title: Reliability and validity of emergency department triage tools in low- and middle-income countries: a systematic review.
abstract: OBJECTIVE
  Despite the universal acknowledgment that triage is necessary to prioritize emergency care, there is no review that provides an overview of triage tools evaluated and utilized in resource-poor settings, such as low- and middle-income countries (LMICs). We seek to quantify and evaluate studies evaluating triage tools in LMICs.
  
  
  METHODS
  We performed a systematic review of the literature between 2000 and 2015 to identify studies that evaluated the reliability and validity of triage tools for adult emergency care in LMICs. Studies were then evaluated for the overall quality of evidence using the GRADE criteria.
  
  
  RESULTS
  Eighteen studies were included in the review, evaluating six triage tools. Three of the 18 studies were in low-income countries and none were in rural hospitals. Two of the six tools had evaluations of reliability. Each tool positively predicted clinical outcomes, although the variety in resource environments limited ability to compare the predictive nature of any one tool. The South African Triage Scale had the highest quality of evidence. In comparison with high-income countries, the review showed fewer studies evaluating reliability and presented a higher number of studies with small sample sizes that decreased the overall quality of evidence.
  
  
  CONCLUSIONS
  The quality of evidence supporting any single triage tool's validity and reliability in LMICs is moderate at best. Research on triage tool applicability in low-resource environments must be targeted to the actual clinical environment where the tool will be utilized, and must include low-income countries and rural, primary care settings.
authors.affiliation: Department of Emergency Medicine, Johns Hopkins Hospital.
authors.forename: Alexander
authors.initials: A
authors.lastname: Jenson
authors.affiliation: Department of Emergency Medicine, Johns Hopkins Hospital.
authors.forename: Bhakti
authors.initials: B
authors.lastname: Hansoti
authors.affiliation: Department of Emergency Medicine, Johns Hopkins Hospital.
authors.forename: Richard
authors.initials: R
authors.lastname: Rothman
authors.affiliation: Global Emergency Services, Department of Emergency Medicine, Johns Hopkins Hospital.
authors.forename: Sarah S
authors.initials: SS
authors.lastname: de Ramirez
authors.affiliation: Welch Medical Library, Johns Hopkins University, Baltimore, Maryland, USA.
authors.forename: Katie
authors.initials: K
authors.lastname: Lobner
authors.affiliation: Department of Emergency Medicine, Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Lee
authors.initials: L
authors.lastname: Wallis
mesh_terms: D000328:Adult; D003906:Developing Countries / Q000191:economics*; D004632:Emergency Medical Services / Q000191:economics / Q000458:organization & administration*; D004636:Emergency Service, Hospital / Q000191:economics / Q000458:organization & administration*; D006801:Humans; D007348:Insurance, Health / Q000191:economics / Q000458:organization & administration*; D009313:National Health Programs / Q000458:organization & administration; D011787:Quality of Health Care / Q000191:economics; D012196:Review Literature as Topic; D014218:Triage