ObjectiveTo 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.MethodsThis 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).ResultsIn 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.ConclusionThe 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.

BackgroundProvision of Emergency Obstetric and Neonatal Care (EmONC) reduces maternal mortality and should include three components: Basic Emergency Obstetric and Neonatal Care (BEmONC) offered at primary care level, Comprehensive EmONC (CEmONC) at secondary level and a good referral system in-between. In a conflict-affected province of Afghanistan (Khost), we assessed the performance of an Médecins Sans Frontières (MSF) run CEmONC hospital without a primary care and referral system. Performance was assessed in terms of hospital utilisation for obstetric emergencies and quality of obstetric care.MethodsA cross-sectional study using routine programme data (2013–2014).ResultsOf 29,876 admissions, 99% were self-referred, 0.4% referred by traditional birth attendants and 0.3% by health facilities. Geographic origins involved clustering around the hospital vicinity and the provincial road axis. While there was a steady increase in hospital caseload, the number and proportion of women with Direct Obstetric Complications (DOC) progressively dropped from 21% to 8% over 2 years. Admissions for normal deliveries continuously increased. In-hospital maternal deaths were 0.03%, neonatal deaths 1% and DOC case-fatality rate 0.2% (all within acceptable limits).ConclusionsDespite a high and ever increasing caseload, good quality Comprehensive EmONC could be offered in a conflict-affected setting in rural Afghanistan. However, the primary emergency role of the hospital is challenged by diversion of resources to normal deliveries that should happen at primary level. Strengthening Basic EmONC facilities and establishing an efficient referral system are essential to improve access for emergency cases and increase the potential impact on maternal mortality.

BackgroundIn Afghanistan, Médecins Sans Frontières provided specialised trauma care in Kunduz Trauma Centre (KTC), including physiotherapy. In this study, we describe the development of an adapted functional score for patient outcome monitoring, and document the rehabilitation care provided and patient outcomes in relation to this functional score.MethodsA descriptive cohort study was done, including all patients admitted in the KTC inpatient department (IPD) between January and June 2015. The adapted functional score was collected at four points in time: admission and discharge from both IPD and outpatient department (OPD).ResultsOut of the 1528 admitted patients, 92.3% (n = 1410) received at least one physiotherapy session. A total of 1022 patients sustained either lower limb fracture, upper limb fracture, traumatic brain injury or multiple injury. Among them, 966 patients received physiotherapy in IPD, of whom 596 (61.7%) received IPD sessions within 2 days of admission; 696 patients received physiotherapy in OPD. Functional independence increased over time; among patients having a functional score taken at admission and discharge from IPD, 32.2% (172/535) were independent at discharge, and among patients having a functional score at OPD admission and discharge, 79% (75/95) were independent at discharge.ConclusionsThe provision of physiotherapy was feasible in this humanitarian setting, and the tailored functional score appeared to be relevant.

ObjectiveThe 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).MethodsUnder 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.ResultsA 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.ConclusionThe 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.

BackgroundTrauma is a leading cause of death and represents a major problem in developing countries where access to good quality emergency care is limited. Médecins Sans Frontières delivered a standard package of care in two trauma emergency departments (EDs) in different violence settings: Kunduz, Afghanistan, and Tabarre, Haiti. This study aims to assess whether this standard package resulted in similar performance in these very different contexts.MethodsA cross-sectional study using routine programme data, comparing patient characteristics and outcomes in two EDs over the course of 2014.Results31 158 patients presented to the EDs: 22 076 in Kunduz and 9082 in Tabarre. Patient characteristics, such as delay in presentation (29.6% over 24 h in Kunduz, compared to 8.4% in Tabarre), triage score, and morbidity pattern differed significantly between settings. Nevertheless, both EDs showed an excellent performance, demonstrating low proportions of mortality (0.1% for both settings) and left without being seen (1.3% for both settings), and acceptable triage performance. Physicians’ maximum working capacity was exceeded in both centres, and mainly during rush hours.ConclusionsThis study supports for the first time the plausibility of using the same ED package in different settings. Mapping of patient attendance is essential for planning of human resources needs.