African Journal of Emergency Medicine (2014) 4, 71–75

African Federation for Emergency Medicine

African Journal of Emergency Medicine

www.afjem.com
www.sciencedirect.com

ORIGINAL RESEARCH

The implementation of the South African Triage Score (SATS) in an urban

teaching hospital, Ghana
L’efficacite´ de la mise en œuvre de l’e´chelle de triage sud-africaine (SATS, South African Triage
Score) dans un hôpital universitaire urbain au Ghana
Sarah Rominski *, Sue Anne Bell, George Oduro, Patience Ampong, Rockefeller Oteng, Peter Donkor
Global REACH, University of Michigan Medical School, Ann Arbor, MI 48103, United States

Received 6 September 2013; revised 30 October 2013; accepted 19 November 2013; available online 17 January 2014

Introduction: Triage is the process of sorting patients based on the level of acuity to ensure the most severely injured and ill patients receive timely care before their
condition worsens. The South African Triage Scale (SATS) was developed out of a need for an accurate and objective measure of urgency based on physiological
parameters and clinical discriminators that is easily implemented in low resource settings. SATS was introduced in the emergency center (EC) of Komfo Anokye Teach-
ing Hospital (KATH) in January 2010. This study seeks to evaluate the accurate use of the SATS by nurses at KATH.
Methods: This cross-sectional study was conducted in the EC at KATH in Kumasi, Ghana. Patients 12 years and over with complete triage information were included
in this study. Each component of SATS was calculated (i.e. for heart rate of 41–50, a score of 1 was given) and summed. This score was compared to the original triage
score. When scores did not equate, the entire triage record was reviewed by an emergency physician and an advanced practice emergency nurse separately to determine
if the triage was appropriate. These reviews were compared and consensus reached.
Results: 52 of 903 adult patients (5.8%) were judged to have been mis-triaged by expert review; 49 under-triaged (sent to a zone that corresponded to a lower acuity
level than they should have been, based on their vital signs) and 3 over-triaged. Of the 49 patients who were under-triaged, 34 were under-triaged by one category and 7
by two categories.
Conclusion: Under-triage is a concern to patient care and safety, and while the under-triage rate of 5.7% in this sample falls within the 5–10% range considered
unavoidable by the American College of Surgeons Committee on Trauma, concentrated efforts to regularly train triage nurses to ensure no patients are under-triaged
have been undertaken. Overall though, SATS has been implemented successfully in the EC at KATH by triage nurses.

Introduction: Le triage est le processus consistant à classer les patients selon le degré de gravité afin de s’assurer que les patients les plus gravement blessés et malades
sont rapidement pris en charge avant que leur état ne s’aggrave. L’échelle de triage sud-africaine (SATS) été développée en raison de la nécessité de disposer d’une
mesure précise et objective du degré d’urgence à l’aide de paramètres physiologiques et de discriminants cliniques, mesure aisément mise en œuvre dans des environn-
ements caractérisés par un manque de ressources. Le SATS a été introduit dans le service d’urgences de l’hôpital universitaire Komfo Anokye (KATH) en janvier 2010.
L’objectif de cette étude est d’évaluer l’usage précis du SATS par les infirmières du KATH.
Méthodes: Cette étude transversale a été menée au service d’urgences du KATH à Kumasi, au Ghana. Des patients âgés de plus de 12 ans, pour lesquels les informa-
tions de triage étaient complètes, ont été intégrés à cette étude. Chaque composante du SATS a été calculée (par ex., pour une fréquence cardiaque comprise entre 41 et
50, une note de 1 a été attribuée) et additionnée. Cette note a été comparée à la note de triage d’origine. Quand les notes n’étaient pas les mêmes, l’intégralité du dossier
de triage était étudiée séparément par un urgentiste et une infirmière urgentiste de pratique avancée afin de déterminer si le triage était approprié. Ces révisions ont été
comparées en vue de parvenir à un consensus.
Résultats: 52 Patients adultes sur 903 (5.8%) ont été considérés comme ayant fait l’objet d’une erreur de triage par l’étude menée par les professionnels; 49 ont été
considérés «sous-triés» (envoyés vers une catégorie de prise en charge correspondant à un degré de gravité inférieur à ce qui aurait dû être choisi, d’après les signes
vitaux), et trois ont été sur-triés. Sur les 49 patients «sous-triés», 34 ont été «sous-triés» d’une catégorie, et sept de deux catégories.
Conclusion: Le «sous-triage» pose problème en termes de prise en charge et de sécurité des patients, et si le taux de «sous-triage» de 5.7% enregistré dans cet échantillon
est considéré comme inévitable par le Comité de traumatologie de l’American College of Surgeons, des efforts intensifs ont été réalisés afin de former régulièrement les
infirmières chargées du triage pour s’assurer qu’aucun patient n’était «sous-trié». Cependant, d’un point de vue général, les infirmières de triage sont parvenues à mettre
le SATS en œuvre avec succès au service d’urgences du KATH.

African relevance
* Correspondence to Sarah Rominski. sarahrom@umich.edu
Peer review under responsibility of African Federation for Emergency Medicine.
 Triage scales used in more developed areas may not be
relevant to Africa.
 This low-cost quality assurance study was able to identify
Production and hosting by Elsevier
needs for further training.
2211-419X ª 2014 Production and hosting by Elsevier on behalf of African Federation for Emergency Medicine.
http://dx.doi.org/10.1016/j.afjem.2013.11.001
72 S. Rominski et al.

 Implementing objective triage is an important part of the implement the material. However, practical applicability had
development of emergency medicine. not been assessed prior to this study.
In February 2010, the patient flow through the EC was
restructured to align the location of patients with the available
Introduction resources. For example, the highest acuity patients are now
seen in the red zone, where necessary equipment and supplies
Triage is the process of sorting patients according to acuity. In to treat these patients are located.
the emergency centers (EC), the purpose of triage is to effec- With the conversion of the EC to nurse-led triage, with the
tively sort patients based on their immediate presentation in SATS as the guiding instrument, there was a need to ensure
order to ensure the most severely injured and ill patients re- that the triage system was being correctly implemented. There-
ceive timely care before their condition worsens.1 Triage tools fore, the purpose of this paper is to objectively evaluate the
developed and widely used in the developed world are not accurate use of the SATS by emergency center nurses at Kom-
applicable to developing country settings.2,3 The South Afri- fo Anokye Teaching Hospital in Ghana using secondary data
can Triage Scale (SATS) was developed out of a need for an analysis of an existing dataset.
accurate measure of urgency based on physiological parame-
ters and clinical discriminators that is easily adopted in low re- Methods
source settings.4 The SATS was designed to be used by a range
of healthcare providers due to the low number of nurses and The cross-sectional study, from which the presently analyzed
doctors and nurses in South Africa. Nurse-led triage has been data were drawn, was conducted in the EC at KATH. This ter-
shown to have high levels of sensitivity and specificity in Bra- tiary care facility provides injury and medical emergency care
zil5 and Malawi.6 Further, nurse-led triage has been shown to to the 1.4 million residents of Kumasi and the 4.4 million
reduce waiting times for emergency patients in South Africa.7 who live in the surrounding Ashanti region. The emergency
Versions of SATS exist for adults, children and infants. center at KATH treats 27,000 patients/year.
This current study focuses on the adult version, meant for When patients arrive to the EC, they are interviewed by a
those over 12 years of age or 150 cm in height.8 Physiologic as- triage nurse to assess presenting complaint, mobility and
pects of triage are measured via the Triage Early Warning AVPU score (A = alert, V = responds to voice, P = responds
Score (TEWS). Patient presentation variables are scored on a to pain, U = unresponsive). Pulse rate, blood pressure, respi-
scale of 0–3 based on established parameters for vital signs ratory rate and temperature are measured and recorded. The
(temperature, heart rate, respiration and systolic blood pres- Triage Early Warning Scale (TEWS) score7 is then matched
sure) in addition to level of consciousness, mobility and expo- to a SATS discriminator list, and an appropriate triage color
sure to trauma (Fig. 1). The TEWS is a good fit with an is assigned. This information is routinely noted by the triage
emergency setting as it allows for accurate and uniform assess- nurse in the chart and is part of regular patient care.
ment of both medical and trauma patients,7 it is fairly low re- Data for this analysis come from an existing dataset
source, requiring only a blood pressure cuff and a that was collected between 13 July 2011 and 12 August
thermometer, and its scoring system facilitates communication 2011. All patients who present to the KATH EC for
between the healthcare team.8 treatment were surveyed as to their medical and personal
The emergency center at Komfo Anokye Teaching Hospital characteristics. Information regarding their vital signs at
(KATH) in Kumasi, Ghana, represents the first formalized the time they were triaged was extracted from the patient
emergency center in West Africa. Opened in 2009, the EC chart and forms the basis on which the present analysis
serves as the regional training and referral center for injury is conducted.
and trauma management. A formal system of post-graduate The TEWS for each patient was calculated by a series of
emergency medical education was established at the EC in algorithms in Excel. For example, for heart rate of 100–110,
October 2009. A specialization in emergency nursing was sub- a score of 1 was given; while a heart rate of 111–120 was given
sequently implemented in 2012. a score of 2 (Fig. 1). These individual scores were then summed
Prior to the introduction of emergency medicine, the EC by Excel. This series of algorithms sought to replicate the pro-
was split into three separate areas; the medical emergency unit, cess undertaken by a triage nurse. The calculated TEWS was
staffed by internal medicine clinicians, the trauma unit, staffed compared to the score recorded by the triage nurse. For those
by traumatologists, and a general surgical area. Upon arrival, scores that did not match, three authors, one an emergency
patients were judged by a nurse to be either medical, surgical nurse, the director of nursing services at KATH, and one emer-
or orthopedic. There was no objective triage occurring at this gency physician, (SAB, PA, RAO) reviewed the information
time. This process caused delays in patients receiving definitive separately and determined whether the patient had been tri-
interventions. After studying a variety of triage methods in aged correctly or not. The reason for the discrepancy docu-
place in other settings, the South African Triage Scale (SATS)3 mented by the nurse, if available, was reviewed. For
was implemented in July 2009, beginning with emergency cen- example, there are some patients who, based only on vital signs
ter training seminars for physicians and nurses, followed by a would have been triaged to Green, but since all suturing is
guided implementation process. Currently, nurses are trained done in the EC, the patient was sent to the Yellow area of
in SATS during their initial EC orientation and then provided the center. If this reasoning was not recorded then the recorded
with periodic refresher trainings. International EM physicians chief complaint was reviewed to evaluate whether the differ-
trained emergency medicine residents to conduct the initial ence could be explained. These separate reviews were then
training of nurse leaders.9 At the end of training, nurses took compared together and discrepancies were discussed until
a paper-based exam to assess comfort with and ability to agreement was reached.
The implementation of the South African Triage Score (SATS) in an urban teaching hospital, Ghana 73

ADULT TRIAGE SCORE © South African Triage Group 2008

3 2 1 0 1 2 3
Stretcher/
Mobility Walking With Help
Immobile
Mobility
less than
RR 9
9-14 15-20 21-29 more than 29 RR
less than
HR 41
41-50 51-100 101-110 111-129 more than 129 HR
less than more than
SBP 71
71–80 81-100 101-199
199
SBP
Cold Hot
Temp OR 35-38.4 OR Temp
Under 35 Over 38.4
Reacts to Reacts to
AVPU Confused Alert
Voice Pain
Unresponsive AVPU

Trauma No Yes Trauma

over 12 years / taller than 150cm

Colour RED ORANGE YELLOW GREEN BLUE

TEWS 7 or more 5-6 3-4 0-2 DEAD
Target time to
Immediate less than 10 mins less than 60 mins less than 240 mins
treat
Mechanism of High energy
injury transfer
Shortness of
breath - acute
Coughing blood
Chest pain
Haemorrhage - Haemorrhage -
uncontrolled controlled

Seizure - current Seizure - post ictal

Focal neurology -
acute
Level of
consciousness
reduced
Psychosis /
Aggression
Threatened limb
Dislocation - Dislocation - ALL DEAD
other joint finger or toe
Presentation OTHER
Fracture - Fracture -
compound closed PATIENTS
Burn over 20%
Burn - electrical
Burn –
Burn - Burn - other
face / inhalation
circumferential
Burn - chemical
Poisoning /
Abdominal pain
Overdose
Diabetic - Diabetic -
Hypoglycaemia -
glucose over 11 glucose over 17
glucose less than 3
& ketonuria (no ketonuria)
Vomiting - Vomiting -
fresh blood persistent
Pregnancy &
Pregnancy &
trauma
abdominal trauma
or pain Pregnancy &
PV bleed
Pain Severe Moderate Mild

Senior Healthcare Professional’s Discretion

Figure 1 The South African Triage Scale; RR, respiration rate; HR, heart rate; SBP, systolic blood pressure; AVPU, awake verbal pain
unresponsive; TEWS, triage early warning score.
74 S. Rominski et al.

Study procedures were approved and conducted in compli- The low rate of over-triage in our sample is worrisome gi-
ance with the Committee on Human Research Publication and ven the emphasis during training of the importance of erring
Ethics, School of Medical Sciences, Kwame Nkrumah Univer- on the side of over-triage. The finding of 17 times as many pa-
sity of Science and Technology and the University of Michigan tients being under-triaged as opposed to over-triaged is trou-
Institutional Review Board for Human Subjects guidelines. blesome, especially given the way the KATH EC is
positioned in the larger hospital where only patients triaged
Results to Yellow, Orange and Red are seen in the EC. Patients triaged
to Green are sent to the outpatient general clinic (Polyclinic)
The total sample size was 909 adults. Five hundred and where they will certainly encounter long waiting times and
forty-six (546) of them i.e. 60% were males, and 331 were may not be evaluated that day. The outpatient department is
females. During the study period, 63 (7.1%) were triaged to also staffed by the family physicians, and not by trained emer-
Red, 260 (29.4%) were triaged to Orange, 539 (61%) to Yellow gency physicians. Similar triage training has been conducted
and 3 (.3%) to Green. The most common chief complaint was with staff in the outpatient area. Although the rate of triage
abdominal pain (n = 126, 14.3%), followed by pain (n = 120, is low, they do have the ability to re-asses the patients they re-
13.6%). The mean age of our adult sub-sample was 43.99 years ceive and send them back to the EC to be evaluated by emer-
(s.d. 19.7). 355 (40.1%) of the patients included were present- gency physicians, if they feel this is necessary. In this analysis
ing for the treatment of an injury. there was only one out of the 909 patients in our sample who
Of all the patients, 173 (19%) were determined by the was incorrectly triaged to Green when they should have,
Excel program to have been incorrectly triaged. After expert according to their recorded vital signs, been seen in the emer-
review, 52 (5.7%) patients were judged to have been wrongly- gency center. However, even with one patient, this should
triaged by the triage nurse; 49 under-triaged (sent to a zone never happen and could lead to significant delays in the appro-
that corresponded to a lower acuity level than they should priated delivery of care. The construction of the EC brought
have been, based on their vital signs) and 3 over-triaged. Many with it some restructuring of resources and departments. The
of those who had been deemed by Excel to have been mis- outpatient general clinics at KATH are now staffed by the
triaged contained missing information, which is why they were departments of Family Medicine and Internal Medicine, and
identified as being incorrectly triaged. thus any patient with a potential surgical issue is to be up-tri-
Of the 49 patients who were identified to have been under- aged to stay and receive management in the EC. However,
triaged, 28 (53.8%) had been triaged to Yellow when they given the lack of patients found in this study to be up-triaged,
should have been sent to Orange, 14 (26.9%) were triaged to this issue may need to be stressed in future nurse trainings. To
Orange when they should have been seen in Red, 6 (11.5%) address this issue, nursing leadership at KATH has initiated
were triaged to Yellow when they should have been triaged plans to provide refresher trainings to all nurses in appropriate
to Red and one (1.9%) was determined to be Green when they triage quarterly.
should have been sent to Orange. As this is a secondary data analysis of an existing dataset,
only information collected for the original study could be used.
Discussion There were some patients for whom it was not possible to
ascertain whether or not they had been correctly triaged due
Triage is an important way to systematically sort patients so to missing information, and it is not possible to assess whether
those who are the most acutely ill or injured receive timely care data is missing because SATS is too complicated for this set-
before their condition worsens.1 Accurate, objective triage has ting. Further, there were no data collected on the individuals
the potential to reduce patient waiting times, and decrease time conducting the triage at any particular time. Thus, it is not
to physician intervention. In a setting such as Ghana where possible to determine whether it is one triage nurse who is
there are low physician-to-population ratios (.9 per 10,000 mis-triaging multiple patients or a general low level of
population10), it is important to utilize the available health mis-triage evenly spread out among all triage nurses.
care professionals in a manner most appropriate to providing Although SATS is an algorithm, there is an important as-
timely and specialized treatment. At Komfo Anokye, while pect of nursing judgment. The level of nursing documentation
there was immediate resistance to the idea of not involving concerning their reasons for adjusting the calculated triage
the physicians in the triage process, the implementation of score was often missing, which is not necessarily indicative of
nurse-led triage appears successful. a lack of judgment being undertaken. As triage was not a focal
While under-triage is a concern to patient care and safety, point of the initial study, we often could not ascertain the rea-
the under-triage rate of 5.7% in this sample falls within the sons why nurses made the judgments they did.
5–10% range considered unavoidable by the American College There is a need to objectively evaluate and validate the
of Surgeons Committee on Trauma.11 Conversely, over-triage, effectiveness of SATS to appropriately triage patients present-
while not posing threats to patients, will stretch already limited ing to the EC at KATH. The predictive validity of SATS at
healthcare resources. It has been suggested that an over-triage KATH has not been established by this study and is an impor-
rate of up to 50% may be required to keep under-triage at an tant area for further research.
acceptable rate11(ACSCOT, 1999). In this sample, less than
1% of patients were over-triaged. Conclusion
The result of 5.7% of patients being under-triaged is higher
than the 4.4% under-triage rate reported in a rural emergency Nurses at the emergency center at Komfo Anokye have
center in South Africa,12 and the over-triage rate of less than correctly implemented objective and systematic triage using
1% in our study is lower than the 4.3% reported. the South African Triage Scale. This important achievement
The implementation of the South African Triage Score (SATS) in an urban teaching hospital, Ghana 75

provides a strong basis in the advancement of a functional References

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