Study Objective Tools proposed to triage acuity in suspected COVID-19 in the ED have been derived and validated in higher-income settings during early waves of the pandemic. We estimated the accuracy of seven risk-stratification tools recommended to predict severe illness in the Western Cape, South Africa. Methods An observational cohort study using routinely collected data from EDs across the Western Cape, from the 27th of August 2020 to 11th March 2022 was conducted to assess performance of

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... e PRIEST tool, NEWS2, TEWS, the WHO algorithm, CRB-65, Quick COVID-19 Severity Index and PMEWS in suspected COVID-19. The primary outcome was death or ICU admission. Results Of 446,084 patients, 15,397 patients (3.45%, 95% CI:34% to 35.1%) experienced the primary outcome. Clinical decision-making for inpatient admission achieved a sensitivity of 0.77 (95% CI 0.76 to 0.78), specificity 0.88 (95% CI 0.87 to 0.88) and the negative predictive value (NPV) 0.99 (95% CI 0.99 to 0.99). NEWS2, PMEWS and PRIEST tool algorithm identified patients at risk of adverse outcomes at recommended cut-offs with moderate sensitivity (>0.8) and specificity ranging from 0.47 (NEWS2) to 0.65 (PRIEST tool). Use of the tools at recommended thresholds would have more than doubled admissions with only a 0.01% reduction in false negative triage. Conclusion Use of the PRIEST score, NEWS2 and PMEWS at a threshold of a point higher would achieve similar accuracy to current clinical admission decision, with possible gains in transparency and speed of decision-making.