To our knowledge, this study is the first to investigate the perspectives and experiences of prehospital providers using SATS in the out-of-hospital setting. The study findings advance our understanding of the adoption of SATS into a prehospital clinical environment for which it was not initially designed. Overall, participants spoke positively about many aspects of their experience with SATS, but they also recognized issues regarding the EMS implementation, clinical application and health systems consequences of using SATS in the prehospital setting. Many of the prehospital challenges with SATS are related to its use as a decision tool for destination facility selection which also determines what resources are available to the patient once they arrive at the facility.
The identified thematic areas — implementation and use of SATS, perceived effectiveness of SATS, use and limitations of the clinical discriminator, and special EMS considerations — are critical to understanding how SATS is actually used in the field and what components of SATS require modification for the prehospital setting.
Implementation and use of SATS
SATS was implemented into WCG EMS with only brief formal training for those employed by the agency at the time of implementation and largely informal peer-to-peer training on the job for those who subsequently joined. A previous study of 102 WCG EMS providers found an unacceptable under-triage rate of 29.5%, much higher than similar studies of doctors and nurses in-hospital . While EMS provider qualification levels and differences in scope of practice may contribute to the poorer prehospital SATS performance, we posit that on-going formal training, including SATS competency assessments, are important for optimal use of SATS by prehospital providers in the long-term. Additionally, we posit the challenges identified as other themes in this study reflect EMS providers reliance on their gestalt, facility considerations, and socio-cultural factors considered during assignment of a triage colour and that re-training alone would not improve performance. It is important to note that previous in-hospital validation studies of SATS relied on doctors, nurses, and nursing assistants who had undergone formal training sessions prior to validation assessments [3, 5, 6].
Participants practicing in urban areas with many potential destination facilities discussed the beneficial use of SATS to help select the most appropriate destination. Inappropriate selection of the destination facility has been found to be a major issue in other prehospital systems in Africa . Participants indicated that being able to use the tool to select an appropriate destination was valuable, although issues arose with certain types of patients (e.g., traumatic injuries). SATS did not help providers advocate for their choice of destination when facilities declined to accept the patient—either due to a mismatch of understanding of which SATS levels were appropriate to transfer to their facility or to a re-calculation of SATS upon arrival to the facility. The latter could be addressed by issuing or clarifying guidance to WCG EMS providers and hospital personnel as the SATS-based destination decision-making. Issues with trauma patients are already addressed through a WCG EMS protocol for transporting injured patients. The integration of SATS triage acuity with other protocols may help prehospital providers determine best destinations and better optimize health system resource utilization, with unique considerations for rural settings.
Perceived effectiveness of SATS
Most providers described being able to use SATS effectively and felt SATS helps them identify high-acuity patients and communicate in shared terminology with the hospital providers who also use SATS for triage. In contrast to this perceived ease of TEWS, it was recently noted that it is often under-calculated by WCG EMS personnel, particularly for trauma and high-acuity patients . We did not identify a potential reason for this in the focus groups, although simple computational errors while multi-tasking under stress have been proposed as one potential cause. Additional clinical studies may be warranted to better understand this, and an audit and feedback program may potentially help improve accuracy.
Use and limitations of the SATS discriminator
The list of clinical discriminators was originally developed for use by frontline in-hospital clinicians (doctors and nurses). Clinical discriminators are intended to identify high-risk clinical conditions that are otherwise not captured by TEWS and require higher medical priority or more resources . During previous validation of the use of SATS by WCG EMS providers, it was found that clinical discriminators were often missing or incorrectly applied. Several trauma-related discriminators (e.g., ‘high energy transfer‘, ‘burn circumferential‘and ‘haemorrhage controlled‘) were among the least frequent to be correctly applied . In our study, participants echoed difficulties with applying the discriminators due to subjectivity (e.g. ‘severe pain’) and the requirement of advanced diagnostic studies (e.g., ‘diabetic – glucose over 17 (no ketonuria)’). A modified list of clinical discriminators for the use of prehospital providers that are less subjective, require no diagnostics and fall within the scope and training of prehospital providers has the potential for improving prehospital triage in systems like WCG EMS.
Participants also reported situations in which their clinical gestalt or level of concern for a patient was discordant with the final SATS acuity. BLS and ILS providers discussed using free text discriminators to request additional field resources, such as an ALS ambulance “upgrade”, in situations where they feared the patient could decompensate (e.g., patients with significant injuries). All types of providers suggested they create their own discriminator and then manually upgrade their assessed SATS to match their level of concern and destination facility choice. The use of SATS as a decision tool for destination facility will inherently have mismatches due to the conflict between the original hospital-oriented intent and prehospital application. Perhaps, allowing for EMS senior ALS or ILS provider discretion to upgrade the SATS acuity may better allow them to match patients with their prehospital-determined acuity.
Special EMS considerations
Prehospital providers are faced with the challenges of being advocates for their patients, safeguarding health system resource utilization and applying their own clinical assessment. Not infrequently, these priorities come into conflict. Participants noted pressure from patients to modify their triage or destination due to social concerns and healthcare resource needs. While SATS or the EMS provider’s clinical judgement might dictate that a patient from a rural area be transported to a distant referral centre, some patients may lack the resources to return from such long distances and plead to be taken to a closer day hospital. Reconciling SATS destination decisions with patient preference requires clear guidance that respects patient autonomy while serving the overall system.
The potential for a change in clinical status of a patient during prolonged transportations also became apparent in focus groups. On the one hand, the fear of decompensation of their patient may drive providers to try to upgrade the SATS to request further resources (e.g. ALS providers) on scene or transport to a closer (under-resourced) facility, while improvements in a patient’s clinical status during transport (e.g. a hypoglycaemic patient that responds to glucose) may provoke a receiving facility to suggest the patient’s acuity no longer warrants that level of care and suggest they transport to another facility. This creates inefficiencies for the EMS system and frustrations among EMS providers. Integrating SATS into EMS operational policies, and aligning prehospital SATS with local destination guidelines, may help improve this issue.
Limitations and generalizability
While this study was done with one EMS system and may not be generalizable to other EMS systems, the authors feel there are many lessons learned that apply to other EMS systems in limited resource settings that require a prehospital triage tool that has to meet multiple, often conflicting, demands. The challenges identified by participants regarding implementation and use of SATS are important for other EMS systems considering using SATS or another hospital based triage tool in the prehospital setting. Potential solutions or modifications such as modification of the discriminator list and separate or integrated protocols that address challenging sub-populations like trauma would likely apply to other EMS systems.
While the sample size and convenience sampling method inherently limit the data, we were able to recruit a diverse collection of providers with varying experience in rural vs urban setting, level of training, and duration of employment with WCG EMS. Despite having only three focus groups, we reached thematic saturation. The qualitative design and analysis was focused to assess the prehospital providers’ experience with SATS in their setting. As such, we did not investigate the perception of prehospital SATS from in-hospital personnel or dispatchers, both of which interact routinely with the study group as they use SATS.