Comparison between the Smart Triage model and the Emergency Triage Assessment and Treatment (ETAT) guidelines in triaging children presenting to the emergency departments of two public hospitals in Kenya
Authors: Kamau Stephen , Kigo Joyce , Mwaniki Paul , Dunsmuir Dustin , Pillay Yashodani , Zhang Cherri , Nyamwaya Brian , Kimutai David , Ouma Mary , Mohammed Ismael , Gachuhi Keziah , Chege Mary , Thuranira Lydia , Ansermino J Mark , Akech Samuel 
Published: November 2023

Several triage systems have been developed, but little is known about their performance in low-resource settings. Evaluating and comparing novel triage systems to existing triage scales provides essential information about their added value, reliability, safety, and effectiveness before adoption. This prospective observational study included children aged < 15 years who presented to the emergency departments of two public hospitals in Kenya between February and December 2021. We compared the performance of Emergency Triage Assessment and Treatment (ETAT) guidelines and Smart Triage (ST) models (ST-only model,ST model with independent triggers, andrecalibrated ST model with independent triggers) in categorizing children into emergency, priority, and non-urgent triage categories. We visualized changes in classification of participants using Sankey diagrams. 5618 children were enrolled, and the majority (3113, 55.4%) were aged between one and five years of age. Overall admission and mortality rates were 7% and 0.9%, respectively.ETATclassified less children, 513 (9.2%), into the emergency category compared to 790 (14.1%), 1163 (20.8%) and 1161 (20.7%) by theST-only model,ST model with independent triggersandrecalibrated model with independent triggers, respectively.ETATalso classified more children, 3089 (55.1%), into the non-urgent triage category compared to 2442 (43.6%), 2097 (37.4%) and 2617 (46.7%) for the respectiveST models.ETATclassified 191/395 (48.4%) of admitted patients as emergency compared to more than half by all theST models.ETATand theST-only modelclassified 25/49 (51%) children who died as emergencies, while theST models with independent triggersclassified 39/49 (79.6%) children as emergencies. Smart Triage shows potential for identifying critically ill children in low-resource settings, particularly when combined with independent triggers. Additionally, it performs comparably toETAT. Evaluation of Smart Triage in other contexts and comparison to other triage systems is required.

Author summary

Prioritizing children according to the level of severity of illness in the outpatient department is crucial to ensure very sick children are identified and receive life-saving treatment while those with less severe symptoms can safely wait in the queue. Appropriate triage prevents avoidable paediatric mortality. As new triage systems are developed, it is essential to evaluate their performance before being used by healthcare professionals to manage patients. In this study, we compared a newly developed triage algorithm, Smart Triage, to the World Health Organization’s Emergency Triage Assessment and Treatment (ETAT) guidelines. Here, we highlight how participants were categorised into emergency, priority, and non-urgent categories by both triage systems. We also assessed changes in triage categorization by comparing the Smart Triage model only (with and without site specific recalibration) and the model with independent emergency and priority triggers aligned withETAT. Our study shows that Smart Triage had comparable performance toETAT,and it can be used to triage children in resource-limited settings. Smart Triage can be integrated into a digital device allowing frontline healthcare workers to rapidly triage children presenting to the outpatient department and recognize very sick children faster, so that they can be treated in a timely manner.