Evaluation of the implementation of the South African Triage System at an academic hospital in central Haiti

doi:10.1016/j.ienj.2016.12.004

International Emergency Nursing

Volume 33, July 2017, Pages 26-31

https://doi.org/10.1016/j.ienj.2016.12.004 Get rights and content

Highlights

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The South African Triage System (SATS) was successful with limited formal training.
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Completion of clinical discriminators was less common than the numeric triage score.
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In this setting, SATS had low undertriage but high overtriage rates.

Abstract

Background

Effective triage is an important part of high quality emergency care, yet is frequently lacking in resource-limited settings. The South African Triage Scale (SATS) is designed for these settings and consists of a numeric score (triage early warning score, TEWS) and a list of clinical signs (known as discriminators). Our objective was to evaluate the implementation of SATS at a new teaching hospital in Haiti.

Methods

A random sample of emergency department charts from October 2013 were retrospectively reviewed for the completeness and accuracy of the triage form, correct calculation of the triage score, and final patient disposition. Over and under triage were calculated. Comparisons were evaluated with chi-squared analysis.

Results

Of 390 charts were reviewed, 385 contained a triage form and were included in subsequent analysis. The final triage color was recorded for 68.4% of patients, clinical discriminators for 48.6%, and numeric score for 96.1%. The numeric score was calculated correctly 78.3% of the time; in 13.2% of patients a calculation error was made that would have changed triage priority. In 23% of cases, chart review identified clinical discriminators should have been circled but were not recorded. Overtriage and undertriage were 75.6% and 7.4% respectively.

Conclusion

This study demonstrates that with limited structured training, SATS was widely adopted, but the clinical discriminators were used less commonly than the numeric score. This should be considered in future implementations of SATS.

Section snippets

Background

As emergency medicine continues to expand globally, it is increasingly important that hospitals adopt strategies to improve the quality and efficiency of emergency care. Triage, the process of sorting patients according to need so that the sickest patients receive priority treatment [1], has become a corner stone of emergency department (ED) quality and patient flow [2]. Triage allows for early recognition and treatment of critically ill patients, improves resource utilization and patient

Study design

The study was a retrospective chart review of a sample of patients who presented to UTHM ED during a one-month period (October 2013). This study was approved by institutional review boards at Partners Healthcare (Boston, USA) and Zanmi Lasante (Port–au-Prince, Haiti).

Study setting

UTHM is a 300-bed academic referral center in central Haiti. At the time of the study, the ED was a 15-bed unit that saw all non-obstetric emergency patients with a visit volume of approximately 1100 patients per month. Emergency

Results

There were 1060 ED visits during the study period. Of the 400 randomly selected encounters, three were duplicate encounters (e.g. – the exact same visit had been erroneously registered twice), four were actually outside the study period, and seven charts were unable to located, leaving 386 encounters eligible for inclusion. Of these, 381 (98.7%) contained a triage form and were included in the analysis. Most patients were over age 12 (69.6%) and 49.9% were male. The majority (80.6%) were

Discussion

Triage systems are an essential for high quality emergency care. This study demonstrates that the SATS, a triage system developed for low resource settings, was implemented in Haiti with limited training. However, it also demonstrates that in our context, some parts of the system are more widely used than others, suggesting where future training resources should be focused.

Overall at UTHM, triage was widely used despite the limited training permitted by time and resource constraints. In a

Conclusion

This study shows that the SATS can be implemented with only minimal training in a resource-limited environment, but that some components of the triage system were more commonly adopted than others. It also demonstrates that triage audits in a low-resource setting can identify areas in which triage can be strengthened.

Conflict of interest

None

Ethical statement

This study was approved by institutional review boards at Partners Healthcare (Boston, USA) and Zanmi Lasante (Port–au-Prince, Haiti).

Funding source

This work was supported by the Massachusetts Medical Society Resident Research Grant.

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The South African Triage Scale (SATS) is the most comprehensive, well-validated, and reliable tool used widely in LMICs [51]. It is used in most African countries and some other developing countries such as Pakistan, Afghanistan, Haiti, and Sierra Leone [52–54]. However, SATS was mostly validated in urban referral centers and tertiary hospitals, which resemble high-income countries' hospitals; therefore, it is challenging to assume its validity in rural low-resource settings where it is most needed (51).
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Under-triaging of patients has been noted in other studies including non-trauma patients [17] and nurses who were less experienced with the tool [11]. Other contributing factors to triage errors include inaccurate measurement and recording of patient acuity [15], resource constraints and less skilled staff [25] and differences in patient populations or admission practices [18]. In this study, patients were most frequently under- and over-triaged due to incorrect discriminator selection.
Triage is applied in emergency centres (ECs) to assign degrees of urgency to illnesses or injuries to decide in which order to treat patients, especially when there are many patients or casualties, facilitating the allocation of scarce medical resources. A triage nurse determines triage priority by assessing patients using an established triage tool with specific criteria. The South African Triage Scale is widely used in South African ECs. Although the South African Triage Scale has been adopted and implemented in both private and public healthcare ECs in South Africa, few studies have assessed the accuracy of nurse-led triage in private ECs.
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View full text

Evaluation of the implementation of the South African Triage System at an academic hospital in central Haiti

Highlights

Abstract

Background

Methods

Results

Conclusion

Section snippets

Background

Study design

Study setting

Results

Discussion

Conclusion

Conflict of interest

Ethical statement

Funding source

Ann Emergency Med

Lancet

J Emergency Nursing: JEN: Off Publ Emergency Depart Nurses Assoc

Int Emergency Nurs

Afr J Emergency Med

Afr J Emergency Med

J Biomed Inform

The cape triage score: a new triage system South Africa. Proposal from the cape triage group

Emergency Med J

The cape Triage score – a triage system for South Africa

S Afr Med J

Development and technical basis of simplified guidelines for emergency triage assessment and treatment in developing countries. WHO Integrated Management of Childhood Illness (IMCI) Referral Care Project

Arch Disease Childhood

Critical care in low-income countries

Trop Med Int Health

The reliability of the Manchester Triage System (MTS): a meta-analysis

J Evidence Based Med

Reliability and validity of a new five-level Triage instrument

Acad Emergency Med

A prospective evaluation of the Cape triage score in the emergency department of an urban public hospital in South Africa

Emergency Med J