The second part is the Discounted Cash Flow Interview (DCF) survey, which was used to measure patients’ awareness of the quality of nursing care in hospitals. This survey was developed by Seibert et al.,23 in the USA, and it is available in Arabic by Alhabdan et al.24 The tool includes questions with a range of answers, including open-ended responses, multiple-choice, and a 4-point scale (rang- ing from “not at all important” to “very important”). Each answer is assigned a score of (1) or (2), and multiple answers can be select- ed. The tool is designed to gather information about common health issues among the ED patients in the triage rooms. The DCF tool consists of 31 items divided into two sections: sociodemographic data and awareness items. The awareness sec- tion encompasses items across four domains: i) use of primary health care facilities before the patient visits the ED; ii) knowledge of the emergency triage system; iii) the ED visitor’s expectations; iv) the expected time for test results to be obtained in the EDs. For the purpose of this study, the following domains were uti- lized: i) use of primary health care facilities before the patient vis- its the ED (7 items), with different forms of questions (multiple- choice and open-ended questions); ii) knowledge of the emergency triage system (5 items), two open-ended questions and three mul- tiple-choice questions; iii) the expected time for test results to be taken in the EDs (open-ended questions and the answers filled in the minutes as the time required to take the results of x-ray, labo- ratory tests, consultation, Computed Tomography, CT, scan, and admission). This survey tool was validated and found to be reli- able, with a Cronbach’s alpha of 0.77-0.83.23,24 In the current study, the Cronbach’s alpha was 0.85. Data collection procedures The study was approved by Al-Zaytoonah University of Jordan (No. 2024-2023/133/03) and the Ministry of Health (No. MOH/REC/2023/480). The researcher interviewed the head nurse in the ED to explain the purpose of the study, while patients were interviewed in the triage room. Participants who met the study cri- teria were given full description for the study purpose and the sig- nificant of the study. All participants were informed of their right to withdraw without consequences. The interested participants signed the consent form and completed the questionnaire. All filled questionnaires were kept secure and anonymized. The researcher stored the completed questionnaires in a sealed envelope in the researcher’s office, ensuring that only the researcher had access to the data. After data entry, analysis, and publication, the question- naires will be discarded. The study was conducted from June to September 2023 Data analysis The study utilized the Statistical Package for Social Sciences (SPSS) version 26 software for data analysis. Descriptive and inferential statistics were used. Independent t-tests were used to measure the relationship between continuous variables dichoto- mous items. The chi-square correlation test was used to determine the relationship between two categorical variables. Also, ANOVA test was used to find the relationship between continuous variables and categorical variables with 3 or more variables. A p-value <0.05 was considered statistically significant. Results The sample in this study was all patients who received treat- ment in EDs in public hospitals in Jordan. The number of question- naires were distributed was 800, of them, 74 questionnaires were excluded (due to incomplete responses); thus, the final sample for analysis was 726 participants, achieving a response rate of 90.8 % which considered to be a high response rate. Description of the sample The mean age of the participants was 38.1 (Standard Deviation, SD=12.9), and the age of the participants varied from 18 to 89 years. More than half of the participants were male (n=383, 52.8%), and married (n=425, 58.5%). Those who hold a bachelor’s degree were 54.9%, and 17.4% were illiterate. Most of the participants (60.4%) were employed in different jobs, and 20.2% were working in healthcare institutions. The majority of participants (89.4%) were Jordanians and resided in Amman (59.2%). More than one-third of the participants had monthly incomes ranging from more than 400 Jordan dinars (54.4%) (Table 1). Use of primary health care facilities before visiting Article [page 88] [Emergency Care Journal 2024; 20:12549] Non -co mmerc ial us e o nly the Emergency Department Most patients reported that receiving regular care was the high- est reason for coming to the ED (n=243, 33.5%), followed by insurance coverage (n=155, 21.3%). Most of the participants (68.2%) did not have primary care physicians or other healthcare providers (didn’t refer to primary healthcare settings), and 31.7% of participants did not try to call them before coming to the ED. Most participants reported that the current problem began on the same day of the ED visit (46.3%), and 21.2 % had a chronic illness for a long time (Table 2). Knowledge about the triage system and expected time for test results Regarding the knowledge about the triage system, most of the participants (61.3%) were unaware of what it does mean the triage system. More than half of respondents (58.4%) know what does it mean “teaching hospital” and know they are now receiving care in an educational hospital. Most patients (59.8%) know why some patients were taken to a room before others (even though they may not have waited long). The majority think the triaging system is fair enough for all (73.6 %). However, those who did not know what triage means accounted for 61.3% of the participants. Regarding the expected time for test results to be taken in the ED, the highest item was for the laboratory tests, which was 72.93 (SD=31.30), as this time varied from 6-300 minutes. For the expected time for getting the X-ray results, the mean was 31.32 (SD=38.75), which ranged 2-400 minutes. However, the mean expected time to wait for a CT scan, consultation report, and admission were comparable (Table 3). Article Table 1. Characteristics of the sample (N=726). Variable N % Age Mean ± SD 38.1±12.2 Min-Max 18-89 Gender Male 383 52.8 Female 343 47.2 Education level Illiterate 126 17.4 Completed high school 201 27.7 Diploma or higher 399 54.9 Current job Do not work 287 39.6 Healthcare work 147 20.2 Governmental work 139 19.1 Private work 153 21.1 Marital status Married 425 58.5 Single 190 26.2 Other 109 15.3 Nationality Jordanian 649 89.4 Not Jordanian 77 10.6 Place of residence In Amman 430 59.2 Out of Amman 296 40.8 Monthly income (Jordanian dinars) Less than 260 159 21.9 From 260 to 400 172 23.7 More than 400 395 54.4 SD, Standard Deviation. Table 2. Use of primary health care facilities before the patient’s Emergency Department visit (N=726). Item N % When did this problem start? Today 336 46.3 Less than a week ago 158 21.8 More than a week ago 78 10.7 It is a chronic/long-term condition 154 21.2 Do you have a primary care doctor or other health provider? Yes 231 31.8 No 495 68.2 Did you try to call your primary care doctor before coming to the ER? Yes 230 31.7 No 496 68.3 If yes – what did the office say? No appointments 44 6.1 Too sick need to go to ER 85 11.7 Not a patient anymore 51 7.0 Need further testing that the doctor’s office can’t do 48 6.6 Other 2 .3 What is your main reason for coming to the ED? Regular care here 243 33.5 Excellence in care 101 13.9 Insurance reasons 155 21.3 Other financial reasons 125 17.2 My doctor told me to come 27 3.7 Close to where I live/work 75 10.3 ED, Emergency Department; ER, Emergency Room. [Emergency Care Journal 2024; 20:12549] [page 89] Non -co mmerc ial us e o nly Relationship between using primary healthcare resources and socio-demographic variables For using primary healthcare facilities before the patient’s ED visit, the chi-square test revealed a significant relationship between the time of starting the problem and the patient’s age (X2=31.6, p<0.001), education level (X2=17.1, p<0.009), and marital status (X2=39.4, p<0.001). Trying to contact doctors before coming to the emergency room was significantly associated with age (X2=7.22, p<0.007) and family income (X2=5.84, p<0.007). Furthermore, the main rea- son to visit EDs was significantly related to patients’ gender (X2=24.5, p<0.001), current job (X2=56.6, p<0.001), nationality (X2=10.8, p<0.05), and place of residence (X2=31.6, p<0.001), and family income (X2=5.84, p<0.044). however, having a primary care doctor or other health provider was not significantly associat- ed with sociodemographic data (p>0.05) (Table 4). Relationship between patient’s knowledge and socio-demographic variables For participants’ knowledge about the triage system during the patient’s ED visit, the chi-square test revealed that recognizing why some patients are taken to a room before others, even though they may not have waited as long, was significantly related to par- ticipants’ education level (X2=17.9, p<0.001), current job Article Table 4. Relationship between use of primary health care facilities before Emergency Department visit patients’ and sociodemographic variables (N=726). Item When did the Do you have a primary Did you try to call your primary What is your main problem started? care doctor or other care doctor before reason for health provider? for coming to the ED? coming to the ED? Test p Test p Test p Test p Age 31.57 0.001 0.04 0.834 7.22 0.007 9.83 0.080 Gender 1.20 0.754 0.12 0.733 0.34 0.558 24.5 0.001 Education 17.09 0.009 1.16 0.559 2.46 0.293 10.7 0.379 Current job 14.92 0.093 0.88 0.829 6.42 0.093 56.6 0.001 Marital status 39.35 0.001 1.66 0.437 5.18 0.075 16.47 0.087 Nationality 2.96 0.398 1.36 0.244 1.30 0.255 10.8 0.046 Place of residence 7.522 0.057 0.087 0.768 0.60 0.438 31.62 0.001 Family income 11.06 0.087 1.46 0.481 5.84 0.048 5.84 0.044 ED, Emergency Department; ER, Emergency Room. Table 3. Knowledge about the triage system and expected time for test results (N=726). Knowledge about the triage system Item N % Do you know what a teaching hospital is? Yes 424 58.4 No 302 41.6 Do you know if this hospital is a teaching hospital? Yes 402 55.4 No 324 44.6 Do you know why some patients are taken to a room before others even though they may not have waited as long? Yes 434 59.8 No 292 40.2 Do you think this is fair? Yes 534 73.6 No 192 26.4 Do you know what triage means? Yes 281 38.7 No 445 61.3 Expected time for test results Item Mean SD Time expected to wait for lab 72.93 31.30 Time expected to wait for X-ray 38.75 31.32 Time expected to wait for CT 43.33 34.49 Time expected to wait for consult 42.04 25.33 Time expected to wait for admission 42.68 26.01 SD, Standard Deviation. [page 90] [Emergency Care Journal 2024; 20:12549] Non -co mmerc ial us e o nly (X2=18.5, p<0.001), and nationality (X2=10.3, p<0.001). Additionally, thinking that some patients are taken to a room before others are fair was associated significantly with patients’ education level (X2=6.90, p<0.05), current job (X2=13.4, p<0.01), and nationality (X2=20.7, p<0.001) (Table 5). Knowing what triage means also had a significant relationship with participants’ education level (X2=15.6, p<0.001), current job (X2=14.9, p<0.01), marital status (X2=7.26, p<0.05), and national- ity (X2=7.15, p<0.008). However, the other items of the knowledge about triage system variables were not significantly related to sociodemographic variables (p>0.05) (Table 5). Relationship between expected time to wait and socio-demographic variables Table 5 represents the relationship between the socio-demo- graphic variables (age, gender, marital status, monthly income, education, current job, residence, and nationality) and the expected time to wait for the results of diagnostic tests. The results showed that the participants’ gender had a statistically significant relation- ship with time waiting for the laboratory (t=-2.55, p<0.01), X-ray (t=1.79, p<0.05), CT scan (t=2.54, p<0.01), and consultation (t=2.15, p<0.05) results. The male reported a higher waiting time than the female for the results of the X-ray, CT scan, and consulta- tion. In comparison, the female reported a higher waiting time for laboratory results. Also, the education levels and the current jobs of the participants were significantly associated with the waiting time for the results of diagnostic tests. The results of a one-way ANOVA revealed that the education level had a statistically signif- icant difference in the expected time to wait for a CT scan (F=5.983, p<0.01) and consultation (F=5.60, p<0.01) results (Table 5). The post-hoc results showed that the participants who had a diploma or higher educational level reported a higher mean waiting time to receive the CT scan report (Mean difference =9.77) (p<0.01) and consultation (Mean difference =6.96) (p<0.01) than those who completed higher school (p<0.05). As well, for the current job, the expected time to wait for a consultation (F=3.160, p<0.05) and admission (F=2.640, p<0.05) was significantly different. The post-hoc results showed that the participants who worked in the private sector reported a higher mean waiting time for consultation (Mean difference =8.188) (p<0.05) and admission (Mean difference =8.366) (p<0.05) than those in government jobs (Table 6). Discussion The study revealed that there is a low level of awareness about the triage system among patients receiving care in the EDs of Jordanian public hospitals, which is consistent with findings in Article [Emergency Care Journal 2024; 20:12549] [page 91] Table 5. Relationship between knowledge about triage system and sociodemographic variables. Item Do you know what Do you know if this Do you know Do you think Do you know a teaching hospital is? hospital is why some patients this is fair? what triage a teaching hospital? are taken means? others even though they to a room before may not have waited as long? Test p Test p Test p Test p Test p Age 1.40 0.238 0.68 0.408 0.21 0.647 1.98 0.160 0.74 0.391 Gender 2.42 0.120 1.07 0.300 0.38 0.540 0.21 0.648 1.99 0.158 Education 11.9 0.003 16.5 0.001 17.9 0.001 6.90 0.032 15.6 0.000 Current job 25.2 0.001 22.9 0.001 18.46 0.001 13.4 0.004 14.9 0.002 Marital status 0.76 0.685 0.194 0.908 1.99 0.369 2.98 0.223 7.26 0.027 Nationality 7.20 0.007 9.39 0.002 10.3 0.001 20.7 0.001 7.15 0.008 Place of residence 0.03 0.863 1.51 0.219 1.50 0.22 0.541 0.464 0.75 0.388 Family income 15.9 0.001 9.20 0.010 1.49 4.58 0.10 0.476 1.95 0.377 Table 6. The significant relationship between patients’ sociodemographic variables and time expected to wait (N=726). Variable Time expected Time expected Time expected Time expected Time expected to wait lab to wait x-ray to wait CT to wait Consult to wait admission Test p Test p Test p Test p Test p Age 0.67 0.662 1.16 0.406 0.76 0.603 2.55 0.072 2.01 0.154 Gender -2.55 0.010 1.79 0.027 2.54 0.009 2.15 0.025 -.45 0.431 Education 0.910 0.403 1.04 0.356 5.98 0.003 5.60 0.004 2.60 0.075 Current job 0.09 0.968 1.57 0.194 1.17 0.322 3.16 0.024 2.64 0.049 Marital status 1.63 0.197 0.31 0.736 0.62 0.540 1.60 0.204 3.41 0.033 Nationality 0.18 0.743 -0.38 0.296 -1.05 0.363 0.49 0.192 0.30 0.630 Place of residence -3.33 0.405 1.08 0.001 4.25 0.001 3.09 0.001 1.22 0.001 Family income 0.48 0.619 0.85 0.430 1.16 0.315 1.08 0.341 0.10 0.902 Non -co mmerc ial us e o nly other countries.12,25-27 It is crucial to address this lack of awareness by developing a culture that prioritizes learning and advancement to reinforce patient safety. Patients have expressed their willing- ness to receive more information about ED functions, which could enhance treatment quality and reduce wait times.17,22 Offering patients comprehensive information about the triage system and ED operations has been shown to positively influence patient sat- isfaction and overall experience. Therefore, enhancing patient edu- cation and communication could potentially improve patient out- comes and refine healthcare delivery in EDs. The study also highlighted the importance of regular primary care visits, especially for patients with chronic conditions. These visits allow for proactive preventive care and care management, potentially preventing adverse events such as ED visits and hospi- talizations.28 Utilizing primary healthcare facilities effectively can promote patient well-being and reduce healthcare costs. However, a significant proportion of patients are not effectively utilizing pri- mary healthcare facilities, with regular ED visits and insurance coverage being the main reasons for this trend, leading to an increased reliance on EDs for their healthcare needs.24,29,30 Furthermore, the study found that patients who have a primary care doctor or other healthcare providers are more satisfied than others, particularly regarding the use of primary healthcare facili- ties before visiting the ED.29,30 This suggests that having access to primary care and using it before visiting the ED is associated with higher satisfaction with nursing care.31 A study on Medicare fee- for-service beneficiaries found that regular visits to primary care could allow for more orderly and proactive delivery of preventive care and care management, potentially averting adverse events such as ED visits and hospitalizations. Understanding the reasons for ED visits, such as the influence of insurance coverage and the frequency of primary care visits, is essential for improving patient outcomes and healthcare resource utilization. In the healthcare sector of Jordan, a positive association was observed between findings suggesting that a significant proportion of patients are not utilizing primary healthcare facilities effective- ly, leading to an increased reliance on EDs.12 The study emphasizes the need for effective communication, documentation, and regular training in nursing care, emphasizing the need for healthcare pro- fessionals to be aware of these factors and tailor their care accord- ingly.7,12,14,15 The study reveals mixed results regarding patients’ knowledge of the triage system, with some patients not familiar with it, while others understood it. However, the majority of respondents knew what “teaching hospital” meant and were now receiving care in an educational hospital. Most patients were receptive to hearing updates about possible delays, with a prefer- ence for updates every 30 minutes.24 They expressed a desire for further information about how the ED functions, with a preference for receiving this information via a video playing in the waiting room.20 A significant percentage of patients expressed interest in receiving further information about specific medical conditions and the healthcare system, indicating a desire for increased knowl- edge and understanding of their health and the care they receive. Additionally, over half of the participants believed that teach- ing hospitals place more emphasis on patient education, underscor- ing the importance of patient education and the potential impact of the healthcare setting on patient care and experience. Healthcare providers must recognize the significance of patient education and ensure patients have access to accurate and comprehensive infor- mation about their medical conditions and the healthcare system. Addressing patients’ desire for increased knowledge and under- standing empowers them to make informed decisions about their health and actively participate in their care. Understanding patients’ perceptions of teaching hospitals as having a stronger focus on patient education can inform strategies to enhance patient-centered education initiatives. Finally, it’s important to note that there are some limitations in this study. While it provides insights into the use of healthcare resources and awareness of triage in Jordan’s largest public hospi- tals’ emergency rooms, there are certain limitations that may affect the generalizability and accuracy of the study, such as convenience sample bias and the use of self-reported data. Additionally, estab- lishing causal links is hindered by the cross-sectional nature of the study, and bias may be introduced by leaving out some responses. Conclusions Patients are mostly unaware of the triage system. The study highlights that healthcare providers must focus on enhancing patients’ understanding of the triage system to improve treatment quality and reduce wait times. Policymakers could incorporate guidelines and regulations to enhance the importance of effective communication and technology in triage processes. Future studies could focus more on improving triage awareness allocation and motivating patients to adopt a triage-aware culture. References 1. Wolf L, Delao A, Clark P, et al. The effect of mandatory triage questions on triage processes: a qualitative exploratory study. J Emerg Nurs 2024;50:84-94. 2. Sax DR, Warton EM, Mark DG, et al. Evaluation of the emer- gency severity index in US emergency departments for the rate of mistriage. JAMA Network Open 2023;6:e233404. 3. Bazyar J, Farrokhi M, Salari A, et al. The principles of triage in emergencies and disasters: a systematic review. Prehosp Disaster Med 2020;35:305-13. 4. Abass G, Asery A, Al Badr A, et al. Patient satisfaction with the emergency department services at an academic teaching hospital. J Family Med Primary Care 2021;10:1718. 5. Idil H, Kilic TY, Toker I, et al. Non-urgent adult patients in the emergency department: Causes and patient characteristics. Turkish J Emerg Med 2018;18:71-4. 6. Zaboli A, Sibilio S, Magnarelli G, et al. Nurses in the eye of the storm: a study of violence against healthcare personnel working in the emergency department. Emerg Med J 2024;41:501-2. 7. Göransson M, Persson A-C, Abelsson A. Triage in primary healthcare. Nordic J Nurs Res 2020;40:213-20. 8. Wolf LA, Delao AM, Perhats C, et al. Triaging the emergency department, not the patient: United States emergency nurses’ experience of the triage process. J Emerg Nurs 2018;44:258- 66. 9. O’Cathain A, Connell J, Long J, et al. ‘Clinically unnecessary’ use of emergency and urgent care: a realist review of patients’ decision making. Health Expectations 2020;23:19-40. 10. Lutz BJ, Hall AG, Vanhille SB, et al. A framework illustrating care-seeking among older adults in a hospital emergency department. Gerontologist 2018;58:942-52. 11. Bombard Y, Ross Baker G, Orlando E, et al. Engaging patients to improve quality of care: a systematic review. Implement Sci 2018;13:1-22. 12. AlShatarat M, Rayan A, Eshah NF, et al. Triage knowledge and Article [page 92] [Emergency Care Journal 2024; 20:12549] Non -co mmerc ial us e o nly practice and associated factors among emergency department nurses. SAGE Open Nurs 2022;8:23779608221130588. 13. Al-Kalaldeh M, Al-Bdour E, Shosha GA. Patients’ evaluation of the quality of emergency care services in Jordan: integration of patient centeredness model. Res Theory Nurs Practice 2021;RTNP-D-21-00037. 14. Suleiman K, Hijazi Z, Al-Khalalde M, Abu Sharour L. Quality of nursing work life and related factors among emergency nurses in Jordan. J Occupational Health 2019;61:398-406. 15. Subih M, Salem H, Al Omari D. Evaluation of compassion fatigue and compassion satisfaction among emergency nurses in Jordan: a cross-sectional study. Internat Emerg Nurs 2023;66:101232. 16. Phiri M, Heyns T, Coetzee I. Patients’ experiences of triage in an emergency department: a phenomenographic study. Applied Nurs Res 2020;54:151271. 17. Abidova A, da Silva PA, Moreira S. Predictors of patient satis- faction and the perceived quality of healthcare in an emer- gency department in Portugal. Western J Emerg Med 2020;21:391. 18. Kelen GD, et al. Emergency department crowding: the canary in the health care system. NEJM 2021;2:CAT.21.0217. 19. Magnusson C, Herlitz J, Axelsson C. Patient characteristics, triage utilisation, level of care, and outcomes in an unselected adult patient population seen by the emergency medical serv- ices: a prospective observational study. BMC EmergMed 2020;20:1-19. 20. Alsulimani LK. Public awareness of triage in emergency departments in Saudi Arabia in the era of COVID-19. Saudi J Emerg Med 2022;3:120-9. 21. Alowais SA, Alghamdi SS, Alsuhebany N, et al. Revolutionizing healthcare: the role of artificial intelligence in clinical practice. BMC Med Educ 2023;23:689. 22. Özhanlı Y, Akyolcu N. Satisfaction of patients with triage and nursing practice in emergency departments. Florence Nightingale J Nurs 2020;28:49. 23. Seibert T, Veazey K, Leccese P, Druck J. What do patients want? Survey of patient desires for education in an urban uni- versity hospital. Western J Emerg Med 2014;15:764. 24. Alhabdan N, Alhusain F, Alharbi A, et al. Exploring emergency department visits: factors influencing individuals’ decisions, knowledge of triage systems and waiting times, and experi- ences during visits to a tertiary hospital in Saudi Arabia. Internat J Emerg Med 2019;12:1-8. 25. Mirmozaffari M, Kamal N. The application of data envelop- ment analysis to emergency departments and management of emergency conditions: a narrative review. Healthcare 2023;11:2541. 26. Zachariasse JM, van der Hagen V, Seiger N, et al. Performance of triage systems in emergency care: a systematic review and meta-analysis. BMJ Open 2019;9:e026471. 27. Yusefi AR, Sarvestani SR, Kavosi Z, et al. Patients’ percep- tions of the quality of nursing services. BMC Nursing 2022;21:1-11. 28. Khazen M, Abu Ahmad W, Spolter F, et al. Greater temporal regularity of primary care visits was associated with reduced hospitalizations and mortality, even after controlling for conti- nuity of care. BMC Health Serv Res 2023;23:777. 29. Davey K, Jacob S, Prasad N, et al. Characteristics and expec- tations among emergency department patients in India. PLOS Global Public Health 2022;2:e0000009. 30. Rose AJ, Timbie JW, Setodji C, et al. Primary care visit regu- larity and patient outcomes: an observational study. J General Internal Med 2019;34:82-9. 31. Workina A, Habtamu A, Zewdie W. Reasons for emergency department visit, outcomes, and associated factors of oncolog- ic patients at emergency department of Jimma University Medical Centre. Open Access Emerg Med 2022;14:581-90. Article [Emergency Care Journal 2024; 20:12549] [page 93] Non -co mmerc ial us e o nly