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

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.

SUBMITTER: Wangara AA

PROVIDER: S-EPMC6371470 | biostudies-other | 2019 Feb

REPOSITORIES: biostudies-other

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

Wangara Ali A AA Hunold Katherine M KM Leeper Sarah S Ndiawo Frederick F Mweu Judith J Harty Shaun S Fuchs Rachael R Martin Ian B K IBK Ekernas Karen K Dunlop Stephen J SJ Twomey Michèle M Maingi Alice W AW Myers Justin Guy JG

International journal of emergency medicine 20190211 1

<h4>Introduction</h4>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.<h4>Objectives</h4>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 e ...[more]

PMID: 31179944

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Project description:BackgroundTriage 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.MethodsIn 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.Results15 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.ConclusionsOverall, 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.

Project description:BackgroundThe South African Triage Scale (SATS) is a validated in-hospital triage tool that has been innovatively adopted for use in the prehospital setting by Western Cape Government (WCG) Emergency Medical Services (EMS) in South Africa. The performance of SATS by EMS providers has not been formally assessed. The study sought to assess the validity and reliability of SATS when used by WCG EMS prehospital providers for single-patient triage.MethodsThis is a prospective, assessment-based validation study among WCG EMS providers from March to September 2017 in Cape Town, South Africa. Participants completed an assessment containing 50 clinical vignettes by calculating the three components - triage early warning score (TEWS), discriminators (pre-defined clinical conditions), and a final SATS triage color. Responses were scored against gold standard answers. Validity was assessed by calculating over- and under-triage rates compared to gold standard. Inter-rater reliability was assessed by calculating agreement among EMS providers' responses.ResultsA total of 102 EMS providers completed the assessment. The final SATS triage color was accurately determined in 56.5%, under-triaged in 29.5%, and over-triaged in 13.1% of vignette responses. TEWS was calculated correctly in 42.6% of vignettes, under-calculated in 45.0% and over-calculated in 10.9%. Discriminators were correctly identified in only 58.8% of vignettes. There was substantial inter-rater and gold standard agreement for both the TEWS component and final SATS color, but there was lower inter-rater agreement for clinical discriminators.ConclusionThis is the first assessment of SATS as used by EMS providers for prehospital triage. We found that SATS generally under-performed as a triage tool, mainly due to the clinical discriminators. We found good inter-rater reliability, but poor validity. The under-triage rate of 30% was higher than previous reports from the in-hospital setting. The over-triage rate of 13% was acceptable. Further clinically-based and qualitative studies are needed.Trial registrationNot applicable.

Project description:BackgroundNon-malarial febrile illnesses comprise of almost half of all fever presenting morbidities, among under-five children in sub-Saharan Africa. Studies have reported cases of prescription of antimalarial medications to these febrile under-fives who were negative for malaria. The treatment of these children with antimalarial medications increases incidences of antimalarial drug resistance as well as further morbidities and mortalities, due to failure to treat the actual underlying causes of fever.AimTo identify clinical and demographic factors associated with treatment type (malarial/non-malarial) of non-malarial febrile illnesses (NMFI) in children aged ≤5 at the Kenyatta National Hospital in Nairobi, Kenya.MethodsA positivist epistemological approach, cross sectional descriptive study design was used. A structured questionnaire was used on a sample of 341 medical records of children aged ≤5 years to extract data on clinical examinations (recorded as yes or no), diagnostic test results, and demographic data on the child's sex and age. Descriptive and inferential analysis was applied to the data.ResultsPrescription of antimalarial drugs despite negative microscopy results was found in 44 (12.9%) of the children, with mortality reported in 48 (14.1%). Assessment of respiratory distress was 0.13 (0.03,0.58) times associated with less likelihood of prescribing an antimalarial in those with a negative microscopy. A male patient was 0.21 (0.05,0.89) times less likely to receive an intravenous antimalarial after a negative microscopy. Patients aged ˂1 with a negative microscopy result were more likely to receive an antimalarial than older children.ConclusionThere is a need to eliminate incorrect treatment of NMFI with antimalarial medication, while ensuring correct diagnosis and treatment of the specific illness occurs. This requires strengthening and adherence to diagnostic and treatment guidelines of febrile illnesses in under-fives, consequently reducing morbidities and mortalities associated with inadequate management of NMFIs.

Project description:BackgroundThe South African Triage Scale (SATS) was developed to facilitate patient triage in emergency departments (EDs) and is used by Médecins Sans Frontières (MSF) in low-resource environments. The aim was to determine if SATS data, reason for admission, and patient age can be used to develop and validate a model predicting the in-hospital risk of death in emergency surgical centers and to compare the model's discriminative power with that of the four SATS categories alone.MethodsWe used data from a cohort hospitalized at the Nap Kenbe Surgical Hospital in Haiti from January 2013 to June 2015. We based our analysis on a multivariate logistic regression of the probability of death. Age cutoff, reason for admission categorized into nine groups according to MSF classifications, and SATS triage category (red, orange, yellow, and green) were used as candidate parameters for the analysis of factors associated with mortality. Stepwise backward elimination was performed for the selection of risk factors with retention of predictors with P < 0.05, and bootstrapping was used for internal validation. The likelihood ratio test was used to compare the combined and restricted models. These models were also applied to data from a cohort of patients from the Kunduz Trauma Center, Afghanistan, to validate mortality prediction in an external trauma patients population.ResultsA total of 7618 consecutive hospitalized patients from the Nap Kenbe Hospital were analyzed. Variables independently associated with in-hospital mortality were age > 45 and < = 65 years (odds ratio, 2.04), age > 65 years (odds ratio, 5.15) and the red (odds ratio, 65.08), orange (odds ratio, 3.5), and non-trauma (odds ratio, 3.15) categories. The combined model had an area under the receiver operating characteristic curve (AUROC) of 0.8723 and an AUROC corrected for optimism of 0.8601. The AUROC of the model run on the external data-set was 0.8340. The likelihood ratio test was highly significant in favor of the combined model for both the original and external data-sets.ConclusionsSATS category, patient age, and reason for admission can be used to predict in-hospital mortality. This predictive model had good discriminative ability to identify ED patients at a high risk of death and performed better than the SATS alone.

Project description:BackgroundSpecies data from the Museum collections have been shown to be of great value as a tool for prioritising conservation actions in Africa (Fjeldsa and Tushabe 2005). The National Museums of Kenya (NMK) have an entomology collection, housed in 4,000 drawers in cabinets that contain over 1.5 million specimens, including the largest butterfly collection in Africa (Arnett et al. 1997). Lampe and Striebing (2005) demonstrated how to digitise large insect collections in order to make their associated label data into databases that can be used for functions, such as creating distribution maps. The NMK's swallowtail butterflies' collection had not been digitised and thus there was a need to capture the label data to create a database that can be used for mapping the distribution of the species in Kenya and elsewhere. These data have addressed one of the most significant challenges to insect conservation i.e. the lack of baseline information concerning species diversity and distribution (Summerville and Crist 2003). These data have provided key historic papilionid species diversity and distribution data that can be used to monitor their populations, as butterflies are declining due to changes in land use, intensive agriculture and pestcide use, diseases and pest and climate change (Potts et al. 2016; Bongaarts 2019). The publication of the occurrence data records in GBIF has been undertaken, thus making the data available to a wider audience and promoting availability for use.New informationThe swallowtail butterflies collection at the National Museums of Kenya was digitised from 2017-2019 and this paper presents details of the Papilionid collection at the Zoology Department, NMK, Nairobi, Kenya.The collection holds 7,345 voucher specimens, consisting of three genera and 133 species. The collection covers the period between 1850 to 2019.The distribution of the swallowtail butterflies, housed at the NMK, covers East Africa with 88%, Central Africa (6%), Western Africa (4%) and Southern Africa (2%).

Project description:BackgroundScaling up the antiretroviral (ART) program in Kenya has involved a strategy of using clinical guidelines coupled with decentralization of treatment sites. However decentralization pushes clinical responsibility downwards to health facilities run by lower cadre staff. Whether the organizational culture in health facilities affects the outcomes despite the use of clinical guidelines has not been explored. This study aimed to demonstrate the relationship between organizational culture and early mortality and those lost to follow up (LTFU) among patients enrolled for HIV care.Methods and materialsA stratified sample of 31 health facilities in Nairobi County offering ART services were surveyed. Data of patients enrolled on ART and LTFU for the 12 months ending 30th June 2013 were abstracted. Mortality and LTFU were determined and used to rank health facilities. In the facilities with the lowest and highest mortality and LTFU key informant interviews were conducted using a tool adapted from team climate assessment measurement questionnaire and competing value framework tool to assess organizational culture. The strength of association between early mortality, LTFU and organizational culture was tested.ResultsHalf (51.8%) of the 5,808 patients enrolled into care in 31 health facilities over the 12-month study period were started on ART. Of these 48 (1.6% 95% CI 0.8%-2.4%) died within three months of starting treatment, while a further 125 (4.2% 95% CI 2.1%-6.6%) were LTFU giving an attrition rate of 5.7% (95% CI 3.3%-8.6%). Tuberculosis was the most common comorbidity associated with high early mortality and high LTFU. Organizational culture, specifically an adhocratic type was found to be associated with low early mortality and low LTFU of patients enrolled for HIV care (P = 0.034).ConclusionThe use of ART clinical guidelines in a decentralized health systems are not sufficient to achieve required service delivery outcomes. The attrition rate above would mean 85,000 Kenyans missing care based on current HIV disease burden figures. Deliberate efforts to improve individual health facility leadership and inculcate an adhocratic culture may lower mortality and morbidity associated with initiating ART.

Project description:BackgroundDespite its continued use in many low-volume emergency departments (EDs), 3-level triage systems have not been extensively studied, especially on live triage cases. We have modified from the Australasian Triage Scale and developed a 3-level triage scale, and sought to evaluate its validity, reliability, and over- and under-triage rates in real patient encounters in our setting.MethodThis was a cross-sectional study in a single ED with 24,000 attendances per year. At triage, each patient was simultaneously assessed by a triage nurse, an adjudicator (the "criterion standard"), and a study nurse independently. Predictive validity was determined by comparing clinical outcomes, such as hospitalization, across triage levels. The discriminating performance of the triage tool in identifying patients requiring earlier medical attention was determined. Inter-observer reliability between the triage nurse and criterion standard, and across providers were determined using kappa statistics.ResultsIn total, 453 triage ratings of 151 triage cases, involving 17 ED triage nurses and 57 nurse pairs, were analysed. The proportion of hospital admission significantly increased with a higher triage rating. The performance of the scale in identifying patients requiring earlier medical attention was as follows: sensitivity, 68.2% (95% CI 45.1-86.1%); specificity, 99.2% (95% CI 95.8-100%); positive predictive value, 93.8% (95% CI 67.6-99.1%); and negative predictive value, 94.8% (95% CI 90.8-97.1%). The over-triage and under-triage rates were 0.7% and 4.6%, respectively. Agreement between the triage nurse and criterion standard was substantial (quadratic-weighted kappa = 0.76, 95% CI, 0.60-0.92, p < 0.001), so was the agreement across nurses (quadratic-weighted kappa = 0.81, 95% CI 0.65-0.97, p < 0.001).ConclusionsThe 3-level triage system appears to have good validity and reasonable reliability in a low-volume ED setting. Further studies comparing 3-level and prevailing 5-level triage scales in live triage encounters and different ED settings are warranted.

Dataset Information

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

Publications

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

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