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Mitchell R, Fang W, Tee QW, O'Reilly G, Romero L, Mitchell R, Bornstein S, Cameron P. Systematic review: What is the impact of triage implementation on clinical outcomes and process measures in low- and middle-income country emergency departments? Acad Emerg Med 2024; 31:164-182. [PMID: 37803524 DOI: 10.1111/acem.14815] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/15/2023] [Accepted: 09/19/2023] [Indexed: 10/08/2023]
Abstract
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.
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Affiliation(s)
- Rob Mitchell
- Alfred Health, Melbourne, Victoria, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Wendy Fang
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Qiao Wen Tee
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Gerard O'Reilly
- Alfred Health, Melbourne, Victoria, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | | | | | - Peter Cameron
- Alfred Health, Melbourne, Victoria, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Aleka P, Van Koningsbruggen C, Hendrikse C. The value of shock index, modified shock index and age shock index to predict mortality and hospitalisation in a district level emergency centre. Afr J Emerg Med 2023; 13:287-292. [PMID: 37822303 PMCID: PMC10562169 DOI: 10.1016/j.afjem.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 08/11/2023] [Accepted: 09/17/2023] [Indexed: 10/13/2023] Open
Abstract
Introduction Triage is the most important step in patients' journey through an Emergency Centre (EC) and directly impacts time to critical actions. Triage tools, like the South African Triage Scale, are however not designed to predict patient outcomes. The shock index (SI), modified shock index (MSI) and age shock index (ASI) are clinical markers derived from vital signs and correlate with tissue perfusion in critically ill patients. This study aimed to assess the value of SI, MSI and ASI to predict mortality and the need for hospitalisation in all adult patients presenting to a district level emergency centre in South Africa. Methods This diagnostic study was performed as a retrospective observational study, using data from an existing electronic registry at a district level hospital emergency centre over a period of 24 months. All adult patients who presented to Mitchells Plain Hospital were eligible for inclusion. Sensitivity, specificity and likelihood ratios were calculated for each variable as a predictor of mortality and hospitalisation with pre-determined thresholds. Results During the study period of 24 months, a total of 61 329 patients ≥ 18 years old presented to the EC with 60 599 included in the final sample. A red SATS triage category (+LR = 7.2) and SI ≥1.3 (+LR = 4.9) were the only two predictors with any significant clinical value. The same two markers performed well for both patients with and without trauma and specifically for patients who died while under the care of the emergency centre. Discussion The study demonstrated that patients with a SI≥1.3 at triage have a significantly higher likelihood to die or require hospitalisation, whether the presenting complaint is trauma related or not, especially to predict mortality while under the care of the EC. Incorporating this marker as a triage alert could expedite the identification of patients requiring time critical interventions and improve patient throughput in the emergency centre.
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Affiliation(s)
- Patrick Aleka
- Division of Emergency Medicine, Department of Family, Community and Emergency Care, Faculty of Health Sciences, University of Cape Town, F-51 Old Main Building Groote Schuur Hospital Observatory, Cape Town 7925, South Africa
| | - Candice Van Koningsbruggen
- Division of Emergency Medicine, Department of Family, Community and Emergency Care, Faculty of Health Sciences, University of Cape Town, F-51 Old Main Building Groote Schuur Hospital Observatory, Cape Town 7925, South Africa
| | - Clint Hendrikse
- Division of Emergency Medicine, Department of Family, Community and Emergency Care, Faculty of Health Sciences, University of Cape Town, F-51 Old Main Building Groote Schuur Hospital Observatory, Cape Town 7925, South Africa
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Zimmerman A, Elahi C, Hernandes Rocha TA, Sakita F, Mmbaga BT, Staton CA, Vissoci JRN. Machine learning models to predict traumatic brain injury outcomes in Tanzania: Using delays to emergency care as predictors. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002156. [PMID: 37856444 PMCID: PMC10586611 DOI: 10.1371/journal.pgph.0002156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 09/13/2023] [Indexed: 10/21/2023]
Abstract
Constraints to emergency department resources may prevent the timely provision of care following a patient's arrival to the hospital. In-hospital delays may adversely affect health outcomes, particularly among trauma patients who require prompt management. Prognostic models can help optimize resource allocation thereby reducing in-hospital delays and improving trauma outcomes. The objective of this study was to investigate the predictive value of delays to emergency care in machine learning based traumatic brain injury (TBI) prognostic models. Our data source was a TBI registry from Kilimanjaro Christian Medical Centre Emergency Department in Moshi, Tanzania. We created twelve unique variables representing delays to emergency care and included them in eight different machine learning based TBI prognostic models that predict in-hospital outcome. Model performance was compared using the area under the receiver operating characteristic curve (AUC). Inclusion of our twelve time to care variables improved predictability in each of our eight prognostic models. Our Bayesian generalized linear model produced the largest AUC, with a value of 89.5 (95% CI: 88.8, 90.3). Time to care variables were among the most important predictors of in-hospital outcome in our best three performing models. In low-resource settings where delays to care are highly prevalent and contribute to high mortality rates, incorporation of care delays into prediction models that support clinical decision making may benefit both emergency medicine physicians and trauma patients by improving prognostication performance.
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Affiliation(s)
- Armand Zimmerman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Cyrus Elahi
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | | | | | - Blandina T. Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Catherine A. Staton
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Joao Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States of America
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Markussen DL, Brevik HS, Bjørneklett RO, Engan M. Validation of a modified South African triage scale in a high-resource setting: a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2023; 31:13. [PMID: 36941710 PMCID: PMC10026449 DOI: 10.1186/s13049-023-01076-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/04/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Triage systems are widely used in emergency departments, but are not always validated. The South African Triage Scale (SATS) has mainly been studied in resource-limited settings. The aim of this study was to determine the validity of a modified version of the SATS for the general population of patients admitted to an ED at a tertiary hospital in a high-income country. The secondary objective was to study the triage performance according to age and patient categories. METHODS We conducted a retrospective cohort study of patients presenting to the Emergency Department of Haukeland University Hospital in Norway during a four-year period. We used short-term mortality, ICU admission, and the need for immediate surgery and other interventions as the primary endpoints. RESULTS A total of 162,034 emergency department visits were included in the analysis. The negative predictive value of a low triage level to exclude severe illness was 99.1% (95% confidence interval: 99.0-99.2%). The level of overtriage, defined as the proportion of patients assigned to a high triage level who were not admitted to the hospital, was 4.1% (3.9-4.2%). Receiver operating characteristic (ROC) curves showed an area under the ROC for the detection of severe illness of 0.874 (95% confidence interval: 0.870-0.879) for all patients and 0.856 (0.837-0.875), 0.884 (0.878-0.890) and 0.869 (0.862-0.876) for children, adults and elderly individuals respectively. CONCLUSION We found that the modified SATS had a good sensitivity to identify short-term mortality, ICU admission, and the need for rapid surgery and other interventions. The sensitivity was higher in adults than in children and higher in medical patients than in surgical patients. The over- and undertriage rates were acceptable.
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Affiliation(s)
- Dagfinn Lunde Markussen
- Emergency Care Clinic, Haukeland University Hospital, 5021, Bergen, Norway.
- Department of Clinical Science, University of Bergen, Postboks 7804, 5020, Bergen, Norway.
| | | | - Rune Oskar Bjørneklett
- Emergency Care Clinic, Haukeland University Hospital, 5021, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Postboks 7804, 5020, Bergen, Norway
| | - Mette Engan
- Department of Clinical Science, University of Bergen, Postboks 7804, 5020, Bergen, Norway
- Department of Paediatric and Adolescent Medicine, Haukeland University Hospital, 5021, Bergen, Norway
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Is the Triage System Welcomed in the Tertiary Hospital of the Limpopo Province? A Qualitative Study on Patient’s Perceptions. NURSING REPORTS 2023; 13:351-364. [PMID: 36976685 PMCID: PMC10055725 DOI: 10.3390/nursrep13010033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/17/2023] [Accepted: 02/23/2023] [Indexed: 03/03/2023] Open
Abstract
A triage system in the emergency department is necessary to prioritize and allocate scarce health resources to the medical needs of the patients to facilitate quality health service delivery. This paper aimed to ascertain if the triage system is welcomed in the tertiary hospital of Limpopo Province by exploring patients’ perceptions in the emergency department in South Africa. A qualitative research approach was used in this study with descriptive, explorative, and contextual research design to reach the research objective. Purposive sampling was used to select the patients who participated in semi-structured one-on-one interviews, which lasted between 30 and 45 min. The sample size was determined by data saturation after 14 participants were interviewed. A narrative qualitative analysis method was used to interpret and categorize the patients’ perceptions into seven domains of Benner’s theory. The six relevant domains illustrated mixed patients‘ perceptions regarding the triage system in the emergency departments. The domain-helping role of the triage system was overweighed by the dissatisfaction of the needy patients who waited for an extended period to receive emergency services. We conclude that the triage system at the selected tertiary hospital is not welcomed due to its disorganization and patient-related factors in the emergency departments. The findings of this paper are a point of reference for reinforcing the triage practice and improved quality service delivery by the emergency department healthcare professionals and the department of health policymakers. Furthermore, the authors propose that the seven domains of Benner’s theory can serve as a foundation for research and improving triage practice within emergency departments.
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Kasongo N, Siziya S, Banda J. Clinical profile and predictors of renal failure in emergency department patients at a tertiary level hospital, a cross sectional study. Afr J Emerg Med 2022; 12:456-460. [PMID: 36397992 PMCID: PMC9664393 DOI: 10.1016/j.afjem.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/30/2022] [Accepted: 10/25/2022] [Indexed: 11/11/2022] Open
Abstract
Our study was able to highlight the profile of patients at risk of renal failure who were likely older, hypertensive, oliguric and with low hemoglobin compared to those without. This Knowledge can help care givers and policy makers to pay particular attention and institute interventions targeted at treating non communicable diseases (that lead to renal failure) and infections there by reducing progressing to renal failure and end stage renal disease with need for renal replacement therapy. In addition, it also showed that simple bedside tests like dip stick urinalysis and urine output monitoring are key in surveillance of renal failure.
Background Since establishment of the emergency departments (ED) in the country, there is lack of information on clinical profile of patients admitted to the ED and predictors of renal failure in these patients. Renal failure is prevalent in critical patients and a cause of significant mortality and morbidity. The aim of this study was to assess the clinical profile and predictors of renal failure in admissions to the ED. Methods This was a cross-sectional study that was conducted at a tertiary level hospital in Zambia from January to December, 2019 among admissions to the ED after ethical approval. The primary outcome of the study was to describe the clinical profile of admissions to the ED and proportion of renal failure defined as estimated glomerular filtration rate (eGFR) < 60 mls/1.72 m2 Results The final analysis includes 152 patients, 7 excluded for missing key data. The median age was 43.5 years (IQR 32.5-59.5) and 94.7% of patients were medical. Nearly 70.0% of the patients were triaged as emergency (red) or very urgent (orange). The reason for admission to the ED were sepsis and/or sepsis shock in 25.0%, diabetic hyperglycaemia emergencies in 20.0%, hypertensive crisis in 10.5%, respiratory failure (9.9%), severe malaria (7.9%) and poisoning (5.0%). The prevalence of renal failure was 36.1% and proteinuria was observed in 23.0%. Oliguria and hypertension were 5.9-fold and 1.7-fold independent predictors of renal failure in the ED. Patients with renal failure were likely older, hypertensive, oliguric and anaemic compared to those without. During admission to the ED, 19.1% died. Conclusion Sepsis and diabetic and hypertensive emergencies accounted for nearly half of ED admissions. Hypertension and oliguria were key predictors of renal failure. Early diagnosis, management and follow-up of hypertension including urine output monitoring for high-risk patients is key in surveillance and prevention of renal failure.
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Affiliation(s)
- Nancy Kasongo
- Levy Mwanawasa University Teaching Hospital, Lusaka, Zambia
- Copperbelt University School of Medicine, Ndola, Zambia
- Corresponding author.
| | - Seta Siziya
- Copperbelt University School of Medicine, Ndola, Zambia
| | - Justor Banda
- Department of Internal Medicine, Ndola Teaching Hospital, Ndola, Zambia
- Department of Medical Sciences, University of Namibia, Namibia
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Performance of the South African triage score among HIV positive individuals presenting to an emergency department. Afr J Emerg Med 2022; 12:498-504. [PMID: 36583184 PMCID: PMC9788955 DOI: 10.1016/j.afjem.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 08/03/2022] [Accepted: 08/16/2022] [Indexed: 01/01/2023] Open
Abstract
Introduction Over a quarter of patients presenting to South African Emergency Centres (EC) have concurrent human immunodeficiency virus (HIV), yet it is unclear how this impacts their presenting complaints, the severity of illness, and overall resource needs in the EC. The primary objective of this study was to compare the performance of the South African Triage Score (SATS) in people living with HIV (PLWH) compared to HIV-negative patients. Secondary objectives included comparing the presentation characteristics and resource utilisation of these populations. Methods A prospective cross-sectional observational study was conducted in the Livingstone Hospital EC, Gqeberha, South Africa, to compare triage designation and clinical outcomes in PLWH and HIV-negative patients. In this six-week study, all eligible patients received point-of-care HIV testing and extensive data abstraction, including SATS designation and EC clinical course. Descriptive statistical analysis was completed, and a log-binomial model was used to examine the association between HIV status and clinical outcomes using crude (unadjPR) and adjusted prevalence ratios (adjPR). Results During the study period, 755 adult patients who consented to a POC HIV test were enrolled, of which 193 (25.6%) were HIV positive. HIV-positive patients were significantly more likely to be admitted compared to their HIV-negative counterparts when triaged as low acuity (adjPR 1.48, 95% CI 1.14-1.92, (p=0.003)). HIV-positive patients were also significantly more likely to receive laboratory testing when triaged as low acuity (adjPR 1.31, 95% CI 1.08-1.59 (p=0.006)) and as high acuity (adjPR 1.38, 95% CI 1.08-1.59 (p=0.034)) compared to HIV negative patients of the same triage categories. Conclusion In our study, PLWH, compared to HIV-negative patients in the same category, were more likely to be admitted and require more EC resources, thus alluding to possible under triage of HIV-positive patients under the current SATS algorithm.
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Mamalelala TT. Quality emergency care (QEC) in resource limited settings: A concept analysis. Int Emerg Nurs 2022; 64:101198. [PMID: 35926319 DOI: 10.1016/j.ienj.2022.101198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 06/18/2022] [Accepted: 06/29/2022] [Indexed: 11/19/2022]
Abstract
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
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Affiliation(s)
- Tebogo T Mamalelala
- School of Nursing, University of Botswana, Botswana; School of Nursing, Rutgers, The State University of New Jersey, USA.
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Elbaih AH, Elhadary GK, Elbahrawy MR, Saleh SS. Assessment of the patients' outcomes after implementation of South African triage scale in emergency department, Egypt. Chin J Traumatol 2022; 25:95-101. [PMID: 34756667 PMCID: PMC9039833 DOI: 10.1016/j.cjtee.2021.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 08/27/2021] [Accepted: 09/29/2021] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Overcrowding in emergency department (ED) is a concerning global problem and has been identified as a national crisis in some countries. Several emergency sorting systems designed successfully in the world. Launched in 2004, a group of branches in South African triage scale (SATS) developed. The effectiveness of the case sorting system of SATS was evaluated to reduce the patient's length of stay (LOS) and mortality rate within the ED at Suez Canal University Hospital. METHODS The study was designed as an intervention study that included a systematic random sample of patients who presented to the ED in Suez Canal University Hospital. This study was implemented in three phases: pre-intervention phase, 115 patients were assessed by the traditional protocols; intervention phase, a structured training program was provided to the ED staff, including a workshop and lectures; and post-intervention phase, 230 patients were assessed by SATS. All the patients were retriaged 2 h later, calculating the LOS per patient and the mortality. Data was collected and entered using Microsoft Excel software. Collected data from the triage sheet were analyzed using the SPSS software program version 22.0. RESULTS The LOS in the ED was about 183.78 min before the intervention; while after the training program and the application of SATS, it was reduced to 51.39 min. About 15.7% of the patients died before the intervention; however, after the intervention the ratio decreased to 10.7% deaths. CONCLUSION SATS is better at assessing patients without missing important data. Additionally, it resulted in a decrease in the LOS and reduction in the mortality rate compared to the traditional protocol.
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Affiliation(s)
- Adel Hamed Elbaih
- Emergency Medicine Department, Faculty of Medicine, Suez Canal University, Ismailia, Egypt.
| | - Ghada Kamal Elhadary
- Emergency Medicine Department, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Magda Ramdan Elbahrawy
- Emergency Medicine Department, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Samar Sami Saleh
- Emergency Medicine Department, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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Hedding K, Dippenaar E, Wallis L. A descriptive study of demographics, triage allocations and patient outcomes at a private emergency centre in Pretoria. S Afr Fam Pract (2004) 2021; 63:e1-e7. [PMID: 34797094 PMCID: PMC8603161 DOI: 10.4102/safp.v63i1.5308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 09/02/2021] [Accepted: 09/17/2021] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Kirsty Hedding
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town.
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Mitchell R, McKup JJ, Banks C, Nason R, O'Reilly G, Kandelyo S, Bornstein S, Cole T, Reynolds T, Ripa P, Körver S, Cameron P. Validity and reliability of the Interagency Integrated Triage Tool in a regional emergency department in Papua New Guinea. Emerg Med Australas 2021; 34:99-107. [PMID: 34628718 DOI: 10.1111/1742-6723.13877] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/08/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Rob Mitchell
- Emergency and Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - John J McKup
- Emergency Department, Mount Hagen Provincial Hospital, Mount Hagen, Papua New Guinea
| | - Colin Banks
- Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia
| | - Regina Nason
- Emergency Department, Mount Hagen Provincial Hospital, Mount Hagen, Papua New Guinea
| | - Gerard O'Reilly
- Emergency and Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Scotty Kandelyo
- Emergency Department, Port Moresby General Hospital, Port Moresby, Papua New Guinea.,National Department of Health, Port Moresby, Papua New Guinea
| | - Sarah Bornstein
- Global Emergency Care Desk, Australasian College for Emergency Medicine, Melbourne, Victoria, Australia
| | - Travis Cole
- Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia
| | - Teri Reynolds
- Department of Integrated Health Services, World Health Organization, Geneva, Switzerland
| | - Paulus Ripa
- Mount Hagen Provincial Hospital, Mount Hagen, Papua New Guinea
| | - Sarah Körver
- Global Emergency Care Desk, Australasian College for Emergency Medicine, Melbourne, Victoria, Australia
| | - Peter Cameron
- Emergency and Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Mitchell R, Bue O, Nou G, Taumomoa J, Vagoli W, Jack S, Banks C, O'Reilly G, Bornstein S, Ham T, Cole T, Reynolds T, Körver S, Cameron P. Validation of the Interagency Integrated Triage Tool in a resource-limited, urban emergency department in Papua New Guinea: a pilot study. LANCET REGIONAL HEALTH-WESTERN PACIFIC 2021; 13:100194. [PMID: 34527985 PMCID: PMC8358156 DOI: 10.1016/j.lanwpc.2021.100194] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/30/2021] [Accepted: 06/03/2021] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- Rob Mitchell
- Emergency Physician, Emergency & Trauma Centre, Alfred Health, Melbourne, Australia PhD Candidate, Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia
- Corresponding author. Emergency Physician, Emergency & Trauma Centre, Alfred Health, Commercial Rd, Melbourne, VIC, Australia 3004
| | - Ovia Bue
- Emergency Physician, Emergency Department, Gerehu General Hospital, Port Moresby, Papua New Guinea
| | - Gary Nou
- Emergency Physician, Emergency Department, Gerehu General Hospital, Port Moresby, Papua New Guinea
| | - Jude Taumomoa
- Clinical Nurse, Emergency Department, Gerehu General Hospital, Port Moresby, Papua New Guinea
| | - Ware Vagoli
- Emergency Physician, Emergency Department, Gerehu General Hospital, Port Moresby, Papua New Guinea
| | - Steven Jack
- Emergency Physician, Emergency Department, Gerehu General Hospital, Port Moresby, Papua New Guinea
| | - Colin Banks
- Emergency Physician, Emergency Department, Townsville University Hospital, Townsville, Australia
| | - Gerard O'Reilly
- Emergency Physician and Head of Global Programs, Emergency & Trauma Centre, Alfred Health, Melbourne, Australia, Associate Professor, Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia
- Head, Epidemiology and Biostatistics, National Trauma Research Institute, Alfred Health, Melbourne, Australia
| | - Sarah Bornstein
- Project lead, Papua New Guinea Emergency Care Capacity Development Remote Training and Support Model Project, Australasian College for Emergency Medicine, Melbourne, Australia
| | - Tracie Ham
- Associate Nurse Unit Manager, Emergency Department, St Vincent's Hospital, Melbourne, Australia
| | - Travis Cole
- Emergency Clinical Nurse Specialist, Emergency Department, Townsville University Hospital, Townsville, Australia
| | - Teri Reynolds
- Unit Head, Clinical Services and Systems, Department of Integrated Health Services, World Health Organization, Geneva, Switzerland
| | - Sarah Körver
- Global Emergency Care Manager, Australasian College for Emergency Medicine, Melbourne, Australia
| | - Peter Cameron
- Director of Academic Programs, Emergency & Trauma Centre, Alfred Health, Melbourne, Australia,Professor, Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia
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13
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Stellman R, Redfern A, Lahri S, Esterhuizen T, Cheema B. How much time do doctors spend providing care to each child in the ED? A time and motion study. Emerg Med J 2021; 39:23-29. [PMID: 33858862 DOI: 10.1136/emermed-2019-208903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 02/27/2021] [Accepted: 03/03/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The total time per patient doctors spend providing care in emergency departments (EDs) has implications for the development of evidence-based ED staffing models. We sought to measure the total time taken by doctors to assess and manage individual paediatric patients presenting to two EDs in the Western Cape, South Africa and to compare these averages to the estimated benchmarks used regionally to calculate ED staffing allocations. METHODS We conducted a cross-sectional, observational study applying time and motion methodology, using convenience sampling. Data were collected over a 5-week period from 11 December 2015 to 18 January 2016 at Khayelitsha District Hospital Emergency Centre and Tygerberg Hospital Paediatric Emergency and Ambulatory Unit. We assessed total doctor time for each patient stratified by acuity level using the South African Triage Scale. RESULTS Care was observed for a total of 100 patients. Median age was 21 months (IQR 8-55). Median total doctor time per patient (95% CI) was 31 (22 to 38), 39 (31 to 63), 48 (32 to 63) and 96 (66 to 122) min for triage categories green, yellow, orange and red, respectively. Median timing was significantly higher than the estimated local benchmark for the lowest acuity 'green' triage category (31 min (22 to 38) vs 15 min; p=0.001) and the highest acuity 'red' category (96 min (66 to 122) vs 50 min; p=0.002). CONCLUSION Doctor time per patient increased with increasing acuity of triage category and exceeded estimated benchmarks for the highest and lowest acuities. The distinctive methodology can easily be extended to other settings and populations.
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Affiliation(s)
- Robert Stellman
- Department of Emergency Medicine, Barnet Hospital, Royal Free London NHS Foundation Trust, London, UK .,Department of Paediatrics, Barnet Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Andrew Redfern
- Department of Paediatric and Child Health, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Sa'ad Lahri
- Khayelitsha Hospital Emergency Centre, Western Cape, South Africa.,Division of Emergency Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Tonya Esterhuizen
- Division of Epidemiology and Biostatistics, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Baljit Cheema
- Division of Emergency Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
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14
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Tang OY, Marqués CG, Ndebwanimana V, Uwamahoro C, Uwamahoro D, Lipsman ZW, Naganathan S, Karim N, Nkeshimana M, Levine AC, Stephen A, Aluisio AR. Performance of Prognostication Scores for Mortality in Injured Patients in Rwanda. West J Emerg Med 2021; 22:435-444. [PMID: 33856336 PMCID: PMC7972380 DOI: 10.5811/westjem.2020.10.48434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 10/12/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION While trauma prognostication and triage scores have been designed for use in lower-resourced healthcare settings specifically, the comparative clinical performance between trauma-specific and general triage scores for risk-stratifying injured patients in such settings is not well understood. This study evaluated the Kampala Trauma Score (KTS), Revised Trauma Score (RTS), and Triage Early Warning Score (TEWS) for accuracy in predicting mortality among injured patients seeking emergency department (ED) care at the Centre Hospitalier Universitaire de Kigali (CHUK) in Rwanda. METHODS A retrospective, randomly sampled cohort of ED patients presenting with injury was accrued from August 2015-July 2016. Primary outcome was 14-day mortality and secondary outcome was overall facility-based mortality. We evaluated summary statistics of the cohort. Bootstrap regression models were used to compare areas under receiver operating curves (AUC) with associated 95% confidence intervals (CI). RESULTS Among 617 cases, the median age was 32 years and 73.5% were male. The most frequent mechanism of injury was road traffic incident (56.2%). Predominant anatomical regions of injury were craniofacial (39.3%) and lower extremities (38.7%), and the most common injury types were fracture (46.0%) and contusion (12.0%). Fourteen-day mortality was 2.6% and overall facility-based mortality was 3.4%. For 14-day mortality, TEWS had the highest accuracy (AUC = 0.88, 95% CI, 0.76-1.00), followed by RTS (AUC = 0.73, 95% CI, 0.55-0.92), and then KTS (AUC = 0.65, 95% CI, 0.47-0.84). Similarly, for facility-based mortality, TEWS (AUC = 0.89, 95% CI, 0.79-0.98) had greater accuracy than RTS (AUC = 0.76, 95% CI, 0.61-0.91) and KTS (AUC = 0.68, 95% CI, 0.53-0.83). On pairwise comparisons, RTS had greater prognostic accuracy than KTS for 14-day mortality (P = 0.011) and TEWS had greater accuracy than KTS for overall (P = 0.007) mortality. However, TEWS and RTS accuracy were not significantly different for 14-day mortality (P = 0.864) or facility-based mortality (P = 0.101). CONCLUSION In this cohort of emergently injured patients in Rwanda, the TEWS demonstrated the greatest accuracy for predicting mortality outcomes, with no significant discriminatory benefit found in the use of the trauma-specific RTS or KTS instruments, suggesting that the TEWS is the most clinically useful approach in the setting studied and likely in other similar ED environments.
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Affiliation(s)
- Oliver Y Tang
- Brown University Warren Alpert Medical School, Department, Providence, Rhode Island
| | - Catalina González Marqués
- Brown University Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
| | - Vincent Ndebwanimana
- University of Rwanda, Department of Anesthesia, Emergency Medicine, and Critical Care, Kigali, Rwanda.,Centre Hospitalier Universitaire de Kigali, Department of Accident & Emergency, Kigali, Rwanda
| | - Chantal Uwamahoro
- University of Rwanda, Department of Anesthesia, Emergency Medicine, and Critical Care, Kigali, Rwanda.,Centre Hospitalier Universitaire de Kigali, Department of Accident & Emergency, Kigali, Rwanda
| | - Doris Uwamahoro
- University of Rwanda, Department of Anesthesia, Emergency Medicine, and Critical Care, Kigali, Rwanda.,Centre Hospitalier Universitaire de Kigali, Department of Accident & Emergency, Kigali, Rwanda
| | - Zachary W Lipsman
- Kaiser Permanente, GSAA, San Leandro & Fremont Medical Centers, San Leandro, California
| | - Sonya Naganathan
- Brown University Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
| | - Naz Karim
- Brown University Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
| | - Menelas Nkeshimana
- University of Rwanda, Department of Anesthesia, Emergency Medicine, and Critical Care, Kigali, Rwanda.,Centre Hospitalier Universitaire de Kigali, Department of Accident & Emergency, Kigali, Rwanda
| | - Adam C Levine
- Brown University Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
| | - Andrew Stephen
- Brown University Warren Alpert Medical School, Department of Surgery, Providence, Rhode Island
| | - Adam R Aluisio
- Brown University Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
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15
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Mitchell R, McKup JJ, Bue O, Nou G, Taumomoa J, Banks C, O'Reilly G, Kandelyo S, Bornstein S, Cole T, Ham T, Miller JP, Reynolds T, Körver S, Cameron P. Implementation of a novel three-tier triage tool in Papua New Guinea: A model for resource-limited emergency departments. LANCET REGIONAL HEALTH-WESTERN PACIFIC 2020; 5:100051. [PMID: 34327395 PMCID: PMC8315437 DOI: 10.1016/j.lanwpc.2020.100051] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/18/2020] [Accepted: 10/23/2020] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Rob Mitchell
- Emergency Physician, Emergency & Trauma Centre, Alfred Health, Commercial Rd, Melbourne 3004, Australia.,PhD Candidate, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - John Junior McKup
- Emergency Physician, Emergency Department, Mount Hagen Provincial Hospital, Mount Hagen, Papua New Guinea
| | - Ovia Bue
- Emergency Physician, Emergency Department, Gerehu General Hospital, Port Moresby, Papua New Guinea
| | - Gary Nou
- Emergency Physician, Emergency Department, Gerehu General Hospital, Port Moresby, Papua New Guinea
| | - Jude Taumomoa
- Clinical Nurse, Emergency Department, Gerehu General Hospital, Port Moresby, Papua New Guinea
| | - Colin Banks
- Emergency Physician, Emergency Department, Townsville University Hospital, Townsville, Australia
| | - Gerard O'Reilly
- Emergency Physician and Head of Global Programs, Emergency & Trauma Centre, Alfred Health, Melbourne, Australia.,Associate Professor, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Scotty Kandelyo
- Emergency Physician Emergency Department, Port Moresby General Hospital, Port Moresby, Papua New Guinea.,Regional Chief of Emergency Medicine, Highlands Region, National Department of Health, Port Moresby, Papua New Guinea
| | - Sarah Bornstein
- Critical Care Nurse, Emergency Department, St Vincent's Hospital, Sydney, Australia
| | - Travis Cole
- Emergency Clinical Nurse Specialist, Emergency Department, Townsville Hospital, Townsville, Australia
| | - Tracie Ham
- Associate Nurse Unit Manager, Emergency Department, St Vincent's Hospital, Melbourne, Australia
| | - Jean-Philippe Miller
- Critical Care Nurse, Emergency & Trauma Centre, Alfred Health, Melbourne, Australia
| | - Teri Reynolds
- Unit Head, Clinical Services and Systems, Department of Integrated Health Services, World Health Organization, Geneva, Switzerland
| | - Sarah Körver
- Global Emergency Care Manager, Australasian College for Emergency Medicine, Melbourne, Australia
| | - Peter Cameron
- Emergency Physician, Emergency & Trauma Centre, Alfred Health, Commercial Rd, Melbourne 3004, Australia.,Director of Academic Programs, Emergency & Trauma Centre, Alfred Health, Melbourne, Australia.,Professor, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
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16
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Joshi N, Wadhwani R, Nagpal J, Bhartia S. Implementing a triage tool to improve appropriateness of care for children coming to the emergency department in a small hospital in India. BMJ Open Qual 2020; 9:bmjoq-2020-000935. [PMID: 33046456 PMCID: PMC7552862 DOI: 10.1136/bmjoq-2020-000935] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 06/24/2020] [Accepted: 08/25/2020] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Neha Joshi
- Paediatric, Sitaram Bhartia Institute of Science and Research, New Delhi, Delhi, India
| | - Rakhi Wadhwani
- Quality, Sitaram Bhartia Institute of Science and Research, New Delhi, Delhi, India
| | - Jitender Nagpal
- Paediatric, Sitaram Bhartia Institute of Science and Research, New Delhi, Delhi, India
| | - Saru Bhartia
- Quality, Sitaram Bhartia Institute of Science and Research, New Delhi, Delhi, India
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17
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Zimmerman A, Fox S, Griffin R, Nelp T, Thomaz EBAF, Mvungi M, Mmbaga BT, Sakita F, Gerardo CJ, Vissoci JRN, Staton CA. An analysis of emergency care delays experienced by traumatic brain injury patients presenting to a regional referral hospital in a low-income country. PLoS One 2020; 15:e0240528. [PMID: 33045030 PMCID: PMC7549769 DOI: 10.1371/journal.pone.0240528] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/29/2020] [Indexed: 11/12/2022] Open
Abstract
Background Trauma is a leading cause of death and disability worldwide. In low- and middle-income countries (LMICs), trauma patients have a higher risk of experiencing delays to care due to limited hospital resources and difficulties in reaching a health facility. Reducing delays to care is an effective method for improving trauma outcomes. However, few studies have investigated the variety of care delays experienced by trauma patients in LMICs. The objective of this study was to describe the prevalence of pre- and in-hospital delays to care, and their association with poor outcomes among trauma patients in a low-income setting. Methods We used a prospective traumatic brain injury (TBI) registry from Kilimanjaro Christian Medical Center in Moshi, Tanzania to model nine unique delays to care. Multiple regression was used to identify delays significantly associated with poor in-hospital outcomes. Results Our analysis included 3209 TBI patients. The most common delay from injury occurrence to hospital arrival was 1.1 to 4.0 hours (31.9%). Most patients were evaluated by a physician within 15.0 minutes of arrival (69.2%). Nearly all severely injured patients needed and did not receive a brain computed tomography scan (95.0%). A majority of severely injured patients needed and did not receive oxygen (80.8%). Predictors of a poor outcome included delays to lab tests, fluids, oxygen, and non-TBI surgery. Conclusions Time to care data is informative, easy to collect, and available in any setting. Our time to care data revealed significant constraints to non-personnel related hospital resources. Severely injured patients with the greatest need for care lacked access to medical imaging, oxygen, and surgery. Insights from our study and future studies will help optimize resource allocation in low-income hospitals thereby reducing delays to care and improving trauma outcomes in LMICs.
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Affiliation(s)
- Armand Zimmerman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Samara Fox
- Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Randi Griffin
- Department of Evolutionary Anthropology, Duke University, Durham, North Carolina, United States of America
| | - Taylor Nelp
- Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | | | - Mark Mvungi
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Clinical Research Institute, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Francis Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Charles J Gerardo
- Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Joao Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.,Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Catherine A Staton
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.,Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
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18
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Jachetti A, Massénat RB, Edema N, Woolley SC, Benedetti G, Van Den Bergh R, Trelles M. Introduction of a standardised protocol, including systematic use of tranexamic acid, for management of severe adult trauma patients in a low-resource setting: the MSF experience from Port-au-Prince, Haiti. BMC Emerg Med 2019; 19:56. [PMID: 31627715 PMCID: PMC6798378 DOI: 10.1186/s12873-019-0266-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 09/12/2019] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Bleeding is an important cause of death in trauma victims. In 2010, the CRASH-2 study, a multicentre randomized control trial on the effect of tranexamic acid (TXA) administration to trauma patients with suspected significant bleeding, reported a decreased mortality in randomized patients compared to placebo. Currently, no evidence on the use of TXA in humanitarian, low-resource settings is available. We aimed to measure the hospital outcomes of adult patients with severe traumatic bleeding in the Médecins Sans Frontières Tabarre Trauma Centre in Port-au-Prince, Haiti, before and after the implementation of a Massive Haemorrhage protocol including systematic early administration of TXA. METHODS Patients admitted over comparable periods of four months (December2015- March2016 and December2016 - March2017) before and after the implementation of the Massive Haemorrhage protocol were investigated. Included patients had blunt or penetrating trauma, a South Africa Triage Score ≥ 7, were aged 18-65 years and were admitted within 3 h from the traumatic event. Measured outcomes were hospital mortality and early mortality rates, in-hospital time to discharge and time to discharge from intensive care unit. RESULTS One-hundred and sixteen patients met inclusion criteria. Patients treated after the introduction of the Massive Haemorrhage protocol had about 70% less chance of death during hospitalization compared to the group "before" (adjusted odds ratio 0.3, 95%confidence interval 0.1-0.8). They also had a significantly shorter hospital length of stay (p = 0.02). CONCLUSIONS Implementing a Massive Haemorrhage protocol including early administration of TXA was associated with the reduced mortality and hospital stay of severe adult blunt and penetrating trauma patients in a context with poor resources and limited availability of blood products.
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Affiliation(s)
- Alessandro Jachetti
- Médecins Sans Frontières – Operational Centre Brussels – Haiti Mission, Port-au-Prince, Haiti
- Emergency Department, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Rose Berly Massénat
- Médecins Sans Frontières – Operational Centre Brussels – Haiti Mission, Port-au-Prince, Haiti
| | - Nathalie Edema
- Médecins Sans Frontières – Operational Centre Brussels – Haiti Mission, Port-au-Prince, Haiti
| | - Sophia C. Woolley
- Médecins Sans Frontières – Operational Centre Brussels – Haiti Mission, Port-au-Prince, Haiti
| | - Guido Benedetti
- Médecins Sans Frontières – Operational Centre Brussels – Haiti Mission, Port-au-Prince, Haiti
- Médecins Sans Frontières – Operational Centre Brussels – Operational Research Unit, Brussels, Belgium
| | - Rafael Van Den Bergh
- Médecins Sans Frontières – Operational Centre Brussels – Operational Research Unit, Brussels, Belgium
| | - Miguel Trelles
- Médecins Sans Frontières – Operational Centre Brussels – Surgical and Critical Care Unit, Brussels, Belgium
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19
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Wanefalea LE, Mitchell R, Sale T, Sanau E, Phillips GA. Effective triage in the Pacific region: The development and implementation of the Solomon Islands Triage Scale. Emerg Med Australas 2019; 31:451-458. [PMID: 30866177 DOI: 10.1111/1742-6723.13248] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 12/31/2018] [Accepted: 01/13/2019] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Lynne E Wanefalea
- Emergency Department, Bendigo Hospital, Bendigo, Victoria, Australia
- School of Rural Health, Monash University, Bendigo, Victoria, Australia
| | - Rob Mitchell
- Emergency and Trauma Centre, Alfred Hospital, Melbourne, Victoria, Australia
| | - Trina Sale
- Emergency Department, National Referral Hospital, Honiara, Solomon Islands
| | - Elizabeth Sanau
- Emergency Department, National Referral Hospital, Honiara, Solomon Islands
| | - Georgina A Phillips
- Emergency Practice Innovation Centre, St Vincent's Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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20
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Beltrán Guzmán I, Gil Cuesta J, Trelles M, Jaweed O, Cherestal S, van Loenhout JAF, Guha-Sapir D. Delays in arrival and treatment in emergency departments: Women, children and non-trauma consultations the most at risk in humanitarian settings. PLoS One 2019; 14:e0213362. [PMID: 30835777 PMCID: PMC6400395 DOI: 10.1371/journal.pone.0213362] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 02/20/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Delays in arrival and treatment at health facilities lead to negative health outcomes. Individual and external factors could be associated with these delays. This study aimed to assess common factors associated with arrival and treatment delays in the emergency departments (ED) of three hospitals in humanitarian settings. METHODOLOGY This was a cross-sectional study based on routine data collected from three MSF-supported hospitals in Afghanistan, Haiti and Sierra Leone. We calculated the proportion of consultations with delay in arrival (>24 hours) and in treatment (based on target time according to triage categories). We used a multinomial logistic regression model (MLR) to analyse the association between age, sex, hospital and diagnosis (trauma and non-trauma) with these delays. RESULTS We included 95,025 consultations. Males represented 65.2%, Delay in arrival was present in 27.8% of cases and delay in treatment in 27.2%. The MLR showed higher risk of delay in arrival for females (OR 1.2, 95% CI 1.2-1.3), children <5 (OR 1.4, 95% CI 1.4-1.5), patients attending to Gondama (OR 30.0, 95% CI 25.6-35.3) and non-trauma cases (OR 4.7, 95% CI 4.4-4.8). A higher risk of delay in treatment was observed for females (OR 1.1, 95% CI 1.0-1.1), children <5 (OR 2.0, 95% CI 1.9-2.1), patients attending to Martissant (OR 14.6, 95% CI 13.9-15.4) and non-trauma cases (OR 1.6, 95% CI 1.5-1.7). CONCLUSIONS Women, children <5 and non-trauma cases suffered most from delays. These delays could relate to educational and cultural barriers, and severity perception of the disease. Treatment delay could be due to insufficient resources with consequent overcrowding, and severity perception from medical staff for non-trauma patients. Extended community outreach, health promotion and support to community health workers could improve emergency care in humanitarian settings.
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Affiliation(s)
- Isabel Beltrán Guzmán
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
- Operational Centre Geneva, Médecins Sans Frontières, Geneva, Switzerland
| | - Julita Gil Cuesta
- Operational Centre Brussels, Médecins Sans Frontières, Brussels, Belgium
| | - Miguel Trelles
- Operational Centre Brussels, Médecins Sans Frontières, Brussels, Belgium
| | - Omar Jaweed
- Mission Afghanistan, Médecins Sans Frontières, Kunduz, Afghanistan
| | - Sophia Cherestal
- Mission Haiti, Operational Centre Brussels, Médecins Sans Frontières, Port-au-Prince, Haiti
| | - Joris Adriaan Frank van Loenhout
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
| | - Debarati Guha-Sapir
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
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Wangara AA, Hunold KM, Leeper S, Ndiawo F, Mweu J, Harty S, Fuchs R, Martin IBK, Ekernas K, Dunlop SJ, Twomey M, Maingi AW, Myers JG. Implementation and performance of the South African Triage Scale at Kenyatta National Hospital in Nairobi, Kenya. Int J Emerg Med 2019; 12:5. [PMID: 31179944 PMCID: PMC6371470 DOI: 10.1186/s12245-019-0221-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/21/2019] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Ali A. Wangara
- Accident and Emergency Department, Kenyatta National Hospital, PO Box 3956-00200, Nairobi, Kenya
| | - Katherine M. Hunold
- Department of Emergency Medicine, The Ohio State University, Columbus, OH USA
| | - Sarah Leeper
- Department of Emergency Medicine, University of Maryland Prince George’s Hospital Center, Maryland, MD USA
| | - Frederick Ndiawo
- Accident and Emergency Department, Kenyatta National Hospital, PO Box 3956-00200, Nairobi, Kenya
| | - Judith Mweu
- Critical Care Unit, Kenyatta National Hospital, Nairobi, Kenya
| | - Shaun Harty
- Department of Emergency Medicine, The University of Cincinnati, Cincinnati, OH USA
| | - Rachael Fuchs
- Department of Biostatistics, FHI 360 & UNC Gillings School of Global Public Health, Chapel Hill, NC USA
| | - Ian B. K. Martin
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI USA
| | - Karen Ekernas
- Department of Emergency Medicine, St. Joseph Hospital, Denver, CO USA
| | - Stephen J. Dunlop
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN USA
| | | | - Alice W. Maingi
- Accident and Emergency Department, Kenyatta National Hospital, PO Box 3956-00200, Nairobi, Kenya
| | - Justin Guy Myers
- Department of Emergency Medicine, University of North Carolina at Chapel Hill School of Medicine, 170 Manning Drive, CB 7594, Chapel Hill, NC 27599 USA
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Stott BA, Moosa S. Exploring the sorting of patients in community health centres across Gauteng Province, South Africa. BMC FAMILY PRACTICE 2019; 20:5. [PMID: 30616518 PMCID: PMC6322241 DOI: 10.1186/s12875-018-0899-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 12/27/2018] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- B. A. Stott
- Department of Family Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - S. Moosa
- Department of Family Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Validity of the South African Triage Scale in a rural district hospital. Afr J Emerg Med 2018; 8:145-149. [PMID: 30534518 PMCID: PMC6277536 DOI: 10.1016/j.afjem.2018.07.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 05/20/2018] [Accepted: 07/08/2018] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The implementation of a triage system is a vital step in improving the functioning and patient flow of the emergency centre in a rural district hospital. The South African Triage Scale (SATS) is a well validated and reliable tool used widely in South Africa and other low- and middle-income countries. This study aims to assess the validity of the SATS in a rural district hospital context. METHODS This is a cross-sectional study. All patients presenting to the Zithulele Hospital emergency centre from 1 October 2015 to 31 December 2015 were triaged using the SATS system, routinely collected data was used to determine the correlation between assigned acuity and outcome to determine rates of under- and over-triage. Patient demographics were collected and waiting times were compared to existing standards of the SATS tool. RESULTS Of the 4002 patients presenting to the emergency centre during the study period, 2% were triaged as emergency patients, 15% as very urgent, 38% as urgent and 45% as routine. The assigned acuities correlate well with outcome (f = 0.37; p < 0.0001) and an acceptable rate of over-triage (49%) and under-triage (9%) was found. Waiting time targets were poorly achieved with only 49% of emergency, 23% very urgent, 46% urgent and 69% routine patients seen within ideal target times. DISCUSSION The SATS is a valid tool to implement in a rural district emergency centre. Strict waiting time goals may not be achievable in this setting without structural and resource allocation changes to allow for improvements in the surge capacity of staff to manage urgent and emergency patients.
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Dalwai M, Tayler-Smith K, Twomey M, Nasim M, Popal AQ, Haqdost WH, Gayraud O, Cheréstal S, Wallis L, Valles P. Inter-rater and intrarater reliability of the South African Triage Scale in low-resource settings of Haiti and Afghanistan. Emerg Med J 2018; 35:379-383. [PMID: 29549171 PMCID: PMC5969337 DOI: 10.1136/emermed-2017-207062] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 02/06/2018] [Accepted: 02/13/2018] [Indexed: 11/15/2022]
Abstract
Objective The South African Triage Scale (SATS) has demonstrated good validity in the EDs of Médecins Sans Frontières (MSF)-supported sites in Afghanistan and Haiti; however, corresponding reliability in these settings has not yet been reported on. This study set out to assess the inter-rater and intrarater reliability of the SATS in four MSF-supported EDs in Afghanistan and Haiti (two trauma-only EDs and two mixed (including both medical and trauma cases) EDs). Methods Under classroom conditions between December 2013 and February 2014, ED nurses at each site assigned triage ratings to a set of context-specific vignettes (written case reports of ED patients). Inter-rater reliability was assessed by comparing triage ratings among nurses; intrarater reliability was assessed by asking the nurses to retriage 10 random vignettes from the original set and comparing these duplicate ratings. Inter-rater reliability was calculated using the unweighted kappa, linearly weighted kappa and quadratically weighted kappa (QWK) statistics, and the intraclass correlation coefficient (ICC). Intrarater reliability was calculated according to the percentage of exact agreement and the percentage of agreement allowing for one level of discrepancy in triage ratings. The correlation between years of nursing experience and reliability of the SATS was assessed based on comparison of ICCs and the respective 95% CIs. Results A total of 67 nurses agreed to participate in the study: In Afghanistan there were 19 nurses from Kunduz Trauma Centre and nine from Ahmed Shah Baba; in Haiti, there were 20 nurses from Martissant Emergency Centre and 19 from Tabarre Surgical and Trauma Centre. Inter-rater agreement was moderate across all sites (ICC range: 0.50–0.60; QWK range: 0.50–0.59) apart from the trauma ED in Haiti where it was moderate to substantial (ICC: 0.58; QWK: 0.61). Intrarater agreement was similar across the four sites (68%–74% exact agreement); when allowing for a one-level discrepancy in triage ratings, intrarater reliability was near perfect across all sites (96%–99%). No significant correlation was found between years of nursing experience and reliability. Conclusion The SATS has moderate reliability in different EDs in Afghanistan and Haiti. These findings, together with concurrent findings showing that the SATS has good validity in the same settings, provide evidence to suggest that SATS is suitable in trauma-only and mixed EDs in low-resource settings.
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Affiliation(s)
- Mohammed Dalwai
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa.,Medical Department, Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium
| | - Katie Tayler-Smith
- Operational Research Unit Luxembourg, Médecins Sans Frontières, Luxembourg City, Luxembourg
| | - Michèle Twomey
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Masood Nasim
- Medical Department, Médecins Sans Frontières, Kabul, Afghanistan
| | | | | | - Olivia Gayraud
- Medical Department, Médecins Sans Frontières, Port au Prince, Haiti
| | - Sophia Cheréstal
- Medical Department, Médecins Sans Frontières, Port au Prince, Haiti
| | | | - Pola Valles
- Medical Department, Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium
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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. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018. [PMID: 29534556 PMCID: PMC5877046 DOI: 10.3390/ijerph15030501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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