Validity and reliability of the South African Triage Scale in prehospital providers

Risks of Early Mortality and Associated Factors at Adult Emergency Department of Jimma University Medical Center

Introduction

Mortality in the emergency department is still high in developing countries with resources scarce. Most of emergency department mortality occurred within the first three days; the majority of these deaths are avoidable with proper intervention. Therefore, the purpose of this study was to assess the mortality risks and therapeutic benefits of early and late death.

Methods

Case-control study approach with 87 cases and 174 controls (case to control ratio of 1:2) was used on 261 study participants. Data were extracted from the patient charts using a pretested extraction tool. Then, checked data were entered into Epi-data manager 4.6 versions and analyzed using SPSS 25 versions. Binary logistic regression was used to construct bivariate and multivariable analyses following the descriptive analysis. Finally, a predictor variable in the multivariate logistic regression was deemed to have a significant association if its P-value was less than 0.05 at a 95% confidence level.

Results

Patients who were triaged into the red zone had a 2.3-fold greater risk of dying early than those who were placed in another triage category [(AOR=2.3; 95% CI: 1.10, 5.55) P=0.001]. Besides, having cardiovascular disease (AOR=4.79; 95% CI: 1.73, 13.27), age ≥65 years [(AOR=3.2; 95% CI: 1.74, 7.23) P=0.003)], having rural residency (AOR=6.57; 95% CI: 1.39, 31.13), and having been diagnosed with respiratory failure [(AOR=3.2; 95% CI: 1.04, 7.69), P=0.013)] were associated with early mortality.

Conclusion

The common causes of early mortality were respiratory failure, cardiovascular disease, and road traffic accident. Being aged, having rural residence, being triaged into red zone, and diagnosed for respiratory failure and cardiac failure increase early mortality compared with late death.

Changes in trauma-related emergency medical services during the COVID-19 lockdown in the Western Cape, South Africa

BACKGROUND

To limit virus spread during the COVID pandemic, extensive measures were implemented around the world. In South Africa, these restrictions included alcohol and movement restrictions, factors previously linked to injury burden in the country. Consequently, reports from many countries, including South Africa, have shown a reduction in trauma presentations related to these restrictions. However, only few studies and none from Africa focus on the impact of the pandemic restrictions on the Emergency Medical System (EMS).

METHODS

We present a retrospective, observational longitudinal study including data from all ambulance transports of physical trauma cases collected during the period 2019-01-01 and 2021-02-28 from the Western Cape Government EMS in the Western Cape Province, South Africa (87,167 cases). Within this timeframe, the 35-days strictest lockdown level period was compared to a 35-days period prior to the lockdown and to the same 35-days period in 2019. Injury characteristics (intent, mechanism, and severity) and time were studied in detail. Ambulance transport volumes as well as ambulance response and on-scene time before and during the pandemic were compared. Significance between indicated periods was determined using Chi-square test.

RESULTS

During the strictest lockdown period, presentations of trauma cases declined by > 50%. Ambulance transport volumes decreased for all injury mechanisms and proportions changed. The share of assaults and traffic injuries decreased by 6% and 8%, respectively, while accidental injuries increased by 5%. The proportion of self-inflicted injuries increased by 5%. Studies of injury time showed an increased share of injuries during day shift and a reduction of total injury volume during the weekend during the lockdown. Median response- and on-scene time remained stable in the time-periods studied.

CONCLUSION

This is one of the first reports on the influence of COVID-19 related restrictions on EMS, and the first in South Africa. We report a decline in trauma related ambulance transport volumes in the Western Cape Province as well as changes in injury patterns, largely corresponding to previous findings from hospital settings in South Africa. The unchanged response and on-scene times indicate a well-functioning EMS despite pandemic challenges. More studies are needed, especially disaggregating the different restrictions.

Reliability and validity of Chengdu pediatric emergency triage criteria: case study of a single center in China

BACKGROUND

We aimed to examine the reliability and validity of Chengdu pediatric emergency triage criteria in order to provide a reference for the development of pediatric emergency triage within other hospitals.

METHODS

We developed Chengdu pediatric emergency triage criteria based on the conditions/symptom, vital signs, and the Pediatric Early Warning Score system within our hospital using the Delphi method in 2020. The simulation scenario triage and real-life triage which were conducted in our hospital during January - March 2021, and the retrospective study of triage records extracted from our hospital's health information system in February 2022, were used to measure the agreement in triage decisions between the triage nurses, and between the triage nurses and the expert team.

RESULTS

For the 20 simulation cases, the Kappa value of triage decisions between the triage nurses was 0.6 (95% CI 0.352-0.849), and the Kappa value of triage decisions between the triage nurses and the expert team was 0.73 (95% CI 0.540-0.911). For the 252 cases in the real-life triage, the Kappa value of triage decisions between the triage nurses and the expert team was 0.824 (95% CI 0.680-0.962). For the 20,540 cases selected for the retrospective study of triage records, the Kappa value of triage decisions between the triage nurses was 0.702 (95% CI 0.691-0.713); that between Triage Nurse 1 and the expert team was 0.634 (95% CI 0.623-0.647); and that between Triage Nurse 2 and the expert team was 0.725 (95% CI 0.713-0.736). The overall agreement rate in triage decisions between the triage nurses and the expert team in the simulation scenario triage was 80%; that between the triage nurses and the expert team in the real-life triage was 97.6%; and that between the triage nurses in the retrospective study was 91.9%. In the retrospective study, the agreement rates in triage decisions between Triage Nurse 1 and the expert team, and between Triage Nurse 2 and the expert team, were 88.0% and 92.3%, respectively.

CONCLUSION

Chengdu pediatric emergency triage criteria that developed within our hospital is reliable and valid, and can promote rapid and effective triage by triage nurses.

Comparison of the novel WEst coast System for Triage (WEST) with Rapid Emergency Triage and Treatment System (RETTS©): an observational pilot study

Background

Most Swedish emergency departments (ED) use the triage system Rapid Emergency Triage and Treatment System (RETTS©), which over time has proven to prioritize patients to higher triage levels. When many patients are prioritized to high triage levels, challenges with identifying true high-risk patients and increased waiting time for these patients has emerged. In order to achieve a more balanced triage in relation to actual medical risk, the triage system WEst coast System for Triage (WEST) was developed, based on the South African Triage Scale (SATS). The aim of this study was to perform an initial evaluation of the novel emergency triage system WEST compared to the existing RETTS©.

Methods

Both RETTS© and WEST are five level triage systems illustrated by colors. Nurses from each of the three adult EDs of Sahlgrenska University Hospital in Gothenburg and the ambulance service assessed and triaged 1510 patients according to RETTS© and immediately thereafter filled out the WEST triage form. Data from each triage report were analyzed and grouped according to the triage color, chief complaint, and outcome of each patient. Data on discharge categories and events within 72 h were also collected. Data were analyzed with descriptive statistical methods.

Results

In general, WEST displayed lower levels of prioritization compared to RETTS©, with no observed impact on patients’ medical outcomes. In RETTS© orange triage level, approximately 50% of the patients were down prioritized in WEST to yellow or green triage levels. Also, in the RETTS© yellow triage level, more than 55% were down prioritized to green triage level in WEST. The number of patients who experienced a serious event during the first 72 h was few. Three patients died, these were all prioritized to red triage level in RETTS©. In WEST two of these patients were prioritized to red triage level and one to orange triage level. All these patients were admitted to hospital before deterioration.

Conclusions

WEST may reduce over prioritization at the ED, especially in the orange and yellow triage levels of RETTS©, with no observed increase in medical risk. WEST can be recommended for a clinical comparative study.

Implementation of the South African Triage Scale (SATS) in a New Ambulance System in Beira, Mozambique: A Retrospective Observational Study

In 2019, an urban ambulance system was deployed in the city of Beira, Mozambique to refer patients from peripheral health centres (HCs) to the only hospital of the city (Beira Central Hospital-HCB). Initially, the system worked following a first-in-first-out approach, thus leading to referrals not based on severity condition. With the aim of improving the process, the South African Triage Scale (SATS) has been subsequently introduced in three HCs. In this study, we assessed the impact of SATS implementation on the selection process and the accuracy of triage performed by nurses. We assessed 552 and 1608 referral charts from before and after SATS implementation, respectively, and we retrospectively calculated codes. We compared the expected referred patients' codes from the two phases, and nurse-assigned codes to the expected ones. The proportion of referred orange and red codes significantly increased (+12.2% and +12.9%) while the proportion of green and yellow codes decreased (-18.7% and -5.8%). The overall rates of accuracy, and under- and overtriage were 34.2%, 36.3%, and 29.5%, respectively. The implementation of SATS modified the pattern of referred patients and increased the number of severe cases receiving advanced medical care at HCB. While nurses' accuracy improved with the routine use of the protocol, the observed rates of incorrect triage suggest that further research is needed to identify factors affecting SATS application in this setting.

Quality emergency care (QEC) in resource limited settings: A concept analysis

INTRODUCTION

Providing appropriate high-quality emergency care (QEC) commensurate with patients' needs is critical for continuity of care, patient safety, optimal clinical outcomes, reduced mortality, and patient satisfaction. This concept analysis aims to define and assist in understanding the concept of QEC in resource-limited settings.

METHODS

Quality emergency care concept analysis was conducted using Walker and Avant's approach. Several literature review methods and dictionaries were used to explore the QEC concept.

RESULTS

Immediate assessment, rapid diagnosis, and critical interventions are the attributes of QEC for life-threatening and time-sensitive conditions, leading to timely and safe care provision.

DISCUSSION

Nurses serve as the backbone for most emergency care centers such as primary care, emergency department, and even prehospital care. The first few hours following a potential life- or limb-threatening condition are vital. The emergency care rendered to patients can significantly affect treatment's overall outcome; therefore, quality emergency care is critical.

CONCLUSION

Prehospital triage tools across the world: a scoping review of the published literature

Background

Accurate triage of the undifferentiated patient is a critical task in prehospital emergency care. However, there is a paucity of literature synthesizing currently available prehospital triage tools. This scoping review aims to identify published tools used for prehospital triage globally and describe their performance characteristics.

Methods

A comprehensive search was performed of primary literature in English-language journals from 2009 to 2019. Papers included focused on emergency medical services (EMS) triage of single patients. Two blinded reviewers and a third adjudicator performed independent title and abstract screening and subsequent full-text reviews.

Results

Of 1521 unique articles, 55 (3.6%) were included in the final synthesis. The majority of prehospital triage tools focused on stroke (n = 19; 35%), trauma (19; 35%), and general undifferentiated patients (15; 27%). All studies were performed in high income countries, with the majority in North America (23, 42%) and Europe (22, 40%). 4 (7%) articles focused on the pediatric population. General triage tools aggregate prehospital vital signs, mental status assessments, history, exam, and anticipated resource need, to categorize patients by level of acuity. Studies assessed the tools’ ability to accurately predict emergency department triage assignment, hospitalization and short-term mortality. Stroke triage tools promote rapid identification of patients with acute large vessel occlusion ischemic stroke to trigger timely transport to diagnostically- and therapeutically-capable hospitals. Studies evaluated tools’ diagnostic performance, impact on tissue plasminogen activator administration rates, and correlation with in-hospital stroke scales. Trauma triage tools identify patients that require immediate transport to trauma centers with emergency surgery capability. Studies evaluated tools’ prediction of trauma center need, under-triage and over-triage rates for major trauma, and survival to discharge.

Conclusions

The published literature on prehospital triage tools predominantly derive from high-income health systems and mostly focus on adult stroke and trauma populations. Most studies sought to further simplify existing triage tools without sacrificing triage accuracy, or assessed the predictive capability of the triage tool. There was no clear ‘gold-standard’ singular prehospital triage tool for acute undifferentiated patients.

Trial registration

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-022-01019-z.

Using the South African Triage Scale for prehospital triage: a qualitative study

Background

Triage is a critical component of prehospital emergency care. Effective triage of patients allows them to receive appropriate care and to judiciously use personnel and hospital resources. In many low-resource settings prehospital triage serves an additional role of determining the level of destination facility. In South Africa, the Western Cape Government innovatively implemented the South African Triage Scale (SATS) in the public Emergency Medical Services (EMS) service in 2012. The prehospital provider perspectives and experiences of using SATS in the field have not been previously studied.

Methods

In this qualitative study, focus group discussions with cohorts of basic, intermediate and advanced life support prehospital providers were conducted and transcribed. A content analysis using an inductive approach was used to code transcripts and identify themes.

Results

15 EMS providers participated in three focus group discussions. Data saturation was reached and four major themes emerged from the qualitative analysis: Implementation and use of SATS; Effectiveness of SATS; Limitations of the discriminator; and Special EMS considerations. Participants overall felt that SATS was easy to use and allowed improved communication with hospital providers during patient handover. Participants, however, described many clinical cases when their clinical gestalt triaged the patient to a different clinical acuity than generated by SATS. Additionally, they stated many clinical discriminators were too subjective to effectively apply or covered too broad a range of clinical severity (e.g., ingestions). Participants provided examples of how the prehospital environment presents additional challenges to using SATS such as changing patient clinical conditions, transport times and social needs of patients.

Conclusions

Overall, participants felt that SATS was an effective tool in prehospital emergency care. However, they described many clinical scenarios where SATS was in conflict with their own assessment, the clinical care needs of the patient or the available prehospital and hospital resources. Many of the identified challenges to using SATS in the prehospital environment could be improved with small changes to SATS and provider re-training.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00522-3.