Michele Twomey

Limitations in validating emergency department triage scales

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

Workload and casemix in Cape Town emergency departments

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

Vital signs for children at triage: A multicentre validation of the revised South African Triage Scale (SATS) for children

OBJECTIVE To validate a revised version of the paediatric South African Triage Scale (SATS) against admission as a reference standard and compare the sensitivity of triage using: (i) clinical discriminators; (ii) an age-appropriate physiological composite score; and (iii) a combination of both. METHODS A prospective cohort study was undertaken validating the revised paediatric SATS against outcome markers of children at six emergency centres during a 2-month period in 2011. The primary outcome marker was the proportion of children admitted. Validity indicators including sensitivity (Se), specificity, positive predictive value and negative predictive value (NPV) were used to estimate the validity. Associated percentages for over-/under-triage were used to further assess practical application of the paediatric SATS. RESULTS A total of 2 014 children were included. The percentage of hospital admissions increased with an increase in the level of urgency from 5% in the non-urgent patients to 73% in the emergency patients. The data demonstrated that sensitivity increased substantially when using the SATS, which is a combination of clinical discriminators and the Triage Early Warning Score (TEWS) (Se 91.0%, NPV 95.3%), compared with use of clinical discriminators in isolation (Se 57.1%, NPV 86.3%) or the TEWS in isolation (Se 75.6%, NPV 89.1%). CONCLUSION The results of this study illustrate that the revised paediatric SATS is a safe and robust triage tool.

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

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

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

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

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

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

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

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

Implementation of a triage score system in an emergency room in Timergara, Pakistan.

Following implementation of the South African Triage Scale (SATS) system in the emergency department (ED) at the District Headquarter Hospital in Timergara, Pakistan, we 1) describe the implementation process, and 2) report on how accurately emergency staff used the system. Of the 370 triage forms evaluated, 320 (86%) were completed without errors, resulting in the correct triage priority being assigned. Fifty completed forms displayed errors, but only 16 (4%) resulted in an incorrect triage priority being assigned. This experience shows that the SATS can be implemented successfully and used accurately by nurses in an ED in Pakistan.

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

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

Is the South African Triage Scale valid for use in Afghanistan, Haiti and Sierra Leone?

Objective To assess the validity of the South African Triage Scale (SATS) in four Médecins Sans Frontières (MSF)-supported emergency departments (ED, two trauma-only sites, one mixed site (both medical and trauma cases) and one paediatric-only site) in Afghanistan, Haiti and Sierra Leone. Methods This was a retrospective cohort study conducted between June 2013 and June 2014. Validity was assessed by comparing patients’ SATS ratings with their final ED outcome (ie, hospital admission, death or discharge). Results In the two trauma settings, the SATS demonstrated good validity: it accurately predicted an increase in the likelihood of mortality and hospitalisation across incremental acuity levels (p<0.001) and ED outcomes for ‘green’ and ‘red’ patients matched the predicted ED outcomes in 84%–99% of cases. In the mixed ED, the SATS was able to predict an incremental increase in hospitalisation (p<0.001) across both trauma and non-trauma cases. In the paediatric-only settings, SATS was able to predict an incremental increase in hospitalisation in the non-trauma cases only (p<0.001). However, 87% (non-trauma) and 94% (trauma) of ‘red’ patients in the mixed-medical setting were overtriaged and 76% (non-trauma) and 100% (trauma) of ‘green’ patients in the paediatric settings were undertriaged. Conclusion The SATS is a valid tool for trauma-only settings in low-resource countries. Its use in mixed settings seems justified, but context-specific assessments would seem prudent. Finally, in paediatric settings with endemic malaria, adding haemoglobin level to the SATS discriminator list may help to improve the undertriage of patients with malaria.