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

Enhancing triage accuracy: The influence of nursing education on risk prediction

AIM

This study aimed to compare the performance in risk prediction of various outcomes between specially trained triage nurses and the Manchester Triage System (MTS).

DESIGN

Prospective observational study.

METHODS

The study was conducted from June 1st to December 31st, 2023, at the Emergency Department of Merano Hospital. Triage nurses underwent continuous training through dedicated courses and daily audits. We compared the risk stratification performed by expert nurses with that of MTS on various outcomes such as mortality, hospitalisation, and urgency defined by the physicians. Comparisons were made using the Areas Under the Receiver Operating Characteristic curve (AUROC).

RESULTS

The agreement in code classification between the MTS and the expert nurse was very low. The AUROC curve analysis showed that the expert nurse outperformed the MTS in all outcomes. The triage nurse's experience led to statistically significant better stratification in admission rates, ICU admissions, and all outcomes based on the physician's assessment.

CONCLUSIONS

The continuous training of nurses enables them to achieve better risk prediction compared to standardized triage systems like MTS, emphasizing the utility and necessity of implementing continuous training pathways for these highly specialised personnel.

Performance of the Interagency Integrated Triage Tool in a resource-constrained emergency department during the COVID-19 pandemic

BACKGROUND

The Interagency Integrated Triage Tool (IITT) is a three-tier triage instrument recommended by the World Health Organization, but only the pilot version of the tool has been comprehensively assessed for its validity and reliability. This study sought to evaluate the performance of the IITT in a resource-constrained emergency department (ED) during the COVID-19 pandemic.

METHODS

This prospective observational study was conducted at ANGAU Memorial Provincial Hospital in Lae, Papua New Guinea. The study period commenced approximately six weeks after introduction of the IITT, coinciding with a major COVID-19 wave. The primary outcome was sensitivity for the detection of time-critical illness, defined by eight pre-specified conditions. Secondary outcomes included the relationship between triage category and disposition. Inter-rater reliability was assessed using Cohen's Kappa.

RESULTS

There were 759 eligible presentations during the study period. Thirty patients (4.0%) were diagnosed with one of the eight pre-specified time-critical conditions and 21 were categorised as red or yellow, equating to a sensitivity of 70.0% (95%CI 50.6-85.3). There was a clear association between triage category and disposition, with 22 of 53 red patients (41.5%), 72 of 260 yellow patients (27.7%) and 22 of 452 green patients (4.9%) admitted (p = <0.01). Negative predictive values for admission and death were 95.1% (95%CI 92.7-96.9) and 99.3% (95%CI 98.1-99.9) respectively. Among a sample of 106 patients, inter-rater reliability was excellent (κ = 0.83) and the median triage assessment time was 94 seconds [IQR 57-160].

CONCLUSION

In this single-centre study, the IITT's sensitivity for the detection of time-critical illness was comparable to previous evaluations of the tool and within the performance range reported for other triage instruments. There was a clear relationship between triage category and disposition, suggesting the tool can predict ED outcomes. Health service pressures related to COVID-19 may have influenced the findings.

Triage implementation in resource-limited emergency departments: sharing tools and experience from the Pacific region

According to the World Health Organization's (WHO) Emergency Care Systems Framework, triage is an essential function of emergency departments (EDs). This practice innovation article describes four strategies that have been used to support implementation of the WHO-endorsed Interagency Integrated Triage Tool (IITT) in the Pacific region, namely needs assessment, digital learning, public communications and electronic data management.Using a case study from Vila Central Hospital in Vanuatu, a Pacific Small Island Developing State, we reflect on lessons learned from IITT implementation in a resource-limited ED. In particular, we describe the value of a bespoke needs assessment tool for documenting triage and patient flow requirements; the challenges and opportunities presented by digital learning; the benefits of locally designed, public-facing communications materials; and the feasibility and impact of a low-cost electronic data registry system.Our experience of using these tools in Vanuatu and across the Pacific region will be of interest to other resource-limited EDs seeking to improve their triage practice and performance. Although the resources and strategies presented in this article are focussed on the IITT, the principles are equally relevant to other triage systems.

Triage practices for emergency care delivery: a qualitative study among febrile patients and healthcare workers in a tertiary care hospital in Nepal

BACKGROUND

Improving screening and triage practices is essential for early severity assessments at the first point of contact and ensuring timely attention by healthcare workers (HCWs). The main objective of this study was to explore the triage process among febrile patients and HCWs in the emergency department (ED) of a tertiary care hospital in a resource-constrained setting.

METHODS

This qualitative study was conducted from March to May 2023 at the ED of Tribhuvan University Teaching Hospital (TUTH), Nepal. The study included in-depth interviews with febrile patients (n = 15) and HCWs (n = 15). Additionally, direct observation notes (n = 20) were collected to document the triage process and patients' experiences in the ED. Data underwent thematic analysis using the Interpretative Phenomenological Analysis (IPA) approach.

RESULTS

The ED of TUTH offered comprehensive triage services with clear delineation for the severity of febrile patients in line with the World Health Organization (WHO) guidelines. Nonetheless, challenges and constraints were identified. In the ED, evenings were generally the busiest period, and the triage process was not thorough during night shifts. Perception of triage was limited among patients and variable among HCWs. Digitalizing recordings of patient information including payment was deemed necessary for effective management of patients' waiting times at the triage station. High patient throughput added pressure on HCWs and had a potential influence on the delivery of services. Availability of medical equipment and space were also identified as challenges, with patients sometimes compelled to share beds. There were constraints related to waste disposal, hygiene, cleanliness, and the availability and maintenance of washrooms. Febrile patients experienced delays in receiving timely consultations and laboratory investigation reports, which affected their rapid diagnosis and discharge; nonetheless, patients were satisfied with the overall healthcare services received in the ED.

CONCLUSIONS

Improving current triage management requires resource organization, including optimizing the waiting time of patients through a digitalized system. Urgent priorities involve upgrading visitor facilities, patient consultations, laboratory investigations, hygiene, and sanitation. HCWs' recommendations to resource the ED with more equipment, space, and beds and a dedicated triage officer to ensure 24-hour service, together with training and incentives, warrant further attention.

Systematic review: What is the impact of triage implementation on clinical outcomes and process measures in low- and middle-income country emergency departments?

INTRODUCTION

Triage is widely regarded as an essential function of emergency care (EC) systems, especially in resource-limited settings. Through a systematic search and review of the literature, we investigated the effect of triage implementation on clinical outcomes and process measures in low- and middle-income country (LMIC) emergency departments (EDs).

METHODS

Structured searches were conducted using MEDLINE, CENTRAL, EMBASE, CINAHL, and Global Health. Eligible articles identified through screening and full-text review underwent risk-of-bias assessment using the Newcastle-Ottawa Scale. The quality of evidence for each effect measure was summarized using GRADE.

RESULTS

Among 10,394 articles identified through the search strategy, 58 underwent full-text review and 16 were included in the final synthesis. All utilized pre-/postintervention methods and a majority were single center. Effect measures included mortality, waiting time, length of stay, admission rate, and patient satisfaction. Of these, ED mortality and time to clinician assessment were evaluated most frequently. The majority of studies using these outcomes identified a positive effect, namely a reduction in deaths and waiting time among patients presenting for EC. The quality of the evidence was moderate for these measures but low or very low for all other outcomes and process indicators.

CONCLUSIONS

There is moderate quality of evidence supporting an association between the introduction of triage and a reduction in deaths and waiting time. Although the available data support the value of triage in LMIC EDs, the risk of confounding and publication bias is significant. Future studies will benefit from more rigorous research methods.

Accuracy of Trauma on Scene Triage Screening Tool (Shock Index, Reverse Shock Index Glasgow Coma Scale and National Early Warning Score) to Predict the Severity of Emergency Department Triage: A Retrospective Cross-Sectional Study

Introduction

Prehospital trauma care includes on-scene assessments, essential treatment, and facilitating transfer to an appropriate trauma center to deliver optimal care for trauma patients. While the Simple Triage and Rapid Treatment (START), Revised Triage Sieve (rTS), and National Early Warning Score (NEWS) tools are user-friendly in a prehospital setting, there is currently no standardized on-scene triage protocol in Thailand Emergency Medical Service (EMS). Therefore, this study aims to evaluate the precision of these tools (SI, rSIG, and NEWS) in predicting the severity of trauma patients who are transferred to the emergency department (ED).

Methods

This study was a retrospective cross-sectional and diagnostic research conducted on trauma patients transferred by EMS to the ED of Ramathibodi Hospital, a university-affiliated super tertiary care hospital in Bangkok, Thailand, from January 2015 to September 2022. We compared the on-scene triage tool (SI, rSIG, and NEWS) and ED triage tool (Emergency Severity Index) parameters, massive transfusion protocol (MTP), and intensive care unit (ICU) admission with the area under ROC (univariable analysis) and diagnostic odds ratio (multivariable logistic regression analysis). The optimal cut-off threshold for the best parameter was determined by selecting the value that produced the highest area under the ROC curve.

Results

A total of 218 patients were traumatic patients transported by EMS to the ED, out of which 161 were classified as ESI levels 1-2, while the remaining 57 patients were categorized as levels 3-5 on the ESI triage scale. We found that NEWS was a more accurate triage tool to discriminate the severity of trauma patients than rSIG and SI. The area under the ROC was 0.74 (95% CI 0.70-0.79) (OR 18.98, 95% CI 1.06-337.25), 0.65 (95% CI 0.59-0.70) (OR 1.74, 95% CI 0.17-18.09) and 0.58 (95% CI 0.52-0.65) (OR 0.28, 95% CI 0.04-1.62), respectively (P-value <0.001). The cut point of NEWS to discriminate ESI levels 1-2 and levels 3-5 was >6 points.

Conclusion

NEWS is the best on-scene triage screening tool to predict the severity at the emergency department, massive transfusion protocol (MTP), and intensive care unit (ICU) admission compared with other triage tools SI and rSIG.

Malawi Trauma Score is Predictive of Mortality at a District Hospital: A Validation Study

BACKGROUND

Trauma scoring systems can identify patients who should be transferred to referral hospitals, but their utility in LMICs is often limited. The Malawi Trauma Score (MTS) reliably predicts mortality at referral hospitals but has not been studied at district hospitals. We sought to validate the MTS at a Malawi district hospital and evaluate whether MTS is predictive of transfer to a referral hospital.

METHODS

We performed a retrospective study using trauma registry data from Salima District Hospital (SDH) from 2017 to 2021. We excluded patients brought in dead, discharged from the Casualty Department, or missing data needed to calculate MTS. We used logistic regression modeling to study the relationship between MTS and mortality at SDH and between MTS and transfer to a referral hospital. We used receiver operating characteristic analysis to validate the MTS as a predictor of mortality.

RESULTS

We included 2196 patients (84.3% discharged, 12.7% transferred, 3.0% died). These groups had similar ages, sex, and admission vitals. Mean (SD) MTS was 7.9(3.0) among discharged patients, 8.4(3.9) among transferred patients, and 14.2(8.0) among patients who died (p < 0.001). Higher MTS was associated with increased odds of mortality at SDH (OR 1.21, 95% CI 1.14-1.29, p < 0.001) but was not related to transfer. ROC area for mortality was 0.73 (95% CI 0.65-0.80).

CONCLUSIONS

MTS is predictive of district hospital mortality but not inter-facility transfer. We suggest that MTS be used to identify patients with severe trauma who are most likely to benefit from transfer to a referral hospital.

Implementation of the South African Triage Scale (SATS) in a New Ambulance System in Beira, Mozambique: A Retrospective Observational Study

In 2019, an urban ambulance system was deployed in the city of Beira, Mozambique to refer patients from peripheral health centres (HCs) to the only hospital of the city (Beira Central Hospital-HCB). Initially, the system worked following a first-in-first-out approach, thus leading to referrals not based on severity condition. With the aim of improving the process, the South African Triage Scale (SATS) has been subsequently introduced in three HCs. In this study, we assessed the impact of SATS implementation on the selection process and the accuracy of triage performed by nurses. We assessed 552 and 1608 referral charts from before and after SATS implementation, respectively, and we retrospectively calculated codes. We compared the expected referred patients' codes from the two phases, and nurse-assigned codes to the expected ones. The proportion of referred orange and red codes significantly increased (+12.2% and +12.9%) while the proportion of green and yellow codes decreased (-18.7% and -5.8%). The overall rates of accuracy, and under- and overtriage were 34.2%, 36.3%, and 29.5%, respectively. The implementation of SATS modified the pattern of referred patients and increased the number of severe cases receiving advanced medical care at HCB. While nurses' accuracy improved with the routine use of the protocol, the observed rates of incorrect triage suggest that further research is needed to identify factors affecting SATS application in this setting.

Quality emergency care (QEC) in resource limited settings: A concept analysis

INTRODUCTION

Providing appropriate high-quality emergency care (QEC) commensurate with patients' needs is critical for continuity of care, patient safety, optimal clinical outcomes, reduced mortality, and patient satisfaction. This concept analysis aims to define and assist in understanding the concept of QEC in resource-limited settings.

METHODS

Quality emergency care concept analysis was conducted using Walker and Avant's approach. Several literature review methods and dictionaries were used to explore the QEC concept.

RESULTS

Immediate assessment, rapid diagnosis, and critical interventions are the attributes of QEC for life-threatening and time-sensitive conditions, leading to timely and safe care provision.

DISCUSSION

Nurses serve as the backbone for most emergency care centers such as primary care, emergency department, and even prehospital care. The first few hours following a potential life- or limb-threatening condition are vital. The emergency care rendered to patients can significantly affect treatment's overall outcome; therefore, quality emergency care is critical.

CONCLUSION

A Systematic Review of Linkage-to-Care and Antiretroviral Initiation Implementation Strategies in Low- and Middle-Income Countries Across Sub-Saharan Africa

Linkage to care (LTC) and initiation of antiretroviral therapy (ART) are key components in the longitudinal care cascade for people living with HIV. Many strategies to optimize these stages of HIV care have been implemented, though there is a paucity of analyses comparing the outcomes of these efforts in low- and middle-income countries. We conducted a systematic review of studies assessing interventions along all stages of the HIV care continuum published between 2008 and 2020. A comprehensive search strategy reviewed five electronic databases to capture studies assessing HIV testing, LTC, ART initiation, ART adherence, and viral suppression. Of the 388 articles that met the inclusion criteria, 78 described interventions for improving LTC/ART initiation. Efforts focused on empowering patients through integrative approaches generally yielded more substantive results compared to provider-initiated non-adaptive LTC interventions or cash incentives. Specifically, tailoring care and incorporating ART initiation into existing infrastructures, such as maternal clinics, had a high impact across settings. Moreover, strategies such as home-based HIV counseling and testing (HBHCT) appear to be most effective when implemented in tandem with other approaches including motivational counseling and point-of-care CD4 testing.

A Systematic Review of HIV Testing Implementation Strategies in Sub-Saharan African Countries

HIV/AIDS remains a looming presence in public health across the world, particularly in Sub-Saharan Africa. The HIV Care Cascade hinges on testing and knowledge of HIV status. Though significant advances have been made in diagnosing people living with HIV (PLHIV), limitations in understanding which strategies are best suited to certain regions or populations have contributed to the uneven distribution in the success of various HIV testing strategies. Here, we present a conceptual framework that outlines effective HIV testing strategies for four target groups. This framework is based on a systematic literature review of articles published from January 1st, 2008, to December 31st, 2019. The effectiveness of HIV testing strategies depends on various factors including the setting, type of test and service providers. Multiple strategies are needed to reach the UNAIDS target of 95% of individuals knowing their HIV status. Expansion of community-based approaches, self-testing and HIV testing services in antenatal care will further improve the state of HIV testing in Sub-Saharan Africa.

Prehospital triage tools across the world: a scoping review of the published literature

Background

Accurate triage of the undifferentiated patient is a critical task in prehospital emergency care. However, there is a paucity of literature synthesizing currently available prehospital triage tools. This scoping review aims to identify published tools used for prehospital triage globally and describe their performance characteristics.

Methods

A comprehensive search was performed of primary literature in English-language journals from 2009 to 2019. Papers included focused on emergency medical services (EMS) triage of single patients. Two blinded reviewers and a third adjudicator performed independent title and abstract screening and subsequent full-text reviews.

Results

Of 1521 unique articles, 55 (3.6%) were included in the final synthesis. The majority of prehospital triage tools focused on stroke (n = 19; 35%), trauma (19; 35%), and general undifferentiated patients (15; 27%). All studies were performed in high income countries, with the majority in North America (23, 42%) and Europe (22, 40%). 4 (7%) articles focused on the pediatric population. General triage tools aggregate prehospital vital signs, mental status assessments, history, exam, and anticipated resource need, to categorize patients by level of acuity. Studies assessed the tools’ ability to accurately predict emergency department triage assignment, hospitalization and short-term mortality. Stroke triage tools promote rapid identification of patients with acute large vessel occlusion ischemic stroke to trigger timely transport to diagnostically- and therapeutically-capable hospitals. Studies evaluated tools’ diagnostic performance, impact on tissue plasminogen activator administration rates, and correlation with in-hospital stroke scales. Trauma triage tools identify patients that require immediate transport to trauma centers with emergency surgery capability. Studies evaluated tools’ prediction of trauma center need, under-triage and over-triage rates for major trauma, and survival to discharge.

Conclusions

The published literature on prehospital triage tools predominantly derive from high-income health systems and mostly focus on adult stroke and trauma populations. Most studies sought to further simplify existing triage tools without sacrificing triage accuracy, or assessed the predictive capability of the triage tool. There was no clear ‘gold-standard’ singular prehospital triage tool for acute undifferentiated patients.

Trial registration

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-022-01019-z.

Smart triage: Development of a rapid pediatric triage algorithm for use in low-and-middle income countries

INTRODUCTION

Early and accurate recognition of children at risk of progressing to critical illness could contribute to improved patient outcomes and resource allocation. In resource limited settings digital triage tools can support decision making and improve healthcare delivery. We developed a model for rapid identification of critically ill children at triage.

METHODS

This was a prospective cohort study of acutely ill children presenting at Jinja Regional Referral Hospital in Eastern Uganda. Variables collected in the emergency department informed the development of a logistic model based on hospital admission using bootstrap stepwise regression. Low and high-risk thresholds for 90% minimum sensitivity and specificity, respectively generated three risk level categories. Performance was assessed using receiver operating characteristic curve analysis on a held-out test set generated by an 80:20 split with 10-fold cross validation. A risk stratification table informed clinical interpretation.

RESULTS

The model derivation cohort included 1,612 participants, with an admission rate of approximately 23%. The majority of admitted patients were under five years old and presenting with sepsis, malaria, or pneumonia. A 9-predictor triage model was derived: logit (p) = -32.888 + (0.252, square root of age) + (0.016, heart rate) + (0.819, temperature) + (-0.022, mid-upper arm circumference) + (0.048 transformed oxygen saturation) + (1.793, parent concern) + (1.012, difficulty breathing) + (1.814, oedema) + (1.506, pallor). The model afforded good discrimination, calibration, and risk stratification at the selected thresholds of 8% and 40%.

CONCLUSION

In a low income, pediatric population, we developed a nine variable triage model with high sensitivity and specificity to predict who should be admitted. The triage model can be integrated into any digital platform and used with minimal training to guide rapid identification of critically ill children at first contact. External validation and clinical implementation are in progress.

Validity and reliability of the Interagency Integrated Triage Tool in a regional emergency department in Papua New Guinea

OBJECTIVE

The Interagency Integrated Triage Tool (IITT) is a novel, three-tier triage system recommended by the World Health Organization. The present study sought to assess the validity and reliability of a pilot version of the tool in a resource-limited ED in regional Papua New Guinea.

METHODS

This pragmatic prospective observational study, conducted at Mount Hagen Provincial Hospital, commenced 1 month after IITT implementation. The facility did not have a pre-existing triage system. All ED patients presenting within a 5-month period were included. The primary outcome was sensitivity for the detection of time-critical illness, defined by 10 pre-specified diagnoses. The association between triage category and ED outcomes was examined using Cramer's V correlation coefficient. Reliability was assessed by inter-rater agreement between a local and an experienced external triage officer.

RESULTS

There were 9437 presentations during the study period and 9175 (97.2%) had a triage category recorded. Overall, 138 (1.5%) were classified as category 1 (emergency), 1438 (15.7%) as category 2 (priority) and 7599 (82.8%) as category 3 (non-urgent). When applied by a mix of community health workers, nurses, health extension officers and doctors, the tool's sensitivity for the detection of time-critical illness was 77.8% (95% confidence interval 64.4-88.0). The admission rate was 14.5% (20/138) among emergency patients, 12.0% (173/1438) among priority patients and 0.4% (30/7599) among non-urgent patients (P = 0.00). Death in the ED occurred in 13 (9.4%) of 138 emergency patients, 34 (2.4%) of 1438 priority patients and four (0.1%) of 7599 non-urgent patients (P = 0.00). The negative predictive value for these outcomes was >99.5%. Among 170 observed triage assessments, weighted κ was 0.81 (excellent agreement). On average, it took clinicians 2 min 43 s (standard deviation 1:10) to complete a triage assessment.

CONCLUSION

There is limited published data regarding the predictive validity and inter-rater reliability of the IITT. In this pragmatic study, the pilot version of the tool demonstrated adequate performance. Evaluation in other emergency care settings is recommended.

Validation of the Interagency Integrated Triage Tool in a resource-limited, urban emergency department in Papua New Guinea: a pilot study

Background

The Interagency Integrated Triage Tool (IITT) is a three-tier triage system designed for resource-limited emergency care (EC) settings. This study sought to assess the validity and reliability of a pilot version of the tool in an urban emergency department (ED) in Papua New Guinea.

Methods

A pragmatic observational study was conducted at Gerehu General Hospital in Port Moresby, commencing eight weeks after IITT implementation. All ED patients presenting within the subsequent two-month period were included. Triage assessments were performed by a variety of ED clinicians, including community health workers, nurses and doctors. The primary outcome was sensitivity for the detection of time-critical illness, defined by ten pre-specified diagnoses. The association between triage category and ED outcomes was examined using Cramer's V correlation coefficient. Reliability was assessed by inter-rater agreement between a local and an experienced, external triage officer.

Findings

Among 4512 presentations during the study period, 58 (1.3%) were classified as category one (emergency), 967 (21.6%) as category two (priority) and 3478 (77.1%) as category three (non-urgent). The tool's sensitivity for detecting the pre-specified set of time-sensitive conditions was 70.8% (95%CI 58.2-81.4%), with negative predictive values of 97.3% (95%CI 96.7 - 97.8%) for admission/transfer and 99.9% (95%CI 99.7 - 100.0%) for death. The admission/transfer rate was 44.8% (26/58) among emergency patients, 22.9% (223/976) among priority patients and 2.7% (94/3478) among non-urgent patients (Cramer's V=0.351, p=0.00). Four of 58 (6.9%) emergency patients, 19/976 (2.0%) priority patients and 3/3478 (0.1%) non-urgent patients died in the ED (Cramer's V=0.14, p=0.00). The under-triage rate was 2.7% (94/3477) and the over-triage rate 48.2% (28/58), both within pre-specified limits of acceptability. On average, it took staff 3 minutes 34 seconds (SD 1:06) to determine and document a triage category. Among 70 observed assessments, weighted κ was 0.84 (excellent agreement).

Interpretation

The pilot version of the IITT demonstrated acceptable performance characteristics, and validation in other EC settings is warranted.

Funding

This project was funded through a Friendship Grant from the Australian Government Department of Foreign Affairs and Trade and an International Development Fund Grant from the Australasian College for Emergency Medicine Foundation.

Potential solutions for screening, triage, and severity scoring of suspected COVID-19 positive patients in low-resource settings: a scoping review

OBJECTIVES

Purposefully designed and validated screening, triage, and severity scoring tools are needed to reduce mortality of COVID-19 in low-resource settings (LRS). This review aimed to identify currently proposed and/or implemented methods of screening, triaging, and severity scoring of patients with suspected COVID-19 on initial presentation to the healthcare system and to evaluate the utility of these tools in LRS.

DESIGN

A scoping review was conducted to identify studies describing acute screening, triage, and severity scoring of patients with suspected COVID-19 published between 12 December 2019 and 1 April 2021. Extracted information included clinical features, use of laboratory and imaging studies, and relevant tool validation data.

PARTICIPANT

The initial search strategy yielded 15 232 articles; 124 met inclusion criteria.

RESULTS

Most studies were from China (n=41, 33.1%) or the United States (n=23, 18.5%). In total, 57 screening, 23 triage, and 54 severity scoring tools were described. A total of 51 tools-31 screening, 5 triage, and 15 severity scoring-were identified as feasible for use in LRS. A total of 37 studies provided validation data: 4 prospective and 33 retrospective, with none from low-income and lower middle-income countries.

CONCLUSIONS

This study identified a number of screening, triage, and severity scoring tools implemented and proposed for patients with suspected COVID-19. No tools were specifically designed and validated in LRS. Tools specific to resource limited contexts is crucial to reducing mortality in the current pandemic.

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.

Implementation of a novel three-tier triage tool in Papua New Guinea: A model for resource-limited emergency departments

In emergency departments (EDs), demand for care often exceeds the available resources. Triage addresses this problem by sorting patients into categories of urgency.

The Interagency Integrated Triage Tool (IITT) is a novel triage system designed for resource-limited emergency care (EC) settings. The system was piloted by two EDs in Papua New Guinea as part of an EC capacity development program.

Implementation involved a five-hour teaching program for all ED staff, complemented by training resources including flowcharts and reference guides. Clinical redesign helped optimise flow and infrastructure, and development of simple electronic registries enabled data collection. Local champions were identified, and experienced EC clinicians from Australia acted as mentors during system roll-out.

Evaluation data suggests the IITT, and the associated change management process, have high levels of acceptance amongst staff. Subject to validation, the IITT may be relevant to other resource-limited EC settings.

Implementing a triage tool to improve appropriateness of care for children coming to the emergency department in a small hospital in India

Background

In 2015, senior consultants at Sitaram Bhartia Institute of Science and Research saw several sick children in their outpatient clinics for which they had been seen in the emergency department the previous day. These children seemed to require admission but were sent home. This prompted us to review the paediatric care provided in our emergency department.

Methods

A multidisciplinary team was formed to run this improvement initiative. Review of literature suggested that establishing a triage system around a prevalidated triage tool would help us deliver more appropriate care. The South African Triage Scale was selected and adapted.

Interventions

With the aim of delivering appropriate care to at least 50% of children, a series of sequential interventions were tested using the improvement methodology of Plan-Do-Study-Act (PDSA) cycles, an approach recommended by the Institute for Healthcare Improvement. Learnings from the PDSA cycle of the previous intervention helped decide the subsequent change idea. The interventions included training in use of tool, increasing nurse staffing levels, using team huddles as feedback opportunities, introducing nurse reminders, reducing non-productive work, developing local leadership and training a restricted group of locum paediatricians. Qualitative and quantitative information was analysed to retain or reject change ideas.

Results

At baseline only 16%–17% of children were receiving appropriate care. The sequential changes resulted in a gradual improvement to a median of 63% of children receiving appropriate care by the end of 20 months.

Conclusions

We succeeded in establishing a paediatric emergency triage system and culture in the given setting through a unique enriching experience. We worked on removing systemic barriers and facilitating change while facing several unexpected outcomes. A sustained iterative approach may be the best way to achieving significant improvement in difficult settings like ours.

Harnessing inter-disciplinary collaboration to improve emergency care in low- and middle-income countries (LMICs): results of research prioritisation setting exercise

BACKGROUND

More than half of deaths in low- and middle-income countries (LMICs) result from conditions that could be treated with emergency care - an integral component of universal health coverage (UHC) - through timely access to lifesaving interventions.

METHODS

The World Health Organization (WHO) aims to extend UHC to a further 1 billion people by 2023, yet evidence supporting improved emergency care coverage is lacking. In this article, we explore four phases of a research prioritisation setting (RPS) exercise conducted by researchers and stakeholders from South Africa, Egypt, Nepal, Jamaica, Tanzania, Trinidad and Tobago, Tunisia, Colombia, Ethiopia, Iran, Jordan, Malaysia, South Korea and Phillipines, USA and UK as a key step in gathering evidence required by policy makers and practitioners for the strengthening of emergency care systems in limited-resource settings.

RESULTS

The RPS proposed seven priority research questions addressing: identification of context-relevant emergency care indicators, barriers to effective emergency care; accuracy and impact of triage tools; potential quality improvement via registries; characteristics of people seeking emergency care; best practices for staff training and retention; and cost effectiveness of critical care - all within LMICs.

CONCLUSIONS

Convened by WHO and facilitated by the University of Sheffield, the Global Emergency Care Research Network project (GEM-CARN) brought together a coalition of 16 countries to identify research priorities for strengthening emergency care in LMICs. Our article further assesses the quality of the RPS exercise and reviews the current evidence supporting the identified priorities.

The development and validation of an obstetric triage acuity index: a mixed-method study

Background: There is uncertainty about the applicability of developed country triage scales in the developing population.Objective: To develop and validate an obstetric triage scale in Iran.Methods: This exploratory sequential mixed-method study was conducted on experienced gynecologists, emergency medicine, midwives, and nurses as evaluators, and pregnant or parturient women as sample. Development of obstetric triage acuity index was done using qualitative study and literature review. Thirty-two evaluators in two rounds evaluated the clinical impact score, content validity ratio, and content validity index. The tool performance was compared with a standard reference in 415 women. The association of urgency levels with hospitalization, resource utilization, and emergency department length of stay were assessed in 599 women. Five midwives independently double-triaged 234 convenience women to estimate inter-rater reliability.Results: Out of 191 items in the initial draft, 9 (4.7%) items in the face validity, 33 (18.1%) in the first, and 5 (3.2%) in the second content validity round were removed because not meeting the expected thresholds. Nine items added based on evaluators' suggestions. Finally, total items had a kappa above 0.74, and S-CVI/Ave, S-CVI/UA were 0.99 and 0.86, respectively. There was a significant correlation between the two tools (r = 0.661, p < 0). Level 1 mothers had a higher chance of using ≥ 2 resources (OR = 16.4, 95% CI = 2.06-129.98) and hospitalization (OR = 18.0, 95% CI = 3.96-81.51) compared to the level 5, after adjusting for gestational age/postpartum, and referral method. Sensitivity, specificity, and accuracy of the scale in predicting hospitalization were 74.8% (95% CI = 69.73-79.49), 80.8% (95% CI = 73.60-86.74), and 76.7% (72.67-80.48), respectively. The over and under-triage rates were 6.1% and 17.1%, respectively. The absolute agreement inter-raters was 86.8%, and the linear weighted kappa was 0.86 (95% CI = 0.81-0.91).Conclusion: The designed OB triage scale showed good validity and reliability in the tertiary teaching hospital. Studying this tool at lower levels, non-educational, and public hospitals are recommended for external validity testing.

Obstetric triage systems: a systematic review of measurement properties (Clinimetric)

BACKGROUND

Since labor and delivery units often serve as emergency units for pregnant women, the use of obstetric triage systems with poor or inadequate quality can lead to unintended consequences such as over and under-triage and so a waste of humans and financial resources. Therefore, this systematic review was conducted to evaluate the measurement properties of obstetric triage tools.

METHODS

PubMed, EMBASE, and Medline were searched to identify studies in October 2018 and were updated in May 2019. The risk of bias COSMIN checklist was used to evaluate the quality of the studies. The quality of every measurement property was appraised by the update criteria of COSMIN. Evidence quality was judged using the modified GRADE approach.

RESULTS

A total of 444 studies were retrieved in initial search. Six studies evaluating 4 tools were included in this study. All the included studies reported only content validity and reliability. The quality of evidence varied from very low to moderate. The quality of content validity and reliability of the included tools was sufficient except for the reliability of the maternal-fetal triage index. The obstetric triage acuity scale (OTAS) was found to have higher reliability than other tools.

CONCLUSIONS

Due to insufficient evidence, the conclusions about the quality of measurement properties of each obstetric triage tool may be uncertain. This review emphasizes the necessity for further studies with robust methodological quality on the measurement properties of obstetric triage tools.

Evaluation of a modified South African Triage Score as a predictor of patient disposition at a tertiary hospital in Rwanda

Background

Triage is essential for efficient and effective delivery of care in emergency centers (ECs) where numerous patients present simultaneously with varying acuity of conditions. Implementing EC triage systems provides a method of recognizing which patients may require admission and are at higher risks for poor health outcomes. Rwanda is experiencing increased demand for emergency care; however, triage has not been well-studied. The University Teaching Hospital of Kigali (UTH-K) is an urban tertiary care health center utilizing a locally modified South African Triage Score (mSATS) that classifies patients into five color categories. Our study evaluated the utility of the mSATS tool at UTH-K.

Methods

UTH-K implemented mSATS in April 2013. All patients aged 15 years or older from August 2015 to July 2016 were eligible for inclusion in the database. Variables of interest included demographic information, mSATS category, patient case type (trauma or medical), disposition from the ED and mortality.

Results

1438 cases were randomly sampled; the majority were male (61.9%) and median age was 35 years. Injuries accounted for 56.7% of the cases while medical conditions affected 43.3%. Admission likelihood significantly increased with higher triage color category for medical patients (OR: Yellow = 3.61, p < .001 to Red (with alarm) = 7.80, p < .01). Likelihood for trauma patients, however, was not significantly increased (OR: Yellow = .84, p = .75 to Red (with alarm) = 1.50, p = .65). Mortality rates increased with increasing triage category with the red with alarm category having the highest mortality (7.7%, OR 18.91).

Conclusion

The mSATS tool accurately predicted patient disposition and mortality for the overall ED population. The mSATS tool provided useful clinical guidance on the need for hospital admission for medical patients but did not accurately predict patient disposition for injured patients. Further trauma-specific triage studies are needed to improve emergency care in Rwanda.

Emergency Department Design in Low- and Middle-Income Settings: Lessons from a University Hospital in Haiti

Background:

Studies from high-income settings have demonstrated that emergency department (ED) design is closely related to operational success; however, no standards exist for ED design in low- and middle-income countries (LMICs).

Objective:

We present ED design recommendations for LMICs based on our experience designing and operating the ED at Hôpital Universitaire de Mirebalais (HUM), an academic hospital in central Haiti. We also propose an ideal prototype for similar settings based on these recommendations.

Methods:

As part of a quality improvement project to redesign the HUM ED, we collected feedback on the current design from key stakeholders to identify design features impacting quality and efficiency of care. Feedback was reviewed by the clinical and design teams and consensus reached on key lessons learned, from which the prototype was designed.

Findings and conclusions:

ED design in LMICs must balance construction costs, sustainability in the local context, and the impact of physical infrastructure on care delivery. From our analysis, we propose seven key recommendations: 1) Design the “front end” of the ED with waiting areas that meet the needs of LMICs and dedicated space for triage to strengthen care delivery and patient safety. 2) Determine ED size and bed capacity with an understanding of the local health system and disease burden, and ensure line-of-sight visibility for ill patients, given limited monitoring equipment. 3) Accommodate for limited supply chains by building storage spaces that can manage large volumes of supplies. 4) Prioritize a maintainable system that can provide reliable oxygen. 5) Ensure infection prevention and control, including isolation rooms, by utilizing simple and affordable ventilation systems. 6) Give consideration to security, privacy, and well-being of patients, families, and staff. 7) Site the ED strategically within the hospital. Our prototype incorporates these features and may serve as a model for other EDs in LMICs.

Performance of triage systems in emergency care: a systematic review and meta-analysis

OBJECTIVE

To assess and compare the performance of triage systems for identifying high and low-urgency patients in the emergency department (ED).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

EMBASE, Medline OvidSP, Cochrane central, Web of science and CINAHL databases from 1980 to 2016 with the final update in December 2018.

ELIGIBILITY CRITERIA

Studies that evaluated an emergency medical triage system, assessed validity using any reference standard as proxy for true patient urgency and were written in English. Studies conducted in low(er) income countries, based on case scenarios or involving less than 100 patients were excluded.

REVIEW METHODS

Reviewers identified studies, extracted data and assessed the quality of the evidence independently and in duplicate. The Quality Assessment of studies of Diagnostic Accuracy included in Systematic Reviews -2 checklist was used to assess risk of bias. Raw data were extracted to create 2×2 tables and calculate sensitivity and specificity. ED patient volume and casemix severity of illness were investigated as determinants of triage systems' performance.

RESULTS

Sixty-six eligible studies evaluated 33 different triage systems. Comparisons were restricted to the three triage systems that had at least multiple evaluations using the same reference standard (Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System). Overall, validity of each triage system to identify high and low-urgency patients was moderate to good, but performance was highly variable. In a subgroup analysis, no clear association was found between ED patient volume or casemix severity of illness and triage systems' performance.

CONCLUSIONS

Established triage systems show a reasonable validity for the triage of patients at the ED, but performance varies considerably. Important research questions that remain are what determinants influence triage systems' performance and how the performance of existing triage systems can be improved.

Evaluation of triage quality in the emergency department: a scoping review protocol

The objective of this scoping review is to explore the existing literature on the evaluation of the quality of triage for patients of all ages and medical conditions in emergency departments (EDs).The question for this review is: How is triage in the ED evaluated? More specifically, we are interested in answering the following sub-questions.

Effective triage in the Pacific region: The development and implementation of the Solomon Islands Triage Scale

OBJECTIVE

The ED at the National Referral Hospital in Honiara, Solomon Islands, receives approximately 50 000 patients per year. A 2014 review of ED functioning identified deficiencies in triage processes. Placement of Australian volunteer advisors provided an opportunity to develop and implement a purpose-designed triage system.

METHODS

Action research methodology and the 'plan, act, observe, reflect' cycle was employed, leading to the development of a three-tier triage system based on the South African Triage Scale. ED patient flow and data management processes were simultaneously updated, and staff were trained in the new system. After a pilot period, the Solomon Islands Triage Scale was implemented in August 2017. Evaluation after 3 months of operation included predictive validity (using admission and case fatality rates as surrogate markers of urgency) and reliability (based on inter-rater agreement at retrospective chart review by an independent nurse).

RESULTS

In the period 1 August to 31 October, there were 10 905 presentations, of which 97.1% were allocated a triage category (1% category 1, 21.3% category 2 and the remainder category 3). Admission rates correlated closely with triage category (P < 0.01). The case fatality rate was 22.1% for category 1 patients, 0.09% for category 2 and 0.01% for category 3 (P < 0.01). An audit of 96 records conducted in October 2017 revealed 88.4% agreement for triage category allocation.

CONCLUSION

Solomon Islands Triage Scale is the first three-tier triage scale to be implemented in the Pacific region and appears to have adequate validity and reliability. The partnership between Australian volunteers and local clinicians is a positive example of capacity development and represents a model that could be implemented in other resource-limited settings.

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.

A review of triage accuracy and future direction

BACKGROUND

In the emergency department, it is important to identify and prioritize who requires an urgent intervention in a short time. Triage helps recognize the urgency among patients. An accurate triage decision helps patients receive the emergency service in the most appropriate time. Various triage systems have been developed and verified to assist healthcare providers to make accurate triage decisions. The triage accuracy can represent the quality of emergency service, but there is a lack of review studies addressing this topic.

METHODS

A literature search was conducted in four electronic databases where 'emergency nursing' and 'triage accuracy' were used as keywords. Studies published from 2008 January to 2018 August were included as potential subjects. Nine studies were included in this review after the inclusion and exclusion criteria were applied.

RESULTS

Written case scenarios and retrospective review were commonly used to examine the triage accuracy. The triage accuracy from studies was in moderate level. The single-center studies which held better results than those from multi-center studies revealed the need of triage training and consistent training between emergency departments.

CONCLUSIONS

Regular refresher triage training, collaboration between emergency departments and continuous monitoring were necessary to strengthen the use of triage systems and improve nurse's triage performance.