Implementation and performance of the South African Triage Scale at Kenyatta National Hospital in Nairobi, Kenya

Ali A Wangara; Katherine M Hunold; Sarah Leeper; Frederick Ndiawo; Judith Mweu; Shaun Harty; Rachael Fuchs; Ian B K Martin; Karen Ekernas; Stephen J Dunlop; Michèle Twomey; Alice W Maingi; Justin Guy Myers

doi:10.1186/s12245-019-0221-3

Implementation and performance of the South African Triage Scale at Kenyatta National Hospital in Nairobi, Kenya

Int J Emerg Med. 2019 Feb 11;12(1):5. doi: 10.1186/s12245-019-0221-3.

Authors

Affiliations

¹ Accident and Emergency Department, Kenyatta National Hospital, PO Box 3956-00200, Nairobi, Kenya.
² Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA.
³ Department of Emergency Medicine, University of Maryland Prince George's Hospital Center, Maryland, MD, USA.
⁴ Critical Care Unit, Kenyatta National Hospital, Nairobi, Kenya.
⁵ Department of Emergency Medicine, The University of Cincinnati, Cincinnati, OH, USA.
⁶ Department of Biostatistics, FHI 360 & UNC Gillings School of Global Public Health, Chapel Hill, NC, USA.
⁷ Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
⁸ Department of Emergency Medicine, St. Joseph Hospital, Denver, CO, USA.
⁹ Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA.
¹⁰ University Hospital, Bern, Switzerland.
¹¹ Department of Emergency Medicine, University of North Carolina at Chapel Hill School of Medicine, 170 Manning Drive, CB 7594, Chapel Hill, NC, 27599, USA. justin_myers@med.unc.edu.

Abstract

Introduction: Triage protocols standardize and improve patient care in accident and emergency departments (A&Es). Kenyatta National Hospital (KNH), the largest public tertiary hospital in East Africa, is resource-limited and was without A&E-specific triage protocols.

Objectives: We sought to standardize patient triage through implementation of the South African Triage Scale (SATS). We aimed to (1) assess the reliability of triage decisions among A&E healthcare workers following an educational intervention and (2) analyze the validity of the SATS in KNH's A&E.

Methods: Part 1 was a prospective, before and after trial utilizing an educational intervention and assessing triage reliability using previously validated vignettes administered to 166 healthcare workers. Part 2 was a triage chart review wherein we assessed the validity of the SATS in predicting patient disposition outcomes by inclusion of 2420 charts through retrospective, systematic sampling.

Results: Healthcare workers agreed with an expert defined triage standard for 64% of triage scenarios following an educational intervention, and had a 97% agreement allowing for a one-level discrepancy in the SATS score. There was "good" inter-rater agreement based on an intraclass correlation coefficient and quadratic weighted kappa. We analyzed 1209 pre-SATS and 1211 post-SATS patient charts and found a non-significant difference in undertriage and statistically significant decrease in overtriage rates between the pre- and post-SATS cohorts (undertriage 3.8 and 7.8%, respectively, p = 0.2; overtriage 70.9 and 62.3%, respectively, p < 0.05). The SATS had a sensitivity of 92.2% and specificity of 37.7% for predicting admission, death, or discharge in the A&E.

Conclusion: Healthcare worker triage decisions using the SATS were more consistent with expert opinion following an educational intervention. The SATS also performed well in predicting outcomes with high sensitivity and satisfactory levels of both undertriage and overtriage, confirming the SATS as a contextually appropriate triage system at a major East African A&E.

Keywords: Accident and emergency medicine; East Africa; Triage.

Grants and funding

N/A/Kenyatta National Hospital Office of Research