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Inter-rater and intrarater reliability of the South African Triage Scale in low-resource settings of Haiti and Afghanistan
  1. Mohammed Dalwai1,2,
  2. Katie Tayler-Smith3,
  3. Michèle Twomey1,
  4. Masood Nasim4,
  5. Abdul Qayum Popal4,
  6. Waliul Haq Haqdost5,
  7. Olivia Gayraud6,
  8. Sophia Cheréstal6,
  9. Lee Wallis,
  10. Pola Valles2
  1. 1Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
  2. 2Medical Department, Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium
  3. 3Operational Research Unit Luxembourg, Médecins Sans Frontières, Luxembourg City, Luxembourg
  4. 4Medical Department, Médecins Sans Frontières, Kabul, Afghanistan
  5. 5Ministry of Health, Kabul, Afghanistan
  6. 6Medical Department, Médecins Sans Frontières, Port au Prince, Haiti
  1. Correspondence to Dr Mohammed Dalwai, Division of Emergency Medicine, University of Cape Town, Cape Town 7708, South Africa; mkdalwai{at}


Objective The South African Triage Scale (SATS) has demonstrated good validity in the EDs of Médecins Sans Frontières (MSF)-supported sites in Afghanistan and Haiti; however, corresponding reliability in these settings has not yet been reported on. This study set out to assess the inter-rater and intrarater reliability of the SATS in four MSF-supported EDs in Afghanistan and Haiti (two trauma-only EDs and two mixed (including both medical and trauma cases) EDs).

Methods Under classroom conditions between December 2013 and February 2014, ED nurses at each site assigned triage ratings to a set of context-specific vignettes (written case reports of ED patients). Inter-rater reliability was assessed by comparing triage ratings among nurses; intrarater reliability was assessed by asking the nurses to retriage 10 random vignettes from the original set and comparing these duplicate ratings. Inter-rater reliability was calculated using the unweighted kappa, linearly weighted kappa and quadratically weighted kappa (QWK) statistics, and the intraclass correlation coefficient (ICC). Intrarater reliability was calculated according to the percentage of exact agreement and the percentage of agreement allowing for one level of discrepancy in triage ratings. The correlation between years of nursing experience and reliability of the SATS was assessed based on comparison of ICCs and the respective 95% CIs.

Results A total of 67 nurses agreed to participate in the study: In Afghanistan there were 19 nurses from Kunduz Trauma Centre and nine from Ahmed Shah Baba; in Haiti, there were 20 nurses from Martissant Emergency Centre and 19 from Tabarre Surgical and Trauma Centre. Inter-rater agreement was moderate across all sites (ICC range: 0.50–0.60; QWK range: 0.50–0.59) apart from the trauma ED in Haiti where it was moderate to substantial (ICC: 0.58; QWK: 0.61). Intrarater agreement was similar across the four sites (68%–74% exact agreement); when allowing for a one-level discrepancy in triage ratings, intrarater reliability was near perfect across all sites (96%–99%). No significant correlation was found between years of nursing experience and reliability.

Conclusion The SATS has moderate reliability in different EDs in Afghanistan and Haiti. These findings, together with concurrent findings showing that the SATS has good validity in the same settings, provide evidence to suggest that SATS is suitable in trauma-only and mixed EDs in low-resource settings.

  • research, operational
  • triage
  • global health
  • emergency care systems, emergency departments

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  • Contributors MD, PV, MT, LW and KTS designed, analysed and interpreted the study and data. AQP, WHH and MN were the project leads in Afghanistan. OG and SC were the project leads in Haiti. All authors contributed to the revision of the final article.

  • Funding The degree from which this study emanated was funded by the South African Medical Research Council under the SAMRC Clinicians Researcher Development Scholarship PhD programme.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Ethics approval was obtained from the National Ethics Committees in Afghanistan and Haiti, from the MSF Ethics Review Board and from the University of Cape Town (UCT).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data sharing is available on request.

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