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Reliability and validity of emergency department triage tools in low- and middle-income countries

a systematic review

Jenson, Alexandera; Hansoti, Bhaktia; Rothman, Richarda; de Ramirez, Sarah S.b; Lobner, Katiec; Wallis, Leed

European Journal of Emergency Medicine: June 2018 - Volume 25 - Issue 3 - p 154–160
doi: 10.1097/MEJ.0000000000000445

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.

Conclusion 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.

aDepartment of Emergency Medicine, Johns Hopkins Hospital

bGlobal Emergency Services, Department of Emergency Medicine, Johns Hopkins Hospital

cWelch Medical Library, Johns Hopkins University, Baltimore, Maryland, USA

dDepartment of Emergency Medicine, Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa

Correspondence to Alexander Jenson, MD, Department of Emergency Medicine, Johns Hopkins Hospital, 1830 E Monument St Suite 6-100, Baltimore, MD 21287, USA Tel: +410 955 2280; fax: +410 502 5146; e-mail:

Received December 8, 2015

Accepted December 12, 2016

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