Implementation and performance of the South African Triage Scale at Kenyatta National Hospital in Nairobi, Kenya.

INTRODUCTION: Triage protocols standardize and improve patient care in accident and emergency departments (A&Es). Kenyatta National Hospital (KNH), the largest public tertiary hospital in East Africa, is resource-limited and was without A&E-specific triage protocols. OBJECTIVES: We sought to standardize patient triage through implementation of the South African Triage Scale (SATS). We aimed to (1) assess the reliability of triage decisions among A&E healthcare workers following an educational intervention and (2) analyze the validity of the SATS in KNH's A&E. METHODS: Part 1 was a prospective, before and after trial utilizing an educational intervention and assessing triage reliability using previously validated vignettes administered to 166 healthcare workers. Part 2 was a triage chart review wherein we assessed the validity of the SATS in predicting patient disposition outcomes by inclusion of 2420 charts through retrospective, systematic sampling. RESULTS: Healthcare workers agreed with an expert defined triage standard for 64% of triage scenarios following an educational intervention, and had a 97% agreement allowing for a one-level discrepancy in the SATS score. There was "good" inter-rater agreement based on an intraclass correlation coefficient and quadratic weighted kappa. We analyzed 1209 pre-SATS and 1211 post-SATS patient charts and found a non-significant difference in undertriage and statistically significant decrease in overtriage rates between the pre- and post-SATS cohorts (undertriage 3.8 and 7.8%, respectively, p = 0.2; overtriage 70.9 and 62.3%, respectively, p < 0.05). The SATS had a sensitivity of 92.2% and specificity of 37.7% for predicting admission, death, or discharge in the A&E. CONCLUSION: Healthcare worker triage decisions using the SATS were more consistent with expert opinion following an educational intervention. The SATS also performed well in predicting outcomes with high sensitivity and satisfactory levels of both undertriage and overtriage, confirming the SATS as a contextually appropriate triage system at a major East African A&E.

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.

Strengthening Emergency Care Systems to Mitigate Public Health Challenges Arising from Influxes of Individuals with Different Socio-Cultural Backgrounds to a Level One Emergency Center in South East Europe.

Emergency center visits are mostly unscheduled, undifferentiated, and unpredictable. A standardized triage process is an opportunity to obtain real-time data that paints a picture of the variation in acuity found in emergency centers. This is particularly pertinent as the influx of people seeking asylum or in transit mostly present with emergency care needs or first seek help at an emergency center. Triage not only reduces the risk of missing or losing a patient that may be deteriorating in the waiting room but also enables a time-critical response in the emergency care service provision. As part of a joint emergency care system strengthening and patient safety initiative, the Serbian Ministry of Health in collaboration with the Centre of Excellence in Emergency Medicine (CEEM) introduced a standardized triage process at the Clinical Centre of Serbia (CCS). This paper describes four crucial stages that were considered for the integration of a standardized triage process into acute care pathways.

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.

Community-based perceptions of emergency care in Zambian communities lacking formalised emergency medicine systems.

BACKGROUND: In Zambia, an increasing burden of acute illness and injury emphasised the necessity of strengthening the national emergency care system. OBJECTIVE: The objective of this study was to identify critical interventions necessary to improve the Zambian emergency care system by determining the current pattern of emergency care delivery as experienced by members of the community, identifying the barriers faced when trying to access emergency care and gathering community-generated solutions to improve emergency care in their setting. METHODS: We used a qualitative research methodology to conduct focus groups with community members and healthcare providers in three Zambian provinces. Twenty-one community focus groups with 183 total participants were conducted overall, split equally between the provinces. An additional six focus groups were conducted with Zambian healthcare providers. Data were coded, aggregated and analysed using the content analysis approach. RESULTS: Community members in Zambia experience a wide range of medical emergencies. There is substantial reliance on family members and neighbours for assistance, commonly with transportation. Community-identified and provider-identified barriers to emergency care included transportation, healthcare provider deficiencies, lack of community knowledge, the national referral system and police protocols. CONCLUSIONS: Creating community education initiatives, strengthening the formal prehospital emergency care system, implementing triage in healthcare facilities and training healthcare providers in emergency care were community-identified and provider-identified solutions for improving access to emergency care.

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.

Evaluating the construct of triage acuity against a set of reference vignettes developed via modified Delphi method.

OBJECTIVE: To evaluate the construct of triage acuity as measured by the South African Triage Scale (SATS) against a set of reference vignettes. METHODS: A modified Delphi method was used to develop a set of reference vignettes. Delphi participants completed a 2-round consensus-building process, and independently assigned triage acuity ratings to 100 written vignettes unaware of the ratings given by others. Triage acuity ratings were summarised for all vignettes, and only those that reached 80% consensus during round 2 were included in the reference set. Triage ratings for the reference vignettes given by two independent experts using the SATS were compared with the ratings given by the international Delphi panel. Measures of sensitivity, specificity, associated percentages for over-triage/under-triage were used to evaluate the construct of triage acuity (as measured by the SATS) by examining the association between the ratings by the two experts and the international panel. RESULTS: On completion of the Delphi process, 42 of the 100 vignettes reached 80% consensus on their acuity rating and made up the reference set. On average, over all acuity levels, sensitivity was 74% (CI 64% to 82%), specificity 92% (CI 87% to 94%), under-triage occurred 14% (CI 8% to 23%) and over-triage 12% (CI 8% to 23%) of the time. CONCLUSIONS: The results of this study provide an alternative to evaluating triage scales against the construct of acuity as measured with the SATS. This method of using 80% consensus vignettes may, however, systematically bias the validity estimate towards better performance.

A strategy to implement and support pre-hospital emergency medical systems in developing, resource-constrained areas of South Africa.

Resource-constrained countries are in extreme need of pre-hospital emergency care systems. However, current popular strategies to provide pre-hospital emergency care are inappropriate for and beyond the means of a resource-constrained country, and so new ones are needed-ones that can both function in an under-developed area's particular context and be done with the area's limited resources. In this study, we used a two-location pilot and consensus approach to develop a strategy to implement and support pre-hospital emergency care in one such developing, resource-constrained area: the Western Cape province of South Africa. Local community members are trained to be emergency first aid responders who can provide immediate, on-scene care until a Transporter can take the patient to the hospital. Management of the system is done through local Community Based Organizations, which can adapt the model to their communities as needed to ensure local appropriateness and feasibility. Within a community, the system is implemented in a graduated manner based on available resources, and is designed to not rely on the whole system being implemented first to provide partial function. The University of Cape Town's Division of Emergency Medicine and the Western Cape's provincial METRO EMS intend to follow this model, along with sharing it with other South African provinces.

The South African Triage Scale (adult version) provides reliable acuity ratings.

OBJECTIVE: To estimate the inter- and intra-rater reliability of triage ratings on Emergency Centre patients by South African nurses and doctors using the South African Triage Scale (SATS). METHODS: A cross-sectional reliability study was performed. Five emergency physicians and ten enrolled nursing assistants independently assigned triage categories to 100 written vignettes unaware of the ratings given by others. Four different quantitative reliability measures were calculated and compared. Graphical displays portrayed rating distributions for vignettes with mean ratings at different acuity categories. RESULTS: The estimated quadratically weighted kappa for the group of emergency physicians was 0.76 (95% CI: 0.67-0.84) and for the group of nurses 0.66 (95% CI: 0.58-0.74). These values were close to the estimated intra-class correlation coefficients. For intra-rater reliability, the average exact agreement was 84%. The graphical displays showed that the least variability was evident in the vignettes that had a mean rating of 'emergency', 'very urgent' or 'routine'. CONCLUSION: This study indicates good inter- and intra-rater reliability among nurses and doctors using the SATS. It suggests that the SATS is reliably applied, and supports the feasibility of further implementation of the SATS in similar settings.

The Princess Marina Hospital accident and emergency triage scale provides highly reliable triage acuity ratings.

OBJECTIVE: To determine the interrater reliability of triage acuity ratings by healthcare workers (HCW) using a previous triage system (PTS) and the Princess Marina Hospital accident and emergency centre triage scale (PATS), a local adaptation of the widely used and studied South African triage scale. METHODS: A cross-sectional study was performed on HCW in an emergency department (ED) in Botswana to determine the interrater reliability of triage acuity ratings when using PTS and PATS to assign triage categories to 25 written vignettes after PATS training. The intraclass correlation coefficient (ICC) was calculated to assess interrater reliability, and graphic displays were used to portray rating distributions for vignettes with a mean rating of different acuity categories for PTS and PATS. RESULTS: 44 HCW completed the scenarios. The ICC for the group of HCW was 0.52 (95% CI 0.37 to 0.67) using PTS and 0.87 (95% CI 0.80 to 0.93) using PATS. The ICC values were higher for PATS than PTS regardless of the number of years of experience of the HCW and the level of the HCW (specialist, medical officer, nurse, nurse aide). Graphic displays showed that there was less variability at all acuity levels when using PATS compared with PTS. CONCLUSION: The reliability measures in this study indicate very high interrater agreement and limited variability in acuity ratings when using the PATS as opposed to moderate agreement and increased variability in acuity ratings when using PTS. This suggests that PATS is reliably applied by all levels of HCW and supports the feasibility of the further implementation of PATS in ED in Botswana and in other similar settings.

The need for a usable assessment tool to analyse the efficacy of emergency care systems in developing countries: proposal to use the TEWS methodology.

BACKGROUND: Ninety percent of emergency incidents occur in developing countries, and this is only expected to get worse as these nations develop. As a result, governments in developing countries are establishing emergency care systems. However, there is currently no widely-usable, objective method to monitor or research the rapid growth of emergency care in the developing world. METHODS: Analysis of current quantitative methods to assess emergency care in developing countries, and the proposal of a more appropriate method. RESULTS: Currently accepted methods to quantitatively assess the efficacy of emergency care systems cannot be performed in most developing countries due to weak record-keeping infrastructure and the inappropriateness of applying Western derived coefficients to developing country conditions. As a result, although emergency care in the developing world is rapidly growing, researchers and clinicians are unable to objectively measure its progress or determine which policies work best in their respective countries. We propose the TEWS methodology, a simple analytical tool that can be handled by low-resource, developing countries. CONCLUSIONS: By relying on the most basic universal parameters, simplest calculations and straightforward protocol, the TEWS methodology allows for widespread analysis of emergency care in the developing world. This could become essential in the establishment and growth of new emergency care systems worldwide.

Emergency triage, assessment and treatment at a district hospital in Malawi.

Rumphi District Hospital in Northern Malawi had no emergency triage, assessment or treatment system for the over 5 year olds. Eighty healthcare workers were trained on the South African Triage Scale, which was then implemented within a modified outpatient department. Provision of medical equipment and construction of an emergency room took place to allow early life saving treatment.

Limitations in validating emergency department triage scales.

OBJECTIVE: To examine whether current validation methods of emergency department triage scales actually assess the instrument's validity. METHODS: Optimal methods of emergency department triage scale validation are examined in developed countries and their application to developing countries is considered. RESULTS AND CONCLUSION: Numerous limitations are embedded in the process of validating triage scales. Methods of triage scale validation in developed countries may not be appropriate and repeatable in developing countries. Even in developed countries there are problems in conceptualising validation methods. A new consensus building validation approach has been constructed and recommended for a developing country setting. The Delphi method, a consensual validation process, is advanced as a more appropriate alternative for validating triage scales in developing countries.

Workload and casemix in Cape Town emergency departments.

INTRODUCTION: Little is known about the nature of patients presenting to emergency departments (EDs) in South Africa. This study aimed to provide evidence on ED usage in Cape Town by studying patients at four community health centre (CHC) EDs, with details of the severity of their presentation and their disposal. METHODS: A total of 16,392 patients presented in this 8-week prospective observational study, and 15,681 were included in the descriptive data analysis. One-quarter were children. RESULTS: There were clear and predictable peaks in attendance after 1600 hr and at weekends, with a steady stream of patients presenting overnight. Case severity was evenly distributed between emergency, urgent and routine care. Nearly 10% of patients were referred on to a higher level of care. CONCLUSION: The data from this study present a model for staffing and resource allocation. It has implications for the provision of emergency care in CHC EDs.