WTG-SOP-003: Urgent patients waiting to be seen: re-triage and safety

Standard operating procedure (SOP) · WTG-SOP-003 · Version 0.1 · Draft for local review

Supports: 45.2

1. Purpose

To make sure that patients with an urgent need are not left unseen while they wait, that their condition is checked again while they wait, and that any deterioration is acted on at once (45.2).

2. Scope

Item	Coverage
Applies to	Triage, reception, nursing and medical staff in any area where patients wait for assessment or treatment
Patients	All patients waiting for emergency, urgent or booked care, including those waiting in the corridor, in the waiting room or in a parked trolley
Locations	Emergency department, urgent care, outpatient clinics, day units and the on-call service

3. Definitions

Term	Meaning in this SOP
Re-triage	A check of a waiting patient's condition, using the same tool as at triage, to confirm or change their category
Set interval	The time between re-triage checks for each category, set by the service and displayed in the waiting area
Unseen patient	A patient who has been triaged to a category but has not been seen by a clinician within the time set for that category

4. Background

Patients who wait in an area with few staff can deteriorate without anyone noticing. Most harm from waiting is avoided by repeated checks, clear escalation and a simple rule that a patient whose condition changes is seen again at once.

5. Responsibilities

Role	Responsibility
Triage nurse	Sets the initial category, carries out re-triage at the set intervals, and escalates any change
Nurse in charge of the waiting area	Keeps the board of waiting patients up to date, arranges re-triage checks and reviews the list every hour
Senior clinician	Reviews the highest-category waiting patients and any patient escalated by re-triage
Reception staff	Tell the nurse in charge when a patient is in pain, distressed or has not been seen for longer than the set time
Service manager	Keeps the procedure, the tool and the audit in place

6. Procedure

6.1 Waiting board

1. Record every waiting patient on the board with the category, the time of triage and the next re-triage time.
2. Check the board at the start of each hour and after each new arrival.
3. Flag any patient who is past the set time for their category.

6.2 Re-triage

1. Re-triage each waiting patient at the set interval for their category, using the same tool used at triage.
2. Ask the patient and any companion whether anything has changed, and check the red flags listed in ONC-SOP-007, section 6, where relevant.
3. Record the new category and time. If the category has gone up, bring the patient forward at once.
4. Tell the patient what has changed and what the new expected wait is.

6.3 Deterioration while waiting

1. Any waiting patient who is in pain, short of breath, confused, bleeding, drowsy or unwell is brought to the senior clinician immediately.
2. If the patient cannot be reached, or cannot be found, search the waiting area at once and inform the nurse in charge.
3. Record the event, the action taken and the time.

6.4 Patients who leave before being seen

1. Record the time the patient left and whether they were advised to stay.
2. Follow ED-SOP-003 for the follow-up of patients who leave before assessment.

7. Decision points

Situation	Action
Patient's category is high and no senior clinician is free	Escalate to the consultant on call the same minute, and keep the patient in view
Patient is in a corridor or on a trolley with no staff in view	Move the patient to a monitored area or bring a nurse to them now
Companion asks why the wait is long	Explain the reason honestly, give the expected time and the re-triage time, and record the conversation if it becomes a complaint
Patient does not speak the language	Use a professional interpreter for re-triage questions

8. Escalation

• Patient waiting beyond the set limit for their category: the nurse in charge informs the senior clinician within 15 minutes.
• Repeated delays for the same category: the service manager reviews staffing the same day.
• Harm or near miss while waiting: report under INC-SOP-001 within 24 hours.

9. Monitoring

The service manager reviews every waiting-list record each week, and reports the audit each quarter to the governance meeting.

Measure	Target
Urgent patients seen within the set time for their category	At least 95 percent
Re-triage completed at the set interval	At least 95 percent
Patients who deteriorated while waiting and were brought forward at once	100 percent
Patients who left before being seen and were followed up	100 percent

10. Records

• Waiting board record.
• Re-triage record with category and time.
• Escalation record.
• Record of patients who left before being seen.

11. Training

All triage, reception and nursing staff who manage waiting areas complete training on the tool, re-triage and deterioration signs at induction and every year.

12. Related documents

Code	Document
WTG-SOP-001	Keeping waiting patients informed
WTG-FRM-001	Waiting time review record
WTG-FRM-002	Waiting patient update record
ONC-SOP-007	Urgent triage of patients with cancer
ED-SOP-003	Patients who leave before assessment

13. Evidence

This SOP is based on the reference sources listed below and on the requirement of criterion 45.2 of the ASF standards. The intervals and time limits must be set by the service and checked at each review.

E-learning for this document

• No course linked yet. Request a triage and waiting-area safety course from the academy (see the Standard 45 request list).

References

1. Mackway-Jones K, Marsden J, Windle J, editors. Emergency Triage: Manchester Triage System. Current edition.
2. Facility triage and waiting-area policy and set re-triage intervals (to be inserted by the unit at adoption).

Change history

Version	Date	Change
0.1	2026-10-26	First draft for review. Not yet approved by the ASF Expert Committee.