Validation of the Interagency Integrated Triage Tool in a resource-limited, urban emergency department in Papua New Guinea: a pilot study

Abstract

Background:The Interagency Integrated Triage Tool (IITT) is a three-tier triage system designed for resource-limited emergency care (EC) settings. This study sought to assess the validity and reliability of a pilot version of the tool in an urban emergency department (ED) in Papua New Guinea.Methods: A pragmatic observational study was conducted at Gerehu General Hospital in Port Moresby, commencing eight weeks after IITT implementation. All ED patients presenting within the subsequent two-month period were included. Triage assessments were performed by a variety of ED clinicians, including community health workers, nurses and doctors. The primary outcome was sensitivity for the detection of time-critical illness, defined by ten pre-specified diagnoses. The association between triage category and ED outcomes was examined using Cramer's V correlation coefficient. Reliability was assessed by inter-rater agreement between a local and an experienced, external triage officer.Findings: Among 4512 presentations during the study period, 58 (1.3%) were classified as category one (emergency), 967 (21.6%) as category two (priority) and 3478 (77.1%) as category three (non-urgent). The tool's sensitivity for detecting the pre-specified set of time-sensitive conditions was 70.8% (95%CI 58.2-81.4%), with negative predictive values of 97.3% (95%CI 96.7 -97.8%) for admission/transfer and 99.9% (95%CI 99.7 -100.0%) for death. The admission/transfer rate was 44.8% (26/58) among emergency patients, 22.9% (223/976) among priority patients and 2.7% (94/3478) among non-urgent patients (Cramer's V = 0.351, p = 0.00). Four of 58 (6.9%) emergency patients, 19/976 (2.0%) priority patients and 3/3478 (0.1%) non-urgent patients died in the ED (Cramer's V = 0.14, p = 0.00). The under-triage rate was 2.7% (94/3477) and the over-triage rate 48.2% (28/58), both within pre-specified limits of acceptability. On average, it took staff 3 minutes 34 seconds (SD 1:06) to determine and document a triage category. Among 70 observed assessments, weighted κ was 0.84 (excellent agreement).

Sudanese emergency departments: a study to identify the barriers to a well-functioning triage

“…Our study determined the proportion of the assessed hospitals that had an established triage protocol in Khartoum State, the two hospital namely, Ibrahim Malik and Omdurman use the Sudan Triage Tool and IITT, respectively. Despite the fact that the evidence on triaging in LMICs is limited, the value of simple and context-specific approaches is widely recognized [ 16 ]. The key to improvement of the triage system is to reach a consensus on a single standardized system that allows nurses and other health care providers to use something that is simple yet consistent.…”

“…This can be readily achieved by implementing an already developed and validated triage scale, an effective strategy that could be useful in ensuring uniform application of triage across EDs, as there is little evidence to back up the validity and reliability of the existing triage tools in LMICs [ 10 ]. The four-tier SATS is the most extensively researched of the small number of tools specifically designed for resource-limited settings [ 12 , 16 ]. Although the tool has been shown to have adequate validity and reliability in a number of countries and contexts, it is also been noted to be too complicated for some settings, necessitating provider capacity that isn't always available [ 16 ].However, tools utilising three categories such as IITT are well-suited to developing EDs because they are intuitive and efficient [ 15 , 16 ].…”

“…The four-tier SATS is the most extensively researched of the small number of tools specifically designed for resource-limited settings [ 12 , 16 ]. Although the tool has been shown to have adequate validity and reliability in a number of countries and contexts, it is also been noted to be too complicated for some settings, necessitating provider capacity that isn't always available [ 16 ].However, tools utilising three categories such as IITT are well-suited to developing EDs because they are intuitive and efficient [ 15 , 16 ]. Furthermore, it fits to the three-level profile established by the Sudanese Ministry of Health in certain hospitals [ 17 ], and it would be a simpler system to teach to nurses and possibly nursing assistants in rural or understaffed smaller hospitals, since the IITT does not require calculation of a triage early warning score unlike the SATS.…”

“…At the point of entry, the IITT is configured for use at ED. It groups patients into one of three color coded classes based on certain symptoms and indications (categories 1 and 2) or the absence of dangerous vital signs (category three) [ 15 , 16 ].…”

What is the ideal triage process and the resources it requires?

“…The World Health Organization, International Committee of the Red Cross and Médecins Sans Frontières have developed the Integrated Interagency Triage Tool (IITT) for use in resource-limited emergency departments. In The Lancet Regional Health -Western Pacific Rob Mitchell and colleagues validated it in what they describe as a resource-limited urban emergency department in Papua New Guinea [3] . Triage using the tool took an average time of three and a half minutes, and it was claimed to perform well in the detection of time-critical diagnoses, and the identification of patients who were likely to die or require admission to hospital.…”