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.

Emergency department care for trauma patients in settings of active conflict versus urban violence: all of the same calibre?

BACKGROUND: Trauma is a leading cause of death and represents a major problem in developing countries where access to good quality emergency care is limited. Médecins Sans Frontières delivered a standard package of care in two trauma emergency departments (EDs) in different violence settings: Kunduz, Afghanistan, and Tabarre, Haiti. This study aims to assess whether this standard package resulted in similar performance in these very different contexts. METHODS: A cross-sectional study using routine programme data, comparing patient characteristics and outcomes in two EDs over the course of 2014. RESULTS: 31 158 patients presented to the EDs: 22 076 in Kunduz and 9082 in Tabarre. Patient characteristics, such as delay in presentation (29.6% over 24 h in Kunduz, compared to 8.4% in Tabarre), triage score, and morbidity pattern differed significantly between settings. Nevertheless, both EDs showed an excellent performance, demonstrating low proportions of mortality (0.1% for both settings) and left without being seen (1.3% for both settings), and acceptable triage performance. Physicians' maximum working capacity was exceeded in both centres, and mainly during rush hours. CONCLUSIONS: This study supports for the first time the plausibility of using the same ED package in different settings. Mapping of patient attendance is essential for planning of human resources needs.

Open Source Software For Patient Data Management In Critical Care.

We have previously developed a Patient Data Management System for Intensive Care based on Open Source Software. The aim of this work was to adapt this software to use in Emergency Departments in low resource environments. The new software includes facilities for utilization of the South African Triage Scale and prediction of mortality based on independent predictive factors derived from data from the Tabarre Emergency Trauma Center in Port au Prince, Haiti.

Violence and mortality in West Darfur, Sudan (2003-04): epidemiological evidence from four surveys.

BACKGROUND: Violence in Darfur, Sudan, has rendered more than one million people internally displaced. An epidemiological study of the effect of armed incursions on mortality in Darfur was needed to provide a basis for appropriate assistance to internally displaced people. METHODS: Between April and June, 2004, we did retrospective cluster surveys among 215?400 internally displaced people in four sites of West Darfur (Zalingei, Murnei, Niertiti, El Geneina). Mortality recall periods covered both the pre-displacement and post-displacement periods in Zalingei, Murnei, and Niertiti, but not in El Geneina. Heads of households provided dates, causes, and places of deaths, and described the family structure. FINDINGS: Before arrival at displacement sites, mortality rates (expressed as deaths per 10?000 per day), were 5.9 (95% CI 2.2-14.9) in Zalingei, 9.5 (6.4-14.0) in Murnei, and 7.3 (3.2-15.7) in Niertiti. Violence caused 68-93% of these deaths. People who were killed were mostly adult men (relative risk 29.1-117.9 compared with children younger than 15 years), but included women and children. Most households fled because of direct village attacks. In camps, mortality rates fell but remained above the emergency benchmark, with a peak of 5.6 in El Geneina. Violence persisted even after displacement. Age and sex pyramids of surviving populations were skewed, with a deficit in men. INTERPRETATION: This study, which was done in a difficult setting, provides epidemiological evidence of this conflict's effect on civilians, confirming the serious nature of the crisis, and reinforcing findings from other war contexts.