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

Abstract

Background. Triage in the emergency department (ED) is necessary to prioritise management according to the severity of a patient's condition. The South African Triage Scale (SATS) is a hospital-based triage tool that has been adopted by numerous EDs countrywide. Many factors can influence the outcome of a patient's triage result, and evaluation of performance is therefore pivotal. Objectives. To determine how often patients were allocated to the correct triage category and the extent to which they were incorrectly promoted or demoted, and to determine the main reasons for errors in a nurse-led triage system. Methods. Triage forms from a tertiary hospital ED in Gauteng Province, South Africa, were collected over a 1-week period and reviewed retrospectively. Results. A total of 1 091 triage forms were reviewed. Triage category allocations were correct 68.3% of the time. Of the incorrect category assignments, 44.4% of patients were promoted and 55.6% demoted. Patients in the green category were most commonly promoted (29.4%) and patients who should have been in orange were most commonly demoted (35.0%). Trauma patients were more likely to be incorrectly promoted and non-trauma patients to be incorrectly demoted. Mistakes were mainly due to discriminator errors (57.8%), followed by numerical miscalculations (21.5%). The leading omitted discriminators were 'abdominal pain' , 'chest pain' and 'shortness of breath' . Conclusions. Mis-triaging using the SATS can be attributed to incorrect or lack of discriminator use, numerical miscalculations and other human errors. Quality control and quality assurance measures must target training in these areas to minimise mis-triage in the ED.

A quality improvement study of the emergency centre triage in a tertiary teaching hospital in northern Ethiopia

“…One of the most concerning gaps was the lack of thorough nursing documentation concerning calculation of the TEWS, or their reasons for adjusting the calculated TEWS based on presence of discriminators. Similar issues were faced in Kumasi, Ghana, where nurses failed to document reasons for adjusting the calculated TEWS [9] , and in Gauteng, South Africa where 57.8% of triage errors were due to improper of non-existent use of the discriminator list, and 21.5% were due to mathematical miscalculations [25] . Although failure to document does not necessarily equate with a lack of judgment on the part of the triage nurses, haphazard re-assignment of patients without following the established algorithm could result in mis-triage and this have serious ramifications for patient safety.…”

On-scene discharge by Emergency Care Practitioners – a viable option for South Africa?

“…Patients who are triaged green are so-called 'non-urgent' patients, and they can be seen at a primary healthcare clinic. 17 These patients may also potentially be discharged on-scene by an ECP due to their low acuity. Almost onequarter of patients who were brought to the hospital could therefore potentially not have been conveyed to the hospital.…”

Standardised training is the key to accuracy in triage

“…Taking a step away from patient-centred motives, business-related motives, such as the use of the SATS for billing purposes, would also be affected by accuracy. It may appear to be a good idea from the outset, but as triage accuracy is likely to be either similar or (more likely) worse than that reported by Goldstein et al, [1] this ill-conceived practice (currently used by many private emergency centres) means that an overtriaged patient is also an overcharged customer, leading to the overtriaged subsidising the undertriaged. This issue becomes murkier when one considers that the SATS purposely overtriages -a safety net, built into every major triage tool.…”

“…To the Editor: We read with interest Goldstein et al 's [1] article, 'The accuracy of nurse performance of the triage process in a tertiary hospital emergency department in Gauteng Province, South Africa (SA)' . It is encouraging to observe research-driven improvement in the use of the SA Triage Scale (SATS).…”

“…The Emergency Medicine Society of South Africa provides resources for training (manuals, posters and videos), but fails to provide a structured curriculum or assessment strategy that trainers can adopt. [3] Goldstein et al [1] mention in-service training, but unfortunately do not provide detail with regard to the training.…”