• Implementation of a triage score system in an emergency room in Timergara, Pakistan [Short communication]

      Dalwai, M. K; Tayler-Smith, K; Trelles, M; Jemmy, J-P; Maikéré, J; Twomey, M; Wakeel, M; Iqbal, M; Zachariah, R; Médecins Sans Frontières (MSF), Islamabad, Pakistan (International Union Against Tuberculosis and Lung Disease, 2013-03-21)
      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.
    • Inter-rater and intrarater reliability of the South African Triage Scale in low-resource settings of Haiti and Afghanistan

      Dalwai, M; Tayler-Smith, K; Twomey, M; Nasim, M; Popal, AQ; Haqdost, WH; Gayraud, O; Cheréstal, S; Wallis, L; Valles, P (BMJ Publishing Group, 2018-03-16)
      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).
    • Is the South African Triage Scale Valid for Use in Afghanistan, Haiti and Sierra Leone?

      Dalwai, M; Valles, P; Twomey, M; Nzomukunda, Y; Jonjo, P; Sasikumar, M; Nasim, M; Razaaq, A; Gayraud, O; Jecrois, P; et al. (BMJ Publishing Group Ltd, 2017-06-15)
      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.
    • Reliability and accuracy of the South African Triage Scale when used by nurses in the emergency department of Timergara Hospital, Pakistan

      Dalwai, M K; Twomey, M; Maikere, J; Said, S; Wakeel, M; Jemmy, J-P; Valles, P; Tayler-Smith, K; Wallis, L; Zachariah, R (Health & Medical Publishing Group, 2014-03)
      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 intra-rater 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 over-triage 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.