Implementation and early operational evaluation of a National Pediatric Triage System in a Referral Hospital in Beira, Mozambique: a one-year implementation study

Background Pediatric mortality in low- and middle-income countries (LMICs) remains largely attributable to time-sensitive and treatable conditions. Structured triage systems are essential to prioritize care and reduce preventable deaths, yet implementation evidence in LMIC referral hospitals is limited. Objectives This study aimed to describe the implementation of a newly developed national triage tool in the Pediatric Emergency Department (PED) in a referral hospital in Beira, Mozambique, and evaluate its early operational integration using implementation outcomes over the first year of practice. Methods We conducted a multi-component implementation of the triage tool between October 2023 and January 2026. A retrospective observational analysis evaluated implementation outcomes between April 2024 and March 2025. Results Of 28,469 pediatric visits, 76.3% underwent documented triage. Uptake varied over time, with lower adherence on weekends than weekdays (62.8% vs 80.1%), during night versus morning shifts (70.0% vs 90.3%), in September 2024 (56.6%) and March 2025 (59.1%) coinciding with understaffed shifts and workforce instability. Adherence to data recording improved over time, from an average of 36.7% missing data in April 2024 to 17% in March 2025. Among triaged patients, 83% were classified as non-urgent and 17% as urgent. Overall, 86.9% were discharged, 12.3% hospitalized, 0.7% required intensive care admission, and 0.1% died in the PED. Conclusions Pediatric triage system implementation was feasible in a resource-constrained referral hospital, although sustainability was mainly influenced by workforce instability. Dedicated training, workflow redesign, institutional ownership, and continuous monitoring emerged as key implementation strategies that may inform future scale-up across similar LMIC settings.