Reliability and accuracy of the South African Triage Scale when used by nurses in the emergency department of Timergara Hospital, Pakistan

Abstract

Background. Triage is one of the core requirements for the provision of effective emergency care and has been shown to reduce patient mortality. However, in low-and middle-income countries this strategy is underused, under-resourced and poorly researched. Objective. To assess the inter-and intra-rater reliability and accuracy of nurse triage ratings when using the South African Triage Scale (SATS) in an emergency department (ED) in Timergara, Pakistan. Methods. Fifteen ED nurses assigned triage ratings to a set of 42 reference vignettes (written case reports of ED patients) under classroom conditions. Inter-rater reliability was assessed by comparing these triage ratings; intra-rater reliability was assessed by asking the nurses to re-triage 10 random vignettes from the original set of 42 vignettes and comparing these duplicate ratings. Accuracy of the nurse ratings was measured against the reference standard. Results. Inter-rater reliability was substantial (intraclass correlation coefficient 0.77; 95% confidence interval (CI) 0.69 -0.85). The intrarater agreement was also high with 87% exact agreement (95% CI 67 -100) and 100% agreement allowing for a one-level discrepancy in triage ratings. Overall, the SATS had high specificity (97%) and moderate sensitivity (70%). Across all acuity levels the proportion of overtriage did not exceed the acceptable threshold of 30 -50%. Under-triage was acceptable for all except emergency cases (66%). Conclusion. ED nurses in Pakistan can reliably use the SATS to assign triage acuity ratings. While the tool is accurate for 'very urgent' and 'routine' cases, importantly, it may under-triage 'emergency' cases requiring immediate attention. Approaches that will improve accuracy and validity are discussed.

The accuracy of nurse performance of the triage process in a tertiary hospital emergency department in Gauteng Province, South Africa

“…In this study, 16/25 patients (64.0%) who should have been triaged red were incorrectly demoted to orange, which is similar to the 66% undertriage result for the red category found by Dalwai et al [3] Although we cannot directly compare these results, we can speculate that a similar under-triage result might have been achieved had true acuity levels been determined. When looking at the reasons for mis-triage in the red category, the primary errors were miscalculation and errors in the 'other' category (TEWS were calculated correctly and/ or the correct discriminator was used, but the incorrect category was still chosen).…”

“…A classroom-based study by Dalwai et al [3] assessed the reliability and accuracy of the SATS when used by ED nursing staff in Pakistan. Their reference standard was based on the triage category assigned to case vignettes that had been evaluated by an expert panel (surrogate end-point).…”

“…It was noted that 66% of emergency cases (red) were under-triaged, but fortunately only by one acuity level, to orange. [3] However, the expert panel in the study were mostly based in high-income rather than low-and middleincome healthcare settings, which may have affected their opinion of the patients' acuity level, leading to a tendency to over-rate patients. The authors also suggested that nurses may tend to under-rate a patient's acuity level when only given a paper-based vignette.…”

“…However, overall it RESEARCH was concluded that the SATS is reliable and can be used by nursing staff in Pakistan. [3] It has come to our attention that studies assessing triage tools compare their over-and under-triage rates with the so-called 'acceptable ranges' developed by the American College of Surgeons Committee on Trauma (ACSCOT). [6] This is not a valid comparator, however, as the ACSCOT triage guidelines were developed for prehospital (in-field) use in trauma patients only.…”

“…It has since been adopted by numerous EDs. [3] The SATS categorises patients into different colour groups depending on the severity of their condition. This categorisation is based on vital signs that are used to constitute the Triage Early Warning Score (TEWS), as well as a discriminator list of conditions that acts as a safety net for certain time-critical conditions where patients may present with normal or near-normal vital signs.…”