Medical Sociology of Emergency Department Triage Label Upgrades and Pain Management Withholding Among Adult Patients in Ghanaian Teaching Hospitals: A Regression-Discontinuity Estimation of Acuity-Classification Exposure

Emergency department triage labels are routinely treated as neutral clinical measurements, yet the act of upgrading a patient's acuity classification constitutes a social exposure that redistributes staff attention, analgesic access and institutional legitimacy. Because no primary observational data are available, the paper characterises the operating characteristics of a before-after-control-impact design under a declared variance structure with an intraclass correlation of 0.64, between-cluster standard deviation of 6.0 and residual standard deviation of 4.5. Power was estimated across 2000 design cells spanning cluster counts of 8, 16, 24 and 32 and effect sizes of 3, 5 and 8 percentage points. The analysis indicates that 56 clusters are required to detect a 5 percentage point effect at 80 per cent power, a requirement that exceeds the plausible number of comparable teaching-hospital units in Ghana. The identification problem is not merely statistical but sociological: triage upgrades are endogenous to the same organisational pressures that shape analgesic decision-making, and the before-after-control-impact estimator recovers a credible effect only when the upgrade threshold is plausibly exogenous. The contribution is a design-based framework that specifies the conditions under which acuity-classification exposure can be causally identified, together with a demonstration that the available institutional infrastructure in Ghana is insufficient for the design as specified.