Written by: Dr. Jay Pandya, Dr. Emily Chien, and Dr. Nidhi Kadakia

Edited by: Dr. Wesley Chan 

On Monday 12/14/20, the International Emergency Medicine Mini-Fellowship gathered to discuss triage systems in resource-limited settings, namely two triage scores, the Cape Triage Score (CTS) and South African Triage Score (SATS) score in South Africa and Kenya, respectively. 

Background 

The concept of triage systems was originally developed in France in the 1800s in preparation for times of warfare to help sort patients who required surgical life-saving interventions.[1] Over the centuries, as medical systems developed, triage systems became an integral part of emergency departments and prehospital care. These systems are heterogeneous and differ widely in structure based on the local acute care needs and availability of resources. The purpose of triage criteria is to stratify patients into the following risk categories: immediate loss of life, urgent need, and routine/non-urgent care. 

The most commonly used triage systems worldwide are the Canadian Triage Assessment Scale, Australian Triage Score, Manchester Triage System, and Emergency Severity Index (ESI).[1] While these systems are designed and validated for use in high-income settings, there are some clear distinctions between them. For example, the ESI is the one that’s predominantly used in the United States, triages by acuity and expected resource allocation, rather than expected time to safely wait to be seen (Figure 1). In recent years, triage tools have become available for use in low-resource settings as well, including the Cape Triage Score (CTS), South African Triage Score (SATS), and the WHO Tool. We will briefly summarize some of the triage tools available for use in low-resource countries before we delve into the paper by Wangara et al. 

Figure 1: Emergency Severity Index [2]

Overview of the Triage Systems

WHO Interagency Integrated Triage Tool 

The Interagency Integrated Triage Tool is a novel triage tool developed in collaboration amongst WHO, International Committee of the Red Cross (ICRC), and Medecins Sans Frontieres to provide an integrated set of protocols for routine triage of adults and children (Figures 2 and 3). The tool was released in 2019 and focuses on a three-tier triage system focusing triage to High Acuity Resuscitation Area, Clinical Treatment Area and Low Acuity or Waiting Room based on red, yellow, and green criteria.[3] It can be utilized for facility-based triage, facility-based mass casualty triage, and pre-hospital triage (Figure 4). 

Figure 2: WHO Interagency Integrated Triage Tool [4]

Figure 3: WHO Interagency Integrated Triage Tool [4]

Figure 4: WHO Interagency Integrated Triage Tool [4]

Cape Triage Score (CTS) and South Africian Triage Scale (SATS)

The SATS has been validated in several studies in low-resource settings and is the most extensively studied triage scale across Low and Middle-Income Countries (LMICs) across the African and Asia Continent.[5–9] 

In South Africa, the large disease burden in addition to a high trauma volume (majority motor-vehicle collisions) makes the application of commonly used triage systems difficult to apply.[10] The previous pre-existing triage systems lacked sensitivity and specificity and were often open to interpretation, resulting in variations in triage scores.[11,12] The Cape Triage Group (CTG) initially convened in 2006 and formulated a new system, first adopting the Medical Early Warning Score (MEWS). After several revisions with added mobility parameters and trauma parameters (mechanism of injury, initial presentation, etc), the CTS/SATS was developed (Figure 5).

Figure 5: South African Triage Scale  [13]

Journal Club Discussion

The article we focused on, “Implementation and performance of the South African Triage Scale at Kenyatta National Hospital in Nairobi, Kenya” by Wangara et al, discussed the implementation and validation of the SATS at Kenyatta National Hospital (KNH) in Kenya, the largest public tertiary hospital in East Africa.[6] Prior to this implementation, KNH had no standardized triage protocols in place in their ED. 

Objectives

1) Assess the reliability of triage decisions amongst emergency healthcare workers following SATS training educational intervention

2) Analyze the validity of SATS in KNH, as a local representative of East Africa

Methods/Results

The implementation of the SATS at KNH was done in two parts. The first was a prospective trial done to assess the triage reliability of the SATS amongst healthcare workers who were trained with educational instructions on the application of the SATS. Participants completed a 2-day training course on the SATS and a post-training test. The answers were compared to those of “experts” and the results were used to measure intra- and inter-rater reliability of the triage decisions. The second part was a retrospective chart review done to assess the accuracy of the SATS in predicting patient dispositions. Chart review was done analyzing how many patients were under- and over-triage prior to SATS compared with post-SATS. 

In terms of reliability, there was a 64% exact agreement with expert rating and 97% agreement with expert within one triage category. Inter-class coefficient (ICC) was 0.66 (95% CI 0.54-0.79) which demonstrated “good” agreement.[6] In terms of validity, the authors found that a smaller proportion of patients were triaged as emergent post-SATS than pre-SATS, and a larger proportion of patients were admitted or died than pre-SATS. SATS demonstrated an undertriage rate of 7.8% and overtriage rate of 62.3%.[6] 

Group Discussion 

Though this study is the first of its kind to implement SATS in Kenya- there are some limitations that suggest that further studies may be warranted prior to validating the use of SATs in Kenya and East Africa. The study was limited for a variety of reasons. In part 1 of the study, the study focused on paper-based triage vignettes (created retrospectively from patient charts) which may not be validated on live patients. There may be an opportunity for a further study where the triage standards of health care workers and experts are compared for live patients in situ. Furthermore, it did not take into account that triage is a fluid concept, and patients can transition to higher. 

The data represents a significant decrease in the number of patients triaged as needed to be seen emergently. In LMIC hospitals, where resources are limited, this improvement in appropriate triaging allows providers to spend more time seeing patients that are emergently ill rather than having to allot that time to a patient that could safely wait longer. During the journal club, the discussion focused on the finding that in the SATS implementation study by Wangara et al, more patients were triaged to Red/Emergent areas after taking the SATS training. This observation suggests a previous tendency by the KNH medical personnel to undertriage high-acuity patients.

We also discussed limitations in the author’s definition of overtriage/undertriage. The authors used a definition and calculations that have previously been published and discussed by Lenz et al. [14] This definition associate the triage designation with the disposition of the patients. The authors conclude that “disposition profile of triaged emergent patients appears to be improved with SATS, as proportionally more were admitted and less were discharged. However, we know from our clinical experience that there are a few clinical presentations of patients who qualify for emergent triage such as anaphylaxis or active seizures who do not necessarily require admission.

Lastly, though the undertriage and overtriage rates were found to be acceptable by the study’s authors, they were noted to fall outside the acceptable rates stated per the American College of Surgeons- Committee of Trauma (ACOS) guidelines. It is difficult to know whether the ACOS guidelines are appropriate to be used as a cut off given the differences in hospital systems and available resources. The authors concluded that SATS is a “contextually appropriate triage system” for a major emergency department in East Africa. 

Take Away Points

• 1. There is no one-size-fits-all for triage systems.
• 2. Location-specific factors affect triaging such staff training, resources, and hospital/medical resources.
• 3. Location-specific factors must be considered for appropriate and effective triage tool development.  

References:

1. 1. Robertson-Steel I. Evolution of triage systems. Emerg Med J. 2006;23(2):154-155. doi:10.1136/emj.2005.030270
2. 2. Gilboy N., Tanabe P., Travers D., Rosenau, A. ESI EMERGENCY SEVERITY INDEX: A Triage Tool for Emergency Department Care. Vol. 4. 2019.  Available at: https://www.ena.org/docs/default-source/education-document-library/esi-implementation-handbook-2020.pdf?sfvrsn=fdc327df_2. Accessed January 28, 2020.
3. 3. World Health Organization. Clinical care for severe acute respiratory infection: toolkit: COVID-19 adaptation. 2020. Available at: https://apps.who.int/iris/bitstream/handle/10665/331446/WHO-2019-nCoV-clinical-2020.4-eng.pdf. Accessed January 28, 2020.
4. 4. World Health Organization. Clinical care for severe acute respiratory infection: toolkit: COVID-19 adaptation. 2020. Available at: https://apps.who.int/iris/bitstream/handle/10665/331446/WHO-2019-nCoV-clinical-2020.4-eng.pdf. Accessed January 28, 2020.
5. 5. Fries GR, McCalla G, Levitt MA, Cordova R. A prospective comparison of paramedic judgment and the trauma triage rule in the prehospital setting. Ann Emerg Med. 1994;24(5):885-889. doi:10.1016/s0196-0644(94)70207-1
6. 6. Wangara AA, Hunold KM, Leeper S, et al. Implementation and performance of the South African Triage Scale at Kenyatta National Hospital in Nairobi, Kenya. Int J Emerg Med. 2019;12(1):5. Published 2019 Feb 11. doi:10.1186/s12245-019-0221-3
7. 7. Bruijns SR, Wallis LA, Burch VC. A prospective evaluation of the Cape triage score in the emergency department of an urban public hospital in South Africa. Emerg Med J. 2008;25(7):398-402. doi:10.1136/emj.2007.051177
8. 8. Rominski S, Bell SA, Oduro G, Ampong P, Oteng R, Donkor P. The implementation of the South African Triage Score (SATS) in an urban teaching hospital, Ghana. Afr J Emerg Med. 2014;4(2):71-75. doi:10.1016/j.afjem.2013.11.001
9. 9. Twomey M, de Sá A, Wallis LA, Myers JE. Inter-rater reliability of the South African Triage Scale: assessing two different cadres of health care workers in a real time environment. Afr J Emerg Med. 2011;1(3):113–8..
10. 10. Paniker J, Graham SM, Harrison JW. Global trauma: the great divide. SICOT J. 2015;1:19. Published 2015 Jul 21. doi:10.1051/sicotj/2015019
11. 11. Gottschalk SB, Wood D, DeVries S, Wallis LA, Bruijns S; Cape Triage Group. The Cape Triage Score: a new triage system South Africa. Proposal from the Cape Triage Group. Emerg Med J. 2006;23(2):149-153. doi:10.1136/emj.2005.028332
12. 12. Wuerz R, Fernandes CM, Alarcon J. Inconsistency of emergency department triage. Emergency Department Operations Research Working Group. Ann Emerg Med. 1998;32(4):431-435. doi:10.1016/s0196-0644(98)70171-4
13. 13. Brevik H., Eide M., Engan M., Aalvik R. SATS-N. Standardized Emergency Medicine Assessment and Prioritisation (Triage) Tool. User Manual 3.02. 2020.
14. 14. Lentz BA, Jenson A, Hinson JS, et al. Validity of ED: Addressing heterogeneous definitions of over-triage and under-triage. Am J Emerg Med. 2017;35(7):1023-1025. doi:10.1016/j.ajem.2017.02.012

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Wesley Chan

EM/IM Resident Class of 2024

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