Inter-rater and intrarater reliability of the South African Triage Scale in low-resource settings of Haiti and Afghanistan.

OBJECTIVE: The South African Triage Scale (SATS) has demonstrated good validity in the EDs of Médecins Sans Frontières (MSF)-supported sites in Afghanistan and Haiti; however, corresponding reliability in these settings has not yet been reported on. This study set out to assess the inter-rater and intrarater reliability of the SATS in four MSF-supported EDs in Afghanistan and Haiti (two trauma-only EDs and two mixed (including both medical and trauma cases) EDs). METHODS: Under classroom conditions between December 2013 and February 2014, ED nurses at each site assigned triage ratings to a set of context-specific vignettes (written case reports of ED patients). Inter-rater reliability was assessed by comparing triage ratings among nurses; intrarater reliability was assessed by asking the nurses to retriage 10 random vignettes from the original set and comparing these duplicate ratings. Inter-rater reliability was calculated using the unweighted kappa, linearly weighted kappa and quadratically weighted kappa (QWK) statistics, and the intraclass correlation coefficient (ICC). Intrarater reliability was calculated according to the percentage of exact agreement and the percentage of agreement allowing for one level of discrepancy in triage ratings. The correlation between years of nursing experience and reliability of the SATS was assessed based on comparison of ICCs and the respective 95% CIs. RESULTS: A total of 67 nurses agreed to participate in the study: In Afghanistan there were 19 nurses from Kunduz Trauma Centre and nine from Ahmed Shah Baba; in Haiti, there were 20 nurses from Martissant Emergency Centre and 19 from Tabarre Surgical and Trauma Centre. Inter-rater agreement was moderate across all sites (ICC range: 0.50-0.60; QWK range: 0.50-0.59) apart from the trauma ED in Haiti where it was moderate to substantial (ICC: 0.58; QWK: 0.61). Intrarater agreement was similar across the four sites (68%-74% exact agreement); when allowing for a one-level discrepancy in triage ratings, intrarater reliability was near perfect across all sites (96%-99%). No significant correlation was found between years of nursing experience and reliability. CONCLUSION: The SATS has moderate reliability in different EDs in Afghanistan and Haiti. These findings, together with concurrent findings showing that the SATS has good validity in the same settings, provide evidence to suggest that SATS is suitable in trauma-only and mixed EDs in low-resource settings.

Is the South African Triage Scale valid for use in Afghanistan, Haiti and Sierra Leone?

OBJECTIVE: To assess the validity of the South African Triage Scale (SATS) in four Médecins Sans Frontières (MSF)-supported emergency departments (ED, two trauma-only sites, one mixed site (both medical and trauma cases) and one paediatric-only site) in Afghanistan, Haiti and Sierra Leone. METHODS: This was a retrospective cohort study conducted between June 2013 and June 2014. Validity was assessed by comparing patients' SATS ratings with their final ED outcome (ie, hospital admission, death or discharge). RESULTS: In the two trauma settings, the SATS demonstrated good validity: it accurately predicted an increase in the likelihood of mortality and hospitalisation across incremental acuity levels (p<0.001) and ED outcomes for 'green' and 'red' patients matched the predicted ED outcomes in 84%-99% of cases. In the mixed ED, the SATS was able to predict an incremental increase in hospitalisation (p<0.001) across both trauma and non-trauma cases. In the paediatric-only settings, SATS was able to predict an incremental increase in hospitalisation in the non-trauma cases only (p<0.001). However, 87% (non-trauma) and 94% (trauma) of 'red' patients in the mixed-medical setting were overtriaged and 76% (non-trauma) and 100% (trauma) of 'green' patients in the paediatric settings were undertriaged. CONCLUSION: The SATS is a valid tool for trauma-only settings in low-resource countries. Its use in mixed settings seems justified, but context-specific assessments would seem prudent. Finally, in paediatric settings with endemic malaria, adding haemoglobin level to the SATS discriminator list may help to improve the undertriage of patients with malaria.

Integrating mHealth at point of care in low- and middle-income settings: the system perspective.

While the field represents a wide spectrum of products and services, many aspects of mHealth have great promise within resource-poor settings: there is an extensive range of cheap, widely available tools which can be used at the point of care delivery. However, there are a number of conditions which need to be met if such solutions are to be adequately integrated into existing health systems; we consider these from regulatory, technological and user perspectives. We explore the need for an appropriate legislative and regulatory framework, to avoid 'work around' solutions, which threaten patient confidentiality (such as the extensive use of instant messaging services to deliver sensitive clinical information and seek diagnostic and management advice). In addition, we will look at other confidentiality issues such as the need for applications to remove identifiable information (such as photos) from users' devices. Integration is dependent upon multiple technological factors, and we illustrate these using examples such as products made available specifically for adoption in low- and middle-income countries. Issues such as usability of the application, signal loss, data volume utilization, need to enter passwords, and the availability of automated or in-app context-relevant clinical advice will be discussed. From a user perspective, there are three groups to consider: experts, front-line clinicians, and patients. Each will accept, to different degrees, the use of technology in care - often with cultural or regional variation - and this is central to integration and uptake. For clinicians, ease of integration into daily work flow is critical, as are familiarity and acceptability of other technology in the workplace. Front-line staff tend to work in areas with more challenges around cell phone signal coverage and data availability than 'back-end' experts, and the effect of this is discussed.

Prioritising the care of critically ill children: a pilot study using SCREEN reduces clinic waiting times.

OBJECTIVE: In low-resource settings, childhood mortality secondary to delays in triage and treatment remains high. This paper seeks to evaluate the impact of the novel Sick Children Require Emergency Evaluation Now (SCREEN) tool on the waiting times of critically ill children who present for care to primary healthcare clinics in Cape Town, South Africa. METHODS: We used a pre/postevaluation study design to calculate the median waiting times of all children who presented to four randomly chosen clinics for 5 days before, and 5 days after, the implementation of SCREEN. FINDINGS: The SCREEN programme resulted in statistical and clinically significant reductions in waiting times for children with critical illness to see a professional nurse (2 hours 45 min to 1 hour 12 min; p<0.001). There was also a statistically significant reduction in the proportion of children who left without being seen by a professional nurse (25.8% to 18.48%; p<0.001). CONCLUSIONS: SCREEN is a novel programme that uses readily available laypersons, trained to make a subjective assessment of children arriving at primary healthcare centres, and provides a low cost, simple methodology to prioritise children and reduce waiting times in low-resource healthcare clinics.

Triage capabilities of medical trainees in Ghana using the South African triage scale: an opportunity to improve emergency care.

INTRODUCTION: The incidence of emergency conditions is increasing worldwide, particularly in low- and middle-income countries (LMICs). However, triage and emergency care training has not been prioritized in LMICs. We aimed to assess the reliability and validity of the South African Triage Scale (SATS) when used by providers not specifically trained in SATS, as well as to compare triage capabilities between senior medical students and senior house officers to examine the effectiveness of our curriculum for house officer training with regards to triage. METHODS: Sixty each of senior medical students and senior house officers who had not undergone specific triage or SATS training were asked to triage 25 previously validated emergency vignettes using the SATS. Estimates of reliability and validity were calculated. Additionally, over- and under-triage, as well as triage performance between the medical students and house officers was assessed against a reference standard. RESULTS: Fifty-nine senior medical students (98% response rate) and 43 senior house officers (72% response rate) completed the survey (84% response rate overall). A total of 2,550 triage assignments were included in the analysis (59 medical student and 43 house officer triage assignments for 25 vignettes each; 1,475 and 1,075 triage assignments, respectively). Inter-rater reliability was moderate (quadratically weighted κ 0.59 and 0.60 for medical students and house officers, respectively). Triage using SATS performed by these groups had low sensitivity (medical students: 54%, 95% CI 49-59; house officers: 55%, 95% CI 48-60) and moderate specificity (medical students: 84%, 95% CI 82 - 89; house officers: 84%, 95% CI 82 - 97). Both groups under-triaged most 'emergency' level vignette patients (i.e. SATS Red; 80 and 82% for medical students and house officers, respectively). There was no difference between the groups for any metric. CONCLUSION: Although the SATS has proven utility in a number of different settings in LMICs, its success relies on its use by trained providers. Given the large and growing burden of emergency conditions, training current and future emergency care providers in triage is imperative.

Reliability and accuracy of the South African Triage Scale when used by nurses in the emergency department of Timergara Hospital, Pakistan.

BACKGROUND: Triage is one of the core requirements for the provision of effective emergency care and has been shown to reduce patient mortality. However, in low- and middle-income countries this strategy is underused, under-resourced and poorly researched. OBJECTIVE: To assess the inter- and intra-rater reliability and accuracy of nurse triage ratings when using the South African Triage Scale (SATS) in an emergency department (ED) in Timergara, Pakistan. METHODS: Fifteen ED nurses assigned triage ratings to a set of 42 reference vignettes (written case reports of ED patients) under classroom conditions. Inter-rater reliability was assessed by comparing these triage ratings; intra-rater reliability was assessed by asking the nurses to re-triage 10 random vignettes from the original set of 42 vignettes and comparing these duplicate ratings. Accuracy of the nurse ratings was measured against the reference standard. RESULTS: Inter-rater reliability was substantial (intraclass correlation coefficient 0.77; 95% confidence interval (CI) 0.69 - 0.85). The intra-rater agreement was also high with 87% exact agreement (95% CI 67 - 100) and 100% agreement allowing for a one-level discrepancy in triage ratings. Overall, the SATS had high specificity (97%) and moderate sensitivity (70%). Across all acuity levels the proportion of over-triage did not exceed the acceptable threshold of 30 - 50%. Under-triage was acceptable for all except emergency cases (66%). CONCLUSION: ED nurses in Pakistan can reliably use the SATS to assign triage acuity ratings. While the tool is accurate for 'very urgent' and 'routine' cases, importantly, it may under-triage 'emergency' cases requiring immediate attention. Approaches that will improve accuracy and validity are discussed.