192 Strengthening Emergency Care Operations in East Africa: Implementation of the South African Triage Scale at Kenyatta National Hospital in Nairobi, Kenya

Abstract

Implementation of triage systems standardizes and improves patient care in emergency departments (ED). Kenyatta National Hospital (KNH), the largest public tertiary hospital in Kenya, is both resource limited and without ED-specific triage protocols. To standardize the approach to triage through implementation of the South African Triage Scale (SATS). We aimed to 1) assess the reliability of triage decisions among nurses and doctors following an educational intervention, 2) analyze validity of the SATS at KNH’s ED, comparing prior triage practice with the newly implemented triage protocol. We conducted a two-part prospective observational study to assess the reliability and validity of the SATS as implemented in the ED at KNH. In part one, we assessed the percent agreement with an expert standard (a consensus-derived correct triage category) using previously validated vignettes via paper test administered to health care workers before and after an educational intervention. In part two, we assessed the validity of the SATS in predicting patient disposition outcomes through a retrospective, systematic sampling of triage charts, one month pre- and post-implementation. 104 paper tests were included for reliability analysis. Percent agreement with the expert standard increased after the educational intervention, from 47% to 64% exact agreement (p<0.0001), and from 89% to 97% agreement allowing for a one-level discrepancy in triage ratings (p<0.0001). 2420 total charts were analyzed for validity before and after SATS implementation. There was no significant change in percent of patients under-triaged or over-triaged before and after the implementation. However, neither the proportion of over-triage (12.8%) nor the proportion of under-triage (2.7%) exceeded the American College of Surgeons-Committee on Trauma thresholds (25-35% and 5%, respectively). Health care workers who received the educational intervention achieved high levels of agreement with expert, demonstrating that the intervention is contextually appropriate and represents an ongoing medical education opportunity. SATS scores performed well in predicting outcomes with low levels of both under and over-triage, confirming SATS as a locally appropriate triage system for standardizing care at a major East Africa emergency department.