title: Reliability and accuracy of the South African Triage Scale when used by nurses in the emergency department of Timergara Hospital, Pakistan.
abstract: BACKGROUND
  Triage is one of the core requirements for the provision of effective emergency care and has been shown to reduce patient mortality. However, in low- and middle-income countries this strategy is underused, under-resourced and poorly researched.
  
  
  OBJECTIVE
  To assess the inter- and intra-rater reliability and accuracy of nurse triage ratings when using the South African Triage Scale (SATS) in an emergency department (ED) in Timergara, Pakistan.
  
  
  METHODS
  Fifteen ED nurses assigned triage ratings to a set of 42 reference vignettes (written case reports of ED patients) under classroom conditions. Inter-rater reliability was assessed by comparing these triage ratings; intra-rater reliability was assessed by asking the nurses to re-triage 10 random vignettes from the original set of 42 vignettes and comparing these duplicate ratings. Accuracy of the nurse ratings was measured against the reference standard.
  
  
  RESULTS
  Inter-rater reliability was substantial (intraclass correlation coefficient 0.77; 95% confidence interval (CI) 0.69 - 0.85). The intra-rater agreement was also high with 87% exact agreement (95% CI 67 - 100) and 100% agreement allowing for a one-level discrepancy in triage ratings. Overall, the SATS had high specificity (97%) and moderate sensitivity (70%). Across all acuity levels the proportion of over-triage did not exceed the acceptable threshold of 30 - 50%. Under-triage was acceptable for all except emergency cases (66%).
  
  
  CONCLUSIONS
  ED nurses in Pakistan can reliably use the SATS to assign triage acuity ratings. While the tool is accurate for 'very urgent' and 'routine' cases, importantly, it may under-triage 'emergency' cases requiring immediate attention. Approaches that will improve accuracy and validity are discussed.
authors.affiliation: Médecins Sans Frontières, Pakistan; Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, South Africa. mkdalwai@gmail.com.
authors.forename: Mohammed Khan
authors.initials: MK
authors.lastname: Dalwai
authors.forename: Michele
authors.initials: M
authors.lastname: Twomey
authors.forename: Jacob
authors.initials: J
authors.lastname: Maikere
authors.forename: Shujaat
authors.initials: S
authors.lastname: Said
authors.forename: Muhammed
authors.initials: M
authors.lastname: Wakeel
authors.forename: Jean-Paul
authors.initials: JP
authors.lastname: Jemmy
authors.forename: Pola
authors.initials: P
authors.lastname: Valles
authors.forename: Katie
authors.initials: K
authors.lastname: Tayler-Smith
authors.forename: Lee
authors.initials: L
authors.lastname: Wallis
authors.forename: Rony
authors.initials: R
authors.lastname: Zachariah
mesh_terms: D003430:Cross-Sectional Studies; D016529:Emergency Nursing; D004636:Emergency Service, Hospital; D006761:Hospitals; D006801:Humans; D015588:Observer Variation; D010154:Pakistan; D015203:Reproducibility of Results; D013019:South Africa; D014218:Triage / Q000706:statistics & numerical data*