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Reduced overtriage and undertriage with a new triage system in an urban accident and emergency department in Botswana: a cohort study
  1. Paul C Mullan1,
  2. Susan B Torrey2,
  3. Amit Chandra3,
  4. Ngaire Caruso3,
  5. Andrew Kestler4
  1. 1Division of Emergency Medicine, Children's National Medical Center, George Washington University, Washington, DC, USA
  2. 2Division of Pediatric Emergency Medicine, Department of Emergency Medicine, New York University School of Medicine, New York, New York, USA
  3. 3Department of Emergency Medicine, University of Botswana School of Medicine, Gaborone, Botswana
  4. 4Department of Emergency Medicine, University of British Columbia and St. Paul's Hospital, Vancouver, British Columbia, Canada
  1. Correspondence to Dr Paul C Mullan, Division of Emergency Medicine, 111 Michigan Ave NW, Washington DC 20010, USA. mullan20{at}


Background Improvements in triage have demonstrated improved clinical outcomes in resource-limited settings. In 2009, the Accident and Emergency (A&E) Department at the Princess Marina Hospital (PMH) in Botswana identified the need for a more objective triage system and adapted the South African Triage Scale to create the PMH A&E Triage Scale (PATS).

Aim The primary purpose was to compare the undertriage and overtriage rates in the PATS and pre-PATS study periods.

Methods Data were collected from 5 April 2010 to 1 May 2011 for the PATS and compared with a database of patients triaged from 1 October 2009 to 24 March 2010 for the pre-PATS. Data included patient disposition outcomes, demographics and triage level assignments.

Results 14 706 (pre-PATS) and 25 243 (PATS) patient visits were reviewed. Overall, overtriage rates improved from 53% (pre-PATS) to 38% (PATS) (p<0.001); likewise, undertriage rates improved from 47% (pre-PATS) to 16% (PATS) (p<0.001). Statistically significant decreases in both rates were found when paediatric and adult cases were analysed separately. PATS was more predictive of inpatient admission, Intensive Care Unit (ICU) admission and death rates in the A&E than was the pre-PATS. The lowest acuity category of each system had a 0.6% (pre-PATS) and 0% (PATS) chance of death in the A&E or ICU admission (p<0.001). No change in death rate was seen between the pre-PATS and PATS, but ICU admission rates decreased from 0.35% to 0.06% (p<0.001).

Conclusions PATS is a more predictive triage system than pre-PATS as evidenced by improved overtriage, undertriage and patient severity predictability across triage levels.

  • triage
  • emergency department

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