The South African triage scale (adult version) provides valid acuity ratings when used by doctors and enrolled nursing assistants

Triage implementation audit at the adult emergency department of Debre Tabor Comprehensive Specialized Hospital in Ethiopia

Introduction

In an emergency room, triage is a crucial element that determines the clinical urgency of patients. Triage can dictate important decisions on the use of resources and the treatment that patients need. Many patients are seen later than necessary, wasting resources and time, and some may even be discharged without being seen, risking their lives. This study aimed to determine whether the triage tool was fully completed, properly measured, and documented, the triage early warning score (TEWS) was calculated, and whether patients were examined, distributed, and managed in appropriate areas.

Methods

An institution-based cross-sectional study with a retrospective chart review was conducted at Debre Tabor Comprehensive Specialized Hospital by selecting patients' charts using simple random sampling among patients who visited the adult Emergency Department from January 1, 2021, to December 31, 2023. The descriptive statistics were presented to characterize individual variables, and cross-tabulation was used to see the relationship between individual patient-related factors and their final triage status.

Results

From the randomly selected 345 patients' charts, 67 (19.4 %) didn't contain a triage sheet. The total triage early warning score was correctly calculated for only 21 (7.6 %) patients and properly triaged. Most of the patients were improperly triaged (92.4 %, n = 257), of which 253 (91 %) were under-triaged and four (1.4 %) were over-triaged. Fischer's exact test revealed a statistically significant relationship between patients' color-coding category, triage early warning score documentation, and the use of clinical discriminators and final triage assessment (p = 0.007, p = 0.000, and p = 0.000 respectively).

Conclusion

The status of our triage implementation is alarming and specifically the level of under-triage. There is a significant gap regarding the application of clinical discriminators and TEWS calculations.

A prospective, internal validation of an emergency patient triage tool for use in a low resource setting

Aim

Assess the performance of a simple triage disposition score based on mental status, mobility and either oxygen saturation or respiratory rate by three principal metrics: 24 h mortality, the need for hospital admission and the urgency ranking of patient presentations.

Method

Prospective observational non-interventional study of consecutive patients presenting to the emergency and outpatient departments of a low-resource sub-Saharan hospital

Results

Out of 14,585 consecutive patients arriving to hospital 1,804 (12.4%) were admitted and 39 died (0.3%) within 24 hours. No patients with normal mental status or a stable independent gait died within 24 h, and 95% of those who did had an oxygen saturation <94%. The c statistic of the score for death within 24 hours was >0.95 and not significantly changed if respiratory rate replaced oxygen saturation as a score component, or mental status was assessed subjectively or objectively. However, an objective measure of mental status significantly reduced the c statistic for hospital admission from 0.970 SE 0.003 to 0.956 SE 0.004, p 0.002. The score attributed a higher acuity rating than the South African Triage System urgency ranking of presentations to 11.1% of patients and a lower acuity rating to 1.3%. However, 53% of the patients given a higher acuity rating were subsequently admitted to hospital and 6.1% of them died.

Conclusion

The score identified patients who subsequently required hospital admission and who were likely to die within 24 hours.

The accuracy of nurse-led triage of adult patients in the emergency centre of urban private hospitals

Background

: Triage is applied in emergency centres (ECs) to assign degrees of urgency to illnesses or injuries to decide in which order to treat patients, especially when there are many patients or casualties, facilitating the allocation of scarce medical resources. A triage nurse determines triage priority by assessing patients using an established triage tool with specific criteria. The South African Triage Scale is widely used in South African ECs. Although the South African Triage Scale has been adopted and implemented in both private and public healthcare ECs in South Africa, few studies have assessed the accuracy of nurse-led triage in private ECs.

Aim

: To determine the accuracy of nurse-led triage in ECs in urban, private hospitals.

Methods

: A quantitative, descriptive, retrospective study was done. Three private hospitals with similar average patient volumes were purposively selected. We sampled the nursing notes as follows: 1) we stratified nursing notes by nurse qualification and then 2) for each category of nurse we stratified nursing notes according to triage priority level and 3) then systematically randomly selected the recommended number of notes from each triage priority level for each nurse category. We retrospectively audited 389 EC nursing notes to determine the accuracy of nurse-led triage. For each note, we independently applied the South African Triage Scale, and then determined agreement between our score and the score determined by the triage nurse.

Results

: We recorded 342 triage errors, consisting of triage early warning scores (TEWS) errors (n = 168), discriminator errors (n = 97) and additional investigation errors (n = 77). Overall agreement between the triage nurses and our scores was 71.7% (n = 279). Triage errors (n = 110) consisted of 3.9% (n = 15) over-triage errors and 24.4% (n = 95) under-triage errors. The highest level of agreement was between our scores and the scores of the emergency trained registered nurses (85%) and enrolled nursing assistants (78%).

Conclusion

: In South African ECs, the South African Triage Scale is not always correctly applied, which can lead to almost a quarter (24.4%) of cases being under-triaged and not receiving timeous care. Our results suggest that emergency trained registered nurses are well equipped to be triage nurses, and that this skill should be developed in South African nursing curricula.

A descriptive study of demographics, triage allocations and patient outcomes at a private emergency centre in Pretoria

BACKGROUND

Triage aims to detect critically ill patients and to prioritise those with time-sensitive needs, whilst contributing to the efficiency of an emergency centre (EC). International systems have been relatively well researched; however, little data exists on the use of the South African Triage Scale (SATS) in private healthcare settings in South Africa (SA).

METHODS

A retrospective descriptive study was undertaken. Data relating to demographics, application of triage, time in EC and disposition were collected on all patients presenting to the EC from 1st January to 31st December 2018.

RESULTS

A total of 29 055 patients' data were included. The mean age was 41 years. Most patients were triaged yellow (73.5%); 17.4% were triaged as red and orange. Patients were seen by a doctor in a mean time of 28 min. Delays to be seen exceeded standards for red and orange patients at 8 min and 18 min, respectively. Most patients (76.1%) were discharged; 5.6% were admitted to intensive care unit (ICU)/high care, and 14.4% to general wards. Of patients triaged red and orange, 11.1% and 49.3% were discharged, respectively, whereas 81.7% of yellow patients were discharged home.

CONCLUSION

This study found that most patients were triaged into low acuity categories and were discharged home. High acuity patients were usually admitted to ICU/high care; however, these patients experienced delays in receiving treatment. The causes of these issues, and the implications, remain unknown. Large numbers of high acuity patients were discharged home. Further studies are needed to understand the influence of triage accuracy on these patients' outcomes.

Using the South African Triage Scale for prehospital triage: a qualitative study

Background

Triage is a critical component of prehospital emergency care. Effective triage of patients allows them to receive appropriate care and to judiciously use personnel and hospital resources. In many low-resource settings prehospital triage serves an additional role of determining the level of destination facility. In South Africa, the Western Cape Government innovatively implemented the South African Triage Scale (SATS) in the public Emergency Medical Services (EMS) service in 2012. The prehospital provider perspectives and experiences of using SATS in the field have not been previously studied.

Methods

In this qualitative study, focus group discussions with cohorts of basic, intermediate and advanced life support prehospital providers were conducted and transcribed. A content analysis using an inductive approach was used to code transcripts and identify themes.

Results

15 EMS providers participated in three focus group discussions. Data saturation was reached and four major themes emerged from the qualitative analysis: Implementation and use of SATS; Effectiveness of SATS; Limitations of the discriminator; and Special EMS considerations. Participants overall felt that SATS was easy to use and allowed improved communication with hospital providers during patient handover. Participants, however, described many clinical cases when their clinical gestalt triaged the patient to a different clinical acuity than generated by SATS. Additionally, they stated many clinical discriminators were too subjective to effectively apply or covered too broad a range of clinical severity (e.g., ingestions). Participants provided examples of how the prehospital environment presents additional challenges to using SATS such as changing patient clinical conditions, transport times and social needs of patients.

Conclusions

Overall, participants felt that SATS was an effective tool in prehospital emergency care. However, they described many clinical scenarios where SATS was in conflict with their own assessment, the clinical care needs of the patient or the available prehospital and hospital resources. Many of the identified challenges to using SATS in the prehospital environment could be improved with small changes to SATS and provider re-training.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00522-3.

Augmented Reality for Guideline Presentation in Medicine: Randomized Crossover Simulation Trial for Technically Assisted Decision-making

BACKGROUND

Guidelines provide instructions for diagnostics and therapy in modern medicine. Various mobile devices are used to represent the potential complex decision trees. An example of time-critical decisions is triage in case of a mass casualty incident.

OBJECTIVE

In this randomized controlled crossover study, the potential of augmented reality for guideline presentation was evaluated and compared with the guideline presentation provided in a tablet PC as a conventional device.

METHODS

A specific Android app was designed for use with smart glasses and a tablet PC for the presentation of a triage algorithm as an example for a complex guideline. Forty volunteers simulated a triage based on 30 fictional patient descriptions, each with technical support from smart glasses and a tablet PC in a crossover trial design. The time to come to a decision and the accuracy were recorded and compared between both devices.

RESULTS

A total of 2400 assessments were performed by the 40 volunteers. A significantly faster time to triage was achieved in total with the tablet PC (median 12.8 seconds, IQR 9.4-17.7; 95% CI 14.1-14.9) compared to that to triage with smart glasses (median 17.5 seconds, IQR 13.2-22.8, 95% CI 18.4-19.2; P=.001). Considering the difference in the triage time between both devices, the additional time needed with the smart glasses could be reduced significantly in the course of assessments (21.5 seconds, IQR 16.5-27.3, 95% CI 21.6-23.2) in the first run, 17.4 seconds (IQR 13-22.4, 95% CI 17.6-18.9) in the second run, and 14.9 seconds (IQR 11.7-18.6, 95% CI 15.2-16.3) in the third run (P=.001). With regard to the accuracy of the guideline decisions, there was no significant difference between both the devices.

CONCLUSIONS

The presentation of a guideline on a tablet PC as well as through augmented reality achieved good results. The implementation with smart glasses took more time owing to their more complex operating concept but could be accelerated in the course of the study after adaptation. Especially in a non-time-critical working area where hands-free interfaces are useful, a guideline presentation with augmented reality can be of great use during clinical management.

Two simple replacements for the Triage Early Warning Score to facilitate the South African Triage Scale in low resource settings

BACKGROUND

The South African Triage Scale (SATS) requires the calculation of the Triage Early Warning Score (TEWS), which takes time and is prone to error.

AIM

to derive and validate triage scores from a clinical database collected in a low-resource hospital in sub-Saharan Africa over four years and compare them with the ability of TEWS to triage patients.

METHODS

A retrospective observational study carried out in Kitovu Hospital, Masaka, Uganda as part of an ongoing quality improvement project. Data collected on 4482 patients was divided into two equal cohorts: one for the derivation of scores by logistic regression and the other for their validation.

RESULTS

Two scores identified the largest number of patients with the lowest in-hospital mortality. A score based on oxygen saturation, mental status and mobility had a c statistic for discrimination of 0.83 (95% CI 0.079-0.87) in the derivation, and 0.81 (95% CI 0.77-0.86) in the validation cohort. Another score based on respiratory rate, mental status and mobility had a c statistic of 0.82 (95% CI 0.078-0.87) in the derivation, and 0.81 (95% CI 0.77-0.86) in the validation cohort. The oxygen saturation-based score of zero points identified 51% of patients in the derivation cohort who had in-hospital mortality rate of 0.5%, and 49% of patients in the validation cohort who had in-hospital mortality of 1.0%. A respiratory rate-based score of zero points identified 45% in the derivation cohort who had in-hospital mortality rate of 0.5%, and 44% of patients in the validation cohort who had in-hospital mortality of 0.8%. Both scores had comparable performance to TEWS.

CONCLUSION

Two easy to calculate scores have comparable performance to TEWS and, therefore, could replace it to facilitate the adoption of SATS in low-resource settings.

Validity and reliability of the South African Triage Scale in prehospital providers

Background

The South African Triage Scale (SATS) is a validated in-hospital triage tool that has been innovatively adopted for use in the prehospital setting by Western Cape Government (WCG) Emergency Medical Services (EMS) in South Africa. The performance of SATS by EMS providers has not been formally assessed. The study sought to assess the validity and reliability of SATS when used by WCG EMS prehospital providers for single-patient triage.

Methods

This is a prospective, assessment-based validation study among WCG EMS providers from March to September 2017 in Cape Town, South Africa. Participants completed an assessment containing 50 clinical vignettes by calculating the three components — triage early warning score (TEWS), discriminators (pre-defined clinical conditions), and a final SATS triage color. Responses were scored against gold standard answers. Validity was assessed by calculating over- and under-triage rates compared to gold standard. Inter-rater reliability was assessed by calculating agreement among EMS providers’ responses.

Results

A total of 102 EMS providers completed the assessment. The final SATS triage color was accurately determined in 56.5%, under-triaged in 29.5%, and over-triaged in 13.1% of vignette responses. TEWS was calculated correctly in 42.6% of vignettes, under-calculated in 45.0% and over-calculated in 10.9%. Discriminators were correctly identified in only 58.8% of vignettes. There was substantial inter-rater and gold standard agreement for both the TEWS component and final SATS color, but there was lower inter-rater agreement for clinical discriminators.

Conclusion

This is the first assessment of SATS as used by EMS providers for prehospital triage. We found that SATS generally under-performed as a triage tool, mainly due to the clinical discriminators. We found good inter-rater reliability, but poor validity. The under-triage rate of 30% was higher than previous reports from the in-hospital setting. The over-triage rate of 13% was acceptable. Further clinically-based and qualitative studies are needed.

Trial registration

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00406-6.

Emergency department admissions Kumasi, Ghana: Prevalence of alcohol and substance use, and associated trauma

INTRODUCTION

Alcohol and substance use (ASU) are significant contributors to global morbidity, mortality, and health resource utilization. We sought to describe the frequency of ASU use among adult injured patients presenting to the Komfo Anokye Teaching Hospital Emergency Department (KATH ED) and to describe injury mechanism and site among injured patients.

METHODS

A cross-sectional study was carried out for six months in 2016 involving all trauma patients and altered mental status patients presenting to the ED in Kumasi, Ghana. Blood alcohol concentration was evaluated with SureScreen Alcometer Breathalyzer, which provided a numeric breath alcohol concentration in mg/L units (BAC). Substance presence was evaluated using saliva strips with Micro-Distribution STATSWAB 6 panel oral fluid devices. Medical charts were reviewed retrospectively for details of history after testing was done at triage.

RESULTS

The total number of patients tested for substance use was 171 comprising 146 trauma patients and 25 non-trauma patients with altered mental statuses. Twenty-four percent (41) of patients tested positive for drugs. Of these 41, 29 tested positive for marijuana, six tested for opiates, two tested for oxycodone, two tested positive for cocaine, one tested positive for benzodiazepines, and one tested positive for methamphetamines. About a third (29%) of the patients tested positive for alcohol. Eleven patients (6.4%) tested positive for ASU. Road traffic injuries were the commonest mechanism of injury. Lower limb (42.1%), upper limb (29.2%), and head injuries constituted the most common injuries.

CONCLUSION

ASU may be a preventable cause of injuries among adults presenting to KATH ED.

Prehospital acute traumatic pain assessment and management practices in the Western Cape, South Africa: a retrospective review

BACKGROUND

Trauma is a common aetiology of acute pain in the emergency setting, and traumatic injuries have been recognised as a global public health crisis leading to numerous deaths and disabilities. This study aimed to identify the prevalence of acute pain among high acuity trauma patients presenting to a public sector emergency medical service and to describe prehospital acute traumatic pain assessment and management practices amongst emergency care providers in the Western Cape Province, South Africa.

METHODS

A retrospective review of electronic patient care reports of trauma patients treated by the South African Western Cape Emergency Medical Services between January 1 and December 31, 2017 was conducted. Stratified random sampling was utilised to select 2401 trauma patients out of 24,575 that met the inclusion criteria.

RESULTS

Of the 2401 patients reviewed, 435 (18.1%) had a pain score recorded, of which 423 (97.2%) were experiencing pain. An additional 8.1% (n = 194) of patients had pain or tenderness mentioned in the working diagnosis but no pain score noted. Eighty-one (18.6%) patients experienced mild pain, 175 (40.2%) moderate pain and 167 (38.2%) severe pain. No association was found between a pain score recorded and age group (≤ 14 versus > 14 years) (p = 0.649) or gender (p = 0.139). Only 7.6% of patients with moderate-to-severe pain and 2.8% of all trauma patients received any form of analgesic medication. No association was found between the administration of analgesia and age group (≤ 14 versus > 14 years) (p = 0.151) or gender (p = 0.054). Patients were more likely to receive analgesia if they had a pain score recorded (p < 0.001), were managed by advanced life support practitioners (p < 0.001) or had severe pain (p = 0.001).

CONCLUSION

Acute trauma pain assessment and management practices in this prehospital cohort are less well established than reported elsewhere and whether this reflects emergency care training, institutional culture, scopes of practice or analgesic resources, requires further research. Emergency medical services need to monitor and promote quality pain care, enhance pain education and ensure that all levels of emergency care providers have access to analgesic medication approved for prehospital use. Clear and rational guidelines would enable better pain management by all cadres of providers, for all levels of pain.

Reliability and validity of three international triage systems within a private health-care group in the Middle East

AIM

To measure and compare the reliability and validity of three international triage systems (CTAS, MTS and ESI) when applied to patient presentations in the emergency centres of a private health-care group in the United Arab Emirates.

BACKGROUND

The ability of triage systems to sort patients into categories based on the urgency of their need and time to physician is a key indicator. Three international triage systems are being used for this purpose in private emergency centre settings.

METHOD

Bespoke reference scenarios, 50 vignettes (10 per severity level) were created and validated by a local expert panel. Nurses performing triage at four emergency centres in the Emirate of Dubai completed online surveys to categorise the vignettes based on the triage system they used in their emergency centre.

RESULTS

Overall inter-rater reliability per triage category was substantial for allocations in category one, moderate for those in categories two and five, and fair for those in categories three and four. Agreement between raters and the reference standard was consistent throughout all four emergency centres. The accuracy of triaging allocations into categories one, two and five were good, whereas allocations in categories three and four were less accurate.

CONCLUSION

International triage systems focus on the identification of more urgent cases and perform poorly in discriminating between those that are less serious, which is less ideal in a setting where less-serious cases are more prevalent.

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.

The burden of trauma at a district hospital in the Western Cape Province of South Africa

BACKGROUND

Sub-Saharan Africa bears a disproportionate burden of mortality from trauma. District hospitals, although not trauma centres, play a critical role in the trauma care system by serving as frontline hospitals. However, the clinical characteristics of patients receiving trauma care in African district hospitals remains under-described and is a barrier to trauma care system development. We aim to describe the burden of trauma at district hospitals by analysing trauma patients at a prototypical district hospital emergency centre.

METHODS

An observational study was conducted in August, 2014 at Wesfleur Hospital, a district facility in the Western Cape Province of South Africa. Data were manually collected from a paper registry for all patients visiting the emergency centre. Patients with trauma were selected for further analysis.

RESULTS

Of 3299 total cases, 565 (17.1%) presented with trauma, of which 348 (61.6%) were male. Of the trauma patients, 256 (47.6%) were ages 18-34 and 298 (52.7%) presented on the weekend. Intentional injuries (assault, stab wounds, and gunshot wounds) represented 251 (44.4%) cases of trauma. There were 314 (55.6%) cases of injuries that were unintentional, including road traffic injuries. There were 144 (60%) intentionally injured patients that arrived overnight (7pm-7am). Patients with intentional injuries were three times more likely to be transferred (to higher levels of care) or admitted than patients with unintentional injuries.

CONCLUSION

This district hospital emergency centre, with a small complement of non-EM trained physicians and no trauma surgical services, cared for a high volume of trauma with over half presenting on weekends and overnight when personnel are limited. The high volume and rate of admission/ transfer of intentional injuries suggests the need for improving prehospital trauma triage and trauma referrals. The results suggest strengthening trauma care systems at and around this resource-limited district hospital in South Africa may help alleviate the high burden of post-trauma morbidity and mortality.

Exploring the sorting of patients in community health centres across Gauteng Province, South Africa

BACKGROUND

Primary health care worldwide faces large numbers of patients daily. Poor waiting times, low patient satisfaction and staff burnout are some problems facing such facilities. Limited research has been done on sorting patients in non-emergency settings in Africa. This research looked at community health centres (CHCs) in Gauteng Province, South Africa where queues appear to be poorly managed and patients waiting for hours. This study explores the views of clinicians in CHCs across Gauteng on sorting systems in the non-emergency ambulatory setting.

METHODS

The qualitative study design used one-to-one, in-depth interviews of purposively selected doctors. Interviews were conducted in English, with open-ended exploratory questions. Interviews were recorded, transcribed, anonymised and checked by interviewees later. Data collection and analysis stopped with information saturation. The co-author supervised and cross-checked the process. A thematic framework was developed by both authors, before final thematic coding of all transcripts was undertaken by the principal author. This analysis was based on the thematic framework approach.

RESULTS

Twelve primary health care (PHC) doctors with experience in patient sorting, from health districts across Gauteng, were interviewed. Two themes were identified, two major themes, namely Systems Implemented and Innovative Suggestions, and Factors Affecting Triage. Systems Implemented included those using vital signs, sorting by specialties, and using the Integrated Management of Childhood Illnesses approach. Systems Implemented also included doctor - nurse triage, first come first serve, eyeball triage and sorting based on main complaint. Innovative Suggestions, such as triage room treatment and investigations, telephone triage, longer clinic hours and a booking system emerged. There were three Factors Affecting Triage: Management Factor, including general management issues, equipment, documentation, infrastructure, protocol, and uniformity; and Staff Factor, including general staffing issues education and teamwork; and Patient Factor.

CONCLUSION

Developing a functional triage protocol with innovative systems for Gauteng is important. Findings from this study can guide the development of a functional triage system in the primary health care non-emergency outpatient setting of Gauteng's CHCs. The Emergency Triage, Assessment and Treatment (ETAT) tool, modified for adult and non-clinician use, could help this. However, addressing management, staff and patient factors must be integral.

Reliability and validity of emergency department triage tools in low- and middle-income countries: a systematic review

OBJECTIVE

Despite the universal acknowledgment that triage is necessary to prioritize emergency care, there is no review that provides an overview of triage tools evaluated and utilized in resource-poor settings, such as low- and middle-income countries (LMICs). We seek to quantify and evaluate studies evaluating triage tools in LMICs.

METHODS

We performed a systematic review of the literature between 2000 and 2015 to identify studies that evaluated the reliability and validity of triage tools for adult emergency care in LMICs. Studies were then evaluated for the overall quality of evidence using the GRADE criteria.

RESULTS

Eighteen studies were included in the review, evaluating six triage tools. Three of the 18 studies were in low-income countries and none were in rural hospitals. Two of the six tools had evaluations of reliability. Each tool positively predicted clinical outcomes, although the variety in resource environments limited ability to compare the predictive nature of any one tool. The South African Triage Scale had the highest quality of evidence. In comparison with high-income countries, the review showed fewer studies evaluating reliability and presented a higher number of studies with small sample sizes that decreased the overall quality of evidence.

CONCLUSION

The quality of evidence supporting any single triage tool's validity and reliability in LMICs is moderate at best. Research on triage tool applicability in low-resource environments must be targeted to the actual clinical environment where the tool will be utilized, and must include low-income countries and rural, primary care settings.

The burden of trauma presenting to the government referral hospital in Freetown, Sierra Leone: An observational study

INTRODUCTION

Trauma accounts for a significant proportion of the global burden of disease, with highest mortality rates seen in Africa. This epidemic is predicted to increase with urbanisation and an aim of the Sustainable Development Goals is to reduce deaths and trauma caused by road accidents. Data available on urban trauma in Sierra Leone is limited.

METHODS

We conducted a retrospective observational study of trauma and injury related presentations to the emergency centre (EC) of Connaught Hospital, the principal adult tertiary referral centre in Freetown, Sierra Leone between January and March 2016. Patient demographics are described with mechanism of injury. Additional data on length of stay and surgical procedures were recorded for admissions to the trauma ward.

RESULTS

During the 3-month period, a total of 340 patients with injury presented to the EC, accounting for 11.6% of total attendances and 68% of adult surgical admissions. The majority were male (66%) and mean age was 26 years (IQR 15-40). The proportion of trauma presentations were higher in the evening and at weekends and 41% of patients were triaged as emergency or very urgent cases. Road traffic accidents were the most frequent cause of injury (55%) followed by falls (17%) and assaults (14%). Burns were more common in children. Head and lower limbs were the most commonly injured body parts and a minority of patients underwent surgical procedures. Median length of stay for adult patients was 4.5 days (IQR 2-11) and 7 days (IQR 4-14) for children.

DISCUSSION

Injury accounts for a high burden of disease at Connaught Hospital and consumes a significant proportion of EC and hospital resources. Efforts should be directed towards strengthening the pre-hospital and emergency trauma systems with accurate, formal data collection as well as targeting injury prevention initiatives and improving road safety to reduce morbidity and mortality.

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.

A quality improvement study of the emergency centre triage in a tertiary teaching hospital in northern Ethiopia

INTRODUCTION

An effective emergency triage system should prioritize both trauma and non-trauma patients according to level of acuity, while also addressing local disease burden and resource availability. In March 2012, an adapted version of the South African Triage Scale was introduced in the emergency centre (EC) of Ayder Comprehensive Specialized Hospital in northern Ethiopia.

METHODS

This quality improvement study was conducted to evaluate the implementation of nurse-led emergency triage in a large Ethiopian teaching hospital using the Donabedian model. A 45% random sample was selected from all adult emergency patients during the study period, May 10th to May 25th 2015. Patient charts were collected and retrospectively reviewed. Presence and proper completion of the triage form were appraised. Triage level was abstracted and compared with patient outcome (dichotomized as "admitted to hospital or died" and "discharged alive from emergency centre") to quantify over- and under-triage triage.

RESULTS

From 251 randomly selected patients, 107 (42.6%) charts were retrieved. From these, only 45/107 (42.1%) contained the triage form filled within the chart. None of the triage forms were filled out completely. From 13 (28.9%) admitted or deceased patients, the under-triage rate was 30.7% and from 32 (71.1%) patients discharged alive from the EC the over-triage rate was 21.9%.

DISCUSSION

The under-triage rate observed in this study exceeds the recommended threshold of 5% and is a serious patient safety concern. However, under-triage may have been magnified by irregularities in the hospital admission process. Haphazard medical record handling, poor documentation, erroneous triage decisions, and poor rapport between nurses and physicians were the main process-related challenges that must be addressed through intensive training and improved human resource management approaches to enhance the quality of triage in the emergency centre.

An assessment of nurse-led triage at Connaught Hospital, Sierra Leone in the immediate post-Ebola period

INTRODUCTION

Nurse-led triage, using the South African Triage Scale, was introduced to the emergency centre of the tertiary referral hospital in Freetown, Sierra Leone in early 2014 prior to the Ebola epidemic. The aim of this study was to measure the effectiveness of the process now that the country has been declared free of Ebola.

METHODS

The study was conducted over a five-day consecutive period in the adult emergency centre of the main government teaching hospital in December 2015. The times from arrival to triage and medical assessment were recorded and compared for each triage category. We also assessed the inter-rater reliability of the process.

RESULTS

111 patients were included during the study period. In terms of acuity, 6% were categorised as red, 27% were orange, 20% yellow and 47% green. Triage Early Warning Score was correctly calculated in 90% of cases and there was inter-rater agreement of colour code and triage category on 92% of occasions (k = 0.877, p < 0.001). Median time from triage to assessment was 15 min for red patients, 20 min for orange, 40 min for yellow and 72 min for green.

DISCUSSION

The triage process is functioning effectively in the emergency centre after the Ebola epidemic and provides a reliable assessment of undifferentiated patients presenting to the hospital to ensure that they are seen in a timely manner based on acuity.

Harmful alcohol use among injured adult patients presenting to a Ghanaian emergency department

We performed a nested convenience sample survey of harmful alcohol use among injured patients aged 18 years and older treated in the Komfo Anokye Teaching Hospital (Kumasi, Ghana) emergency department (ED). Data from the Alcohol Use Disorder Identification Test, alcohol breath or saliva tests, patient demographics and injury characteristics were collected from an administered survey and medical chart review. A total of 403 subjects were surveyed, and 107 (27%; 95% CI 22 to 31) reported harmful alcohol use. High rates of harmful alcohol use were found among males (35%), acutely alcohol-positive subjects (55%), drivers (32%), pedestrians (35%) and assault victims (43%). A substantial proportion of injured patients reported harmful alcohol use. The data obtained support routine screening of injured patients presenting to Ghanaian EDs for harmful alcohol use.

Evaluation of the implementation of the South African Triage System at an academic hospital in central Haiti

BACKGROUND

Effective triage is an important part of high quality emergency care, yet is frequently lacking in resource-limited settings. The South African Triage Scale (SATS) is designed for these settings and consists of a numeric score (triage early warning score, TEWS) and a list of clinical signs (known as discriminators). Our objective was to evaluate the implementation of SATS at a new teaching hospital in Haiti.

METHODS

A random sample of emergency department charts from October 2013 were retrospectively reviewed for the completeness and accuracy of the triage form, correct calculation of the triage score, and final patient disposition. Over and under triage were calculated. Comparisons were evaluated with chi-squared analysis.

RESULTS

Of 390 charts were reviewed, 385 contained a triage form and were included in subsequent analysis. The final triage color was recorded for 68.4% of patients, clinical discriminators for 48.6%, and numeric score for 96.1%. The numeric score was calculated correctly 78.3% of the time; in 13.2% of patients a calculation error was made that would have changed triage priority. In 23% of cases, chart review identified clinical discriminators should have been circled but were not recorded. Overtriage and undertriage were 75.6% and 7.4% respectively.

CONCLUSION

This study demonstrates that with limited structured training, SATS was widely adopted, but the clinical discriminators were used less commonly than the numeric score. This should be considered in future implementations of SATS.

Reliability and validity of pediatric triage tools evaluated in Low resource settings: a systematic review

BACKGROUND

Despite the high burden of pediatric mortality from preventable conditions in low and middle income countries and the existence of multiple tools to prioritize critically ill children in low-resource settings, no analysis exists of the reliability and validity of these tools in identifying critically ill children in these scenarios.

METHODS

The authors performed a systematic search of the peer-reviewed literature published, for studies pertaining to for triage and IMCI in low and middle-income countries in English language, from January 01, 2000 to October 22, 2013. An updated literature search was performed on on July 1, 2015. The databases searched included the Cochrane Library, EMBASE, Medline, PubMed and Web of Science. Only studies that presented data on the reliability and validity evaluations of triage tool were included in this review. Two independent reviewers utilized a data abstraction tool to collect data on demographics, triage tool components and the reliability and validity data and summary findings for each triage tool assessed.

RESULTS

Of the 4,717 studies searched, seven studies evaluating triage tools and 10 studies evaluating IMCI were included. There were wide varieties in method for assessing reliability and validity, with different settings, outcome metrics and statistical methods.

CONCLUSIONS

Studies evaluating triage tools for pediatric patients in low and middle income countries are scarce. Furthermore the methodology utilized in the conduct of these studies varies greatly and does not allow for the comparison of tools across study sites.

Diagnostic accuracy of the Kampala Trauma Score using estimated Abbreviated Injury Scale scores and physician opinion

BACKGROUND

The Kampala Trauma Score (KTS) has been proposed as a triage tool for use in low- and middle-income countries (LMICs). This study aimed to examine the diagnostic accuracy of KTS in predicting emergency department outcomes using timely injury estimation with Abbreviated Injury Scale (AIS) score and physician opinion to calculate KTS scores.

METHODS

This was a diagnostic accuracy study of KTS among injured patients presenting to Komfo Anokye Teaching Hospital A&E, Ghana. South African Triage Scale (SATS); KTS component variables, including AIS scores and physician opinion for serious injury quantification; and ED disposition were collected. Agreement between estimated AIS score and physician opinion were analyzed with normal, linear weighted, and maximum kappa. Receiver operating characteristic (ROC) analysis of KTS-AIS and KTS-physician opinion was performed to evaluate each measure's ability to predict A&E mortality and need for hospital admission to the ward or theatre.

RESULTS

A total of 1053 patients were sampled. There was moderate agreement between AIS criteria and physician opinion by normal (κ=0.41), weighted (κ_lin=0.47), and maximum (κ_max=0.53) kappa. A&E mortality ROC area for KTS-AIS was 0.93, KTS-physician opinion 0.89, and SATS 0.88 with overlapping 95% confidence intervals (95%CI). Hospital admission ROC area for KTS-AIS was 0.73, KTS-physician opinion 0.79, and SATS 0.71 with statistical similarity. When evaluating only patients with serious injuries, KTS-AIS (ROC 0.88) and KTS-physician opinion (ROC 0.88) performed similarly to SATS (ROC 0.78) in predicting A&E mortality. The ROC area for KTS-AIS (ROC 0.71; 95%CI 0.66-0.75) and KTS-physician opinion (ROC 0.74; 95%CI 0.69-0.79) was significantly greater than SATS (ROC 0.57; 0.53-0.60) with regard to need for admission.

CONCLUSIONS

KTS predicted mortality and need for admission from the ED well when early estimation of the number of serious injuries was used, regardless of method (i.e. AIS criteria or physician opinion). This study provides evidence for KTS to be used as a practical and valid triage tool to predict patient prognosis, ED outcomes and inform referral decision-making from first- or second-level hospitals in LMICs.

Frequency of Alcohol Use Among Injured Adult Patients Presenting to a Ghanaian Emergency Department

STUDY OBJECTIVE

Injuries are the cause of almost 6 million deaths annually worldwide, with 15% to 20% alcohol associated. The frequency of alcohol-associated injury varies among countries and is unknown in Ghana. We determined the frequency of positive alcohol test results among injured adults in a Ghanaian emergency department (ED).

METHODS

This is a cross-sectional chart review of consecutive injured patients aged 18 years or older presenting to the Komfo Anokye Teaching Hospital ED for care within 8 hours of injury. Patients were tested for presence of alcohol with a breathalyzer or a saliva alcohol test. Patients were excluded if they had minor injuries resulting in referral to a separate outpatient clinic, or death before admission. Alcohol test results, subject, and injury characteristics were collected. Proportions with 95% confidence intervals were calculated.

RESULTS

Injured adult patients (2,488) presented to the ED from November 2014 to April 2015, with 1,085 subjects (43%) included in this study. Three hundred eighty-two subjects (35%; 95% confidence interval 32% to 38%) tested alcohol positive. Forty-two percent of men (320/756), 40% of subjects aged 25 to 44 years (253/626), 42% of drivers (66/156), 42% of pedestrians (85/204), 49% of assault victims (82/166), 40% of those seriously injured (124/311), and 53% of subjects who died in the ED (8/15) had positive results for presence of alcohol.

CONCLUSION

The frequency of alcohol-associated injury was 35% among tested subjects in this Ghanaian tertiary care hospital ED. These findings have implications for health policy-, ED- and legislative-based interventions, and acute care.

Developing metrics for emergency care research in low- and middle-income countries

INTRODUCTION

There is little research on emergency care delivery in low- and middle-income countries (LMICs). To facilitate future research, we aimed to assess the set of key metrics currently used by researchers in these settings and to propose a set of standard metrics to facilitate future research.

METHODS

Systematic literature review of 43,109 published reports on general emergency care from 139 LMICs. Studies describing care for subsets of emergency conditions, subsets of populations, and data aggregated across multiple facilities were excluded. All facility- and patient-level statistics reported in these studies were recorded and the most commonly used metrics were identified.

RESULTS

We identified 195 studies on emergency care delivery in LMICs. There was little uniformity in either patient- or facility-level metrics reported. Patient demographics were inconsistently reported: only 33% noted average age and 63% the gender breakdown. The upper age boundary used for paediatric data varied widely, from 5 to 20 years of age. Emergency centre capacity was reported using a variety of metrics including annual patient volume (n = 175, 90%); bed count (n = 60, 31%), number of rooms (n = 48, 25%); frequently none of these metrics were reported (n = 16, 8%). Many characteristics essential to describe capabilities and performance of emergency care were not reported, including use and type of triage; level of provider training; admission rate; time to evaluation; and length of EC stay.

CONCLUSION

We found considerable heterogeneity in reporting practices for studies of emergency care in LMICs. Standardised metrics could facilitate future analysis and interpretation of such studies, and expand the ability to generalise and compare findings across emergency care settings.

Electronic Medical Records in low to middle income countries: The case of Khayelitsha Hospital, South Africa

INTRODUCTION

Electronic Medical Records (EMRs) have shown benefit for clinical, organisational, and societal outcomes. In low-to-middle-income countries, the desire for EMRs will continue to rise as increasing trauma and infectious disease rates necessitate adequate record keeping for effective follow-up. 114 nations are currently working on national EMRs, with some using both a full EMR (Clinicom) and a paper-based system scanned to an online Enterprise Content Management (ECM) database.

METHODS

The authors sought to evaluate the ability and completeness of the EMR at Khayelitsha Hospital (KH) to capture all Emergency Centre (EC) encounters classified as trauma. Based on the high trauma rates in the Khayelitsha area and equally high referral rates from KH to higher-level trauma centres, an assumption was made that its rates would mirror nationwide estimates of 40% of EC visits. Records from July 2012 to June 2013 were examined.

RESULTS

3488 patients visited the EC in the month of July 2012. 10% were noted as trauma on Clinicom and within their records were multiple sections with missing information. The remaining months of Aug 2012-June 2013 had an average trauma load of 8%. On further investigation, stacks of un-scanned patient folders were identified in the records department, contributing to the unavailability of records from January 2013 to the time of study (June 2013) on ECM.

CONCLUSION

The results highlight difficulties with implementing a dual record system, as neither the full EMR nor ECM was able to accurately capture the estimated trauma load. Hospitals looking to employ such a system should ensure that sufficient funds are in place for adequate support, from supervision and training of staff to investment in infrastructure for efficient transfer of information. In the long run, efforts should be made to convert to a complete EMR to avoid the many pitfalls associated with handling paper records.