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REVIEW
Efficacy of the Manchester Triage System: a systematic review Thereza Raquel Machado Azeredo (Student in Nursing) a, Helisamara Mota Guedes RN, MS, PhDst (Nurse, Doctorate’s Student in Nursing, Assistant Professor) a,b,*, Ricardo Alexandre Rebelo de Almeida RN, MS (Nurse) c, Tânia Couto Machado Chianca RN, MS, PhD (Nurse, PhD in Nursing, Titular Professor) b, José Carlos Amado Martins RN, MS, PhD (Adjunct Professor, Coordinator, Post-doctoral student (with scholarship of the FCT – Portugal)) d,e,f a
Federal University of the Mucuri and Jequitinhonha Valley, Diamantina, Minas Gerais, Brazil Federal University of Minas Gerais, Minas Gerais, Brazil Centro Hospitalar University of Coimbra, Coimbra, Portugal d Scientific-Pedagogical Unit of Medical-Surgical Nursing, Nursing School of Coimbra, Coimbra, Portugal e Health Sciences Research Unit – Nursing, Coimbra, Portugal f University of São Paulo at Ribeirão Preto College of Nursing/WHO Collaborating Centre for Nursing Research Development, Brazil b c
A R T I C L E
I N F O
Article history: Received 25 January 2014 Received in revised form 19 May 2014 Accepted 14 June 2014 Keywords: Nursing Emergency medical services Triage Risk assessment Manchester triage Manchester protocol
A B S T R A C T
Introduction: The growing number of patients in emergency departments can lead to overcrowding, often adding to organisational problems. Triage aims to predict the severity of disease, with the aim of organising patient flow. The aim of this study was to analyse the efficacy of the Manchester Triage System (MTS) for risk classification of patients. Methods: A systematic review of the literature in Ebscohost, Pubmed and Scielo (2002–2013) was undertaken. Articles were selected independently by two researchers using selection criteria. Twenty-two articles were selected for inclusion in this review. Results: The results support the applicability of the MTS, which has proven validity for use in children, adults, patients with coronary syndrome and patients with acute pulmonary embolism. The MTS was found to be inclusive, and to predict emergency department admission and death in the short term. Conclusion: The majority of studies found that the MTS was useful in triage of patients in emergency departments, but sub-triage and super-triage (i.e. under and over classification of severity, respectively) still occur. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Globally, the number of patients presenting to emergency departments with a wide variety of problems, ranging from high clinical severity to minor injuries, is increasing (Bittencourt and Hortale, 2009). This may lead to overcrowding in emergency deparments which often have other organisational problems, such as assisting patients based on order of arrival as opposed to the severity of their medical conditional (Souza et al., 2011). Triage has emerged as a method to optimise attendance, and to minimise the damage caused by overcrowding, by identifying patients who need immediate care. Patients are classified according to clinical severity, level of suffering and risk to their own health. In this way, triage is defined as a dynamic process of patient clas-
* Corresponding author. Tel.: +55 3835326073. E-mail address: [email protected] (H.M. Guedes).
sification that allows patients to be allocated to the most suitable service for faster treatment (Ganley and Gloster, 2011). Triage scales predict disease severity, mortality rate and required resources, and should be easily understood, applicable and have high interobserver agreement (Christ et al., 2010). Worldwide, various triage scales are used in emergency departments due to functional differences in services. There is a need for a uniform triage scale that is suitable for all services (Christ et al., 2010). There is no infallible measurement instrument, as measurement errors can arise due to personal factors, environmental situations, changes in the method of data collection and cultural adaptation processes (Souza et al., 2011). The Manchester Triage System (MTS) is a classification system of priority and risk prediction for patients seeking emergency care, widely used in the European Union (Cooke and Jinks, 1999; Storm-Versloot et al., 2011). It aims to standardise the service, providing support and emplacement to decision-making when a patient enters the health service, such that patients are seen in order of
http://dx.doi.org/10.1016/j.ienj.2014.06.001 1755-599X/© 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Thereza Raquel Machado Azeredo, Helisamara Mota Guedes, Ricardo Alexandre Rebelo de Almeida, Tânia Couto Machado Chianca, José Carlos Amado Martins, Efficacy of the Manchester Triage System: a systematic review, International Emergency Nursing (2014), doi: 10.1016/j.ienj.2014.06.001
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Table 1 Inclusion and exclusion criteria of articles. Inclusion
Exclusion
1-studies published in Portuguese, Spanish or English;
1-congresses and conferences abstracts;
2-studies published in the last ten years;
2-unpublished studies and theses;
3-studies that consider at least a variable related to implementation, evaluation or characterization of the Manchester Triage System;
3-studies that do not address the STM as the main focus of the work and do not respond to the research question.
4-studies who had as a research subject patients or records of risk classification or STM own.
severity of their clinical condition rather than order of arrival at the emergency department (Storm-Versloot et al., 2011). The MTS has a list of 52 pre-defined conditions or presentation flowcharts that are combined with the main complaint reported by the patient and recorded on a form by a nurse. Classification is divided into five colours: red (immediate), orange (very urgent), yellow (urgent), green (standard) and blue (non-urgent) (Speake et al., 2003). Although theoretical and systematised perspectives have addressed the use of the MTS in emergency departments, it is extremely relevant to identify and analyse the scientific publications on the topic, as the MTS has been introduced into practice relatively recently. This will improve understanding of this triage system, and demonstrate the scientific indications for its implementation in different social contexts. As such, the aim of this study was to assess the efficacy of the MTS for the risk classification of patients, and to describe and analyse its use in relevant articles identified. 2. Methods Systematic reviews involve synthesis of the research related to a specific issue, and frequently involve the efficacy of an intervention (Sampaio and Mancini, 2007). This review aimed to reduce the risk of bias by using a rigorous search methodology for study selection, and evaluating the relevance and validity of the research, collection, synthesis and interpretation of data from the surveys (Galvão et al., 2004). This systematic review assessed the level of evidence of each study in accordance with Sampaio and Mancini (2007): I, systematic review of randomised controlled trials with or without meta-analysis; II, randomized controlled trial; III, cohort study; IV, case–control study; V, quasi-experimental study; VI, descriptive study; VII, single case study or case series; and VIII, expert opinion or case report. Starting from the analysis of theoretical assumptions and defining efficacy as the ability of care, at its best, to improve health (Donabedian, 1990), the following research question was asked: “What is the efficacy of the MTS for risk identification in patients seeking a hospital urgency/emergency service?” Table 1 shows the inclusion and exclusion criteria for articles in this review. On 29 January 2013, Pubmed, Scielo and Ebscohost were searched for relevant articles. Ebscohost includes the following databases:
CINAHL Plus with Full Text, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Cochrane Methodology Register, Library, Information Science Technology Abstracts, Nursing and Allied Health Collection: Comprehensive, Health Technology Assessments, MedicLatina, Academic Search Complete, NHS Economic Evaluation Database, Regional Business News, ERIC and Business Source Complete. This search was performed by two researchers who identified the same number of articles. Scientific articles published between 1 January 2002 and the date of the survey (29 January 2013) were eligible for inclusion in this review. The researchers chose to review articles published only within the last 10 years as part of the selection criteria because it limits the studies to a specific time period. In order to identify relevant studies for inclusion in the review, a set of synonyms and related terms were used to restrict the search and meet the study objectives. The combinations of keywords used by both researchers in each database and the search results are shown in Table 2. Initially, articles were selected independently by two researchers after reading the article titles. Disagreements between researchers were resolved by consensus. In total, 56 articles were selected using Inclusion Criteria 1 and 2, and Exclusion Criteria 1 and 2. The abstracts of these 56 articles were read, with 28 articles selected by one investigator and 25 articles selected by the other investigator. Eleven of these studies were not selected by both reviewers, and following discussion, eight were withdrawn and three were retained. As such, 27 studies were selected using Inclusion Criteria 3 and 4, and Exclusion Criterion 3. Information that was not clearly described in the abstract was obtained by reading the full article. Articles were retained or excluded based on consensus between the two reviewers using Inclusion Criterion 4. Ultimately, 22 articles related to the research question were included in this review. For data analysis, articles were read repeatedly, and the most relevant elements of each study were extracted, namely: author(s), country of publication, study design, sample characterisation, level of evidence and conclusion (Table 2). 3. Results Table 3 summarises the study details (author, year of publication and country) and levels of evidence of the articles in this review.
Table 2 Distribution of keywords for database. Palavra-Chave
Ebsco
Pubmed
Scielo
“Manchester Protocol” OR “Manchester system” OR “Manchester Triage” “Manchester Protocol” OR “Manchester system” OR “Manchester Triage” AND “Triage” “Manchester protocol” OR “Manchester System” OR “Manchester Triage” AND “risk assessment” “Manchester protocol” OR “Manchester System” OR “Manchester Triage” AND “emergency service” “Manchester Protocol” OR “Manchester system” OR “Manchester Triage” AND “triage” AND “risk assessment” “Manchester Protocol” OR “Manchester system” OR “Manchester Triage” AND “triage” AND “emergency service” “Manchester protocol” OR “Manchester System” OR “Manchester Triage” AND “risk assessment” AND “emergency service” “Manchester Protocol” OR “Manchester system” OR “Manchester Triage” AND “triage” AND “risk assessment” AND “emergency service”
98 98 26 62 26 62 24 24
70 55 04 35 02 34 02 01
3 02 00 01 00 01 00 00
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Table 3 Articles’ characteristics found. Author, Year and country Objective
Level of evidence
Evaluates the validity, specificity, sensitivity
Specific condition
What is the specific condition
Affirms validity of the MTS
Matias et al. (2008) – Portugal To assess whether the MTS was used effectively in patients admitted to the hospital with a diagnosis of acute coronary syndrome (ACS). Pinto Júnior et al. (2010) – Portugal To assess the sensitivity of the MTS in assigning high priority to patients with acute coronary syndrome, and the sensitivity and specificity of the combinations of flowcharts and discriminators routinely used for triage in the Emergency Department of Hospital de S. João, Porto. Pinto Júnior et al. (2012) – Brazil To assess the predictive validity of the Manchester Triage System implemented in a municipal hospital in Belo Horizonte, MG, Brazil. Souza et al. (2011) – Brazil To assess the level of agreement between an institutional protocol and the Manchester protocol for the risk assessment of patients attended in an emergency room of a public hospital in Belo Horizonte – MG – Brazil. Soler et al. (2010) – Spain Discuss the system of triage integrated in the computerised clinical history and used in the hospital network of Navarre. Martins et al. (2009) – Portugal To determine whether the subgroups created by the application of MTS have different propensities for indirect triage outcomes such as death in the A&E department or being admitted to hospital. Seiger et al. (2011) – The Netherlands To assess the clinical severity of undertriaged patients in the MTS and to define the determinants of undertriage. Roukema et al. (2006) – The Netherlands To assess the validity of the Manchester Triage System in paediatric emergency care, using information on vital signs, resource utilisation and hospitalization. Dann et al. (2005) – England To determine the efficacy of the MTS discriminator ‘pain’ at identifying ‘standard’ and ‘non-urgent’ attenders in emergency departments, and to estabiish a method of assessing pain duration that allows patients with chronic, mild pain to be more appropriately triaged. Storm-Versloot et al. (2011) – The Netherlands To compare the validity of an existing informally structured triage system with the Emergency Severity Index (ESI) and the Manchester Triage System (MTS). van der Wulp et al. (2009) – The Netherlands To compare the degree to which the Emergency Severity Index (ESI) and the Manchester Triage System (MTS) predict admission and mortality. Santos et al. (2014) – Portugal To determine whether the MTS second version is a useful instrument for determining the risk of hospital admission, intrahospital death and resource utilisation in ED and to compare it with the MTS first version. van Veen et al. (2008) – The Netherlands To validate use of the Manchester triage system in paediatric emergency care. Christ et al. (2010) – Germany To identify modern triage instruments and assess their validity and reliability. Speake et al. (2003) – England To assess the ability of nurses using the MTS to identify those patients with chest pain requiring immediate electrocardiogram (ECG) and physician assessment within ten minutes. van Ierland et al. (2013) – The Netherlands To assess whether the flowcharts and discriminators of the Manchester Triage System can be used as indicators of alarming signs of serious febrile illness to predict the risk of hospitalization for febrile children who present at the emergency department. Providência et al. (2011) – Portugal To evaluate the impact of MTS on short-term mortality in acute myocardial infarction and detect potential improvements, and to analyse high-risk groups: diabetic patients, women and older patients. Paiva et al. (2012) – Portugal To assess the appropriateness of MT in this set of patients presenting acutely to the emergency department, and to determine whether it assists in a rapid diagnosis, acts as a protective triage tool and affects short-term mortality. van der Wulp et al. (2008) – The Netherlands To assess the reliability and validity of the Manchester Triage System in a general emergency department patient population. Trigo et al. (2008) – Portugal To evaluate the effectiveness of the MTS in classifying STEMI patients and its effect on IHD. Nijman et al. (2011) – The Netherlands To evaluate the discriminative ability of the MTS to identify serious bacterial infections in children with fever in the emergency department and to study the association between predictors of SBI and discriminators of MTS urgency of care. van der Straten et al. (2012) – The Netherlands To assess the safety and efficiency of triaging low urgent self-referred patients at the emergency department to a general practitioner based on MTS.
VI
N
Y
ACS
Y
VI
Y
Y
ACS
Y
III
Y
N
Y
VI
Y
N
Y
VI
N
N
Y
III
Y
N
Y
III
N
Y
Pediatric
Y
III
Y
Y
Pediatric
Y
VI
Y
Y
Discriminator ‘pain’
Y
III
Y
N
Y
III
Y
N
Y
III
Y
N
Y
III
Y
Y
VI
Y
N
III
Y
Y
Chest pain
Y
III
Y
Y
Pediatric
Y
III
Y
Y
AMI
Y
III
Y
Y
PE
Y
III
Y
N
III
Y
Y
ACS
N
III
Y
Y
Pediatric
N
III
Y
Y
Triaging low urgent selfreferred patients
Y
Pediatric
Y Y
Y
Y-Yes; N-No; ACS-Acute Coronary Syndrome; PE-Acute Pulmonary Embolism; AMI-Acute Myocardial Infarction.
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Evaluation of validity/specificity/sensitivity of the MTS, evaluation of use of the MTS for a specific condition, and affirmation of efficacy of the MTS are also shown (Table 3). Of the 22 studies in this review, nine (40.9%) were from the Netherlands, seven (31.9%) were from Portugal, two (9.1%) were from Brazil, two (9.1%) were from the UK, one (4.5%) was from Germany and one (4.5%) was from Spain. Only three (13.6%) articles did not use validity, specificity and/ or sensitivity to evaluate the efficacy of the MTS. Twenty (90.9%) studies reported that the MTS had good efficacy, and two (9.1%) studies reported that the MTS was not efficacious. Thirteen articles (59%) evaluated the efficacy of the MTS in a specific group of patients, and studies regarding use of the MTS in children were the most common (Nijman et al., 2011; Seiger et al., 2011). Use of the MTS in patients with clinical conditions such as chest pain, acute coronary syndrome and acute pulmonary embolism was also investigated (Dann et al., 2005; van der Straten et al., 2012). Regarding the evidence levels of studies, 72.7% of studies represented Level III evidence and 27.3% represented Level VI evidence (Table 2). 4. Discussion The MTS is used in many countries around the world, and its efficacy has been shown in scientific studies focusing on a specific disease, age group or the general population. The studies in this review were conducted in different contexts and using different methods to assess the efficacy of the MTS. Most studies used a methodological tool to measure the validity, specificity and/or sensitivity of the MTS. Use of structured triage, such as the MTS, by nurses in the emergency department helps to identify patients who are identified as having life-threatening presentations receive the fastest service. It has been suggested that the ideal triage system should allow resource planning, in addition to the identification of patients who need urgent medical care (Christ et al., 2010). Soler et al. (2010) claimed that triage systems should be structured and based on scales with five levels, such as the MTS. The MTS has a standard nomenclature, uses common definitions, has a robust methodology for screening, implements a model of integral formation, and allows the screening method developed to be audited. Studies that evaluated the MTS without focusing on patients with a specific condition (40.9%) found that, in addition to prioritising the care of patients, the MTS was able to predict the evolution of patients during their stay in the institution, as different rating categories had different developments in severity (Pinto Júnior et al., 2012). In addition, the MTS was considered to be more inclusive compared with an institutional protocol, which increased the level of priority when there were disagreements between classifications (Souza et al., 2011). Martins et al. (2009) reported that the MTS was an extremely important tool to distinguish between patients at low and high risk of death in the short term, and to identify patients who would require hospitalisation for at least 24 h before discharge. Santos et al. (2014) reported that the risk for hospital admission was five times greater in high-priority patients (classified as red or orange using the MTS) compared with low-priority patients (classified as yellow, green or blue), and death during hospitalisation was 5.5 times higher in high-priority patients. In addition, the MTS was considered to be a good discriminator for the use of diagnostic tools in the emergency department. Comparison of the Emergency Severity Index (ESI) with the MTS revealed that both tools were predictive of admission to the emergency department. However, the ESI was a better predictor of admission than the MTS. Mortality was associated with urgency category for both triage systems (van der Wulp et al., 2009).
Storm-Versloot et al. (2011) reported similar validity in both the ESI and the MTS, but the ESI had a higher rate of sub-triage (i.e. classification of more-severe cases as less urgent) than the MTS. van der Wulp et al. (2008) reported that sub-triage into orange and yellow categories was a serious problem with the MTS, especially in elderly patients, because symptoms often presented in an atypical way; sensitivity was greater in children. The MTS was also found to have moderate sensitivity for the identification of patients requiring immediate and very urgent care. Four studies in Portugal evaluated the efficacy of the MTS in patients with Acute Coronary Syndrome (Matias et al., 2008; Paiva et al., 2012; Pinto Júnior et al., 2010; Providência et al., 2011). Pinto Júnior et al. (2010) reported that the MTS had high sensitivity for assigning “immediate” and “very urgent” priority levels in these patients, and use of a flowchart/discriminator suggestive of Acute Coronary Syndrome had very high specificity and moderate sensitivity. Therefore, possible evolution towards a more sensitive instrument without loss of specificity or vice versa is dependent on the analysis of cases of acute coronary syndrome who present with atypical symptoms. This was confirmed by Matias et al. (2008), who found that most in-patients with Acute Coronary Syndrome were categorised as orange and yellow, indicating the need for “very urgent” and “urgent” care, respectively. The number of patients who should have been classified as “very urgent” or “urgent”, but were not classified as such, was high (28%). It is probable that the situation and condition of the patient worsened due to the improper classification. This may not have been due to incorrect screening, but the fact that the complaints of the patient and clinical presentation at the time of screening led to screening results indicating a lower level of priority, in addition to clinical deterioration after admission. Providência et al. (2011) reported that the MTS was highly effective for the triage of most patients with acute myocardial infarction, particularly those presenting with typical symptoms, resulting in rapid diagnosis and initiation of therapy. Younger patients seemed to be better protected, as atypical manifestations were more common in elderly patients. Providência et al. (2011) suggested that the disease may not have developed completely at the time of emergency department presentation, and the patient’s condition may deteriorate after screening, as found by Matias et al. (2008). Trigo et al. (2008) reported that the MTS led to the misclassification of patients with Acute Coronary Syndrome with ST segment elevation; these patients were classified as less urgent, resulting in a longer delay before the onset of treatment. Matias et al. (2008) and Providência et al. (2011), found that this failure in the classification of patients with acute myocardial infarction with ST segment elevation by the MTS was not due to the clinical and demographic characteristics of patients in the study. This proves a failure in the classification of MTS. The MTS has been shown to be a sensitive instrument for the classification of patients with chest pain who present at an emergency department. The stratification of chest pain allowed adequate allocation of resources for these patients, but further studies are needed to assess if the training of professionals responsible for screening can be improved (Matias et al., 2008). Paiva et al. (2012) assessed the adequacy of the MTS for use in patients with acute pulmonary embolism. The MTS was found to have high sensitivity for assigning “urgent” priority in patients who presented at an emergency department. Five studies investigated the use of the MTS for paediatric patients. Seiger et al. (2011) found that the MTS was a moderately sensitive and specific instrument in paediatric patients, but supertriage (i.e. classification of less-severe cases as more urgent) was a problem, and was much more common than sub-triage (Roukema et al., 2006; Seiger et al., 2011).
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In addition, the MTS demonstrated moderate validity compared with a referenced standard independent paediatric emergency care, and had sensitivity for “very urgent” classification of 63%, meaning that 37% of patients who should have been seen within 10 min were not categorised as “urgent” (Roukema et al., 2006). The study looked at multiple MTS categories, ranging from emergent to non-urgent. Thus, specific modifications in the MTS should be considered for paediatric patients in order to reduce super-triage, while maintaining sensitivity in more urgent categories (Seiger et al., 2011). Seiger et al. (2011) evaluated sub-triage of the MTS in paediatric patients, and concluded that the number of cases of severe sub-triage was very small (approximately 1%). However, severe subtriage could have serious consequences. A systematic assessment of vital signs in all children was recommended in order to reduce sub-triage. Another paediatric study reported that the MTS had little discriminative ability to predict the presence of serious bacterial infections in children with fever in the emergency department (Nijman et al., 2011). Although important predictors of severe bacterial infection are represented within the MTS, a different role is assigned to them in the classification of urgency. van Ierland et al. (2013) assessed whether the flowcharts and discriminators of the MTS were able to predict the risk of hospitalisation in children with fever, and found that the MTS has the potential to identify children at risk of hospitalisation at the beginning of the care process in the emergency department. However, they recognised that the MTS may not be the ideal tool to recognise the risk of hospitalisation in children. More sophisticated tools, such as decision support systems, are rare for general clinical complaints because their development and implementation are difficult and time consuming, and they require additional clinical features that are not available from triage assessment. Two of the 22 studies in this review did not report good efficacy for the MTS. These studies found that the MTS classified a high percentage of patients with acute coronary syndrome with ST segment elevation as less urgent (Trigo et al., 2008), and the MTS did not predict the presence of severe bacterial infection in children in the emergency department (Nijman et al., 2011). The study selected people with ECG changes as part of the inclusion criteria of the study. 5. Limitations This study had a few limitations. Unpublished manuscripts, books and abstracts were not included, so items with negative results or without positive results may not have been included (Sousa and Ribeiro, 2008). In addition, articles published outside the designated study period were excluded. One of the other limitations of the study was the selection of the study time period that excluded articles published prior to 2002, even though articles were published in the 1990s. 6. Conclusion This review examined the efficacy of the MTS for risk classification of patients. Only two of 22 studies reported unfavourable results for the MTS. The remaining articles generally considered the MTS to be effective for use in children, adults, and people with acute coronary syndrome and acute pulmonary embolism. The MTS was considered to be predictive of admission to the emergency department and short-term death. The articles in this review were performed in different geographical areas of the world, showing high suitability and validity of the MTS. It is suggested that the two studies with unfavourable results should be replicated in other locations.
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Systematic review and meta-analysis of diagnostic and prognostic studies: a tutorial. Arquivos Brasileiros de Cardiologia. 92, 229–238. Souza, C.C., Toledo, A.D., Tadeu, L.F.R., Chianca, T.C.M., 2011. Risk classification in an emergency room: agreement level between a Brazilian institutional and the Manchester Protocol. Revista Latino-Americana de Enfermagem. 19, 26–33. Speake, D., Teece, S., Mackway-Jones, K., 2003. Detecting high-risk patients with chest pain. Emergency Nurse. 11, 19–21. Storm-Versloot, M.N., Ubbink, D.T., Kappelhof, J., Luitse, J.S.K., 2011. Comparison of informally structured triage system, the Emergency Severity Index, and the Manchester Triage System to distinguish patient priority in the emergency department. Academic Emergency Medicine. 18, 822–829. Trigo, J., Gago, P., Mimoso, J., Santos, W., Marques, N., Gomes, V., 2008. In-hospital delay ST-segment-elevation myocardial infarction after Manchester triage. 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van der Wulp, I., van Baar, M.E., Schrijvers, A.J., 2008. Reliability and validity of the Manchester Triage System in a general emergency department patient population in the Netherlands: results of a simulation study. Emergency Medicine Journal. 25, 431–434. van der Wulp, I., Schrijvers, A.J., van Stel, H.F., 2009. Predicting admission and mortality with the Emergency Severity Index and the Manchester Triage System: a retrospective observational study. Emergency Medicine Journal. 26, 506–509.
van Ierland, Y., Seiger, N., van Veen, M., Moll, H.A., Oostenbrink, R., 2013. Alarming signs in the Manchester Triage System: a tool to identify febrile children at risk of hospitalization. The Journal of Pediatrics. 162, 862–866. van Veen, M., Steyerberg, E.W., Ruige, M., van Meurs, A.H., Roukema, J., van der Lei, J., et al., 2008. Manchester triage system in paediatric emergency care: prospective observational study. BMJ. 337, a1501.
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REVIEW
Efficacy of the Manchester Triage System: a systematic review Thereza Raquel Machado Azeredo (Student in Nursing) a, Helisamara Mota Guedes RN, MS, PhDst (Nurse, Doctorate’s Student in Nursing, Assistant Professor) a,b,*, Ricardo Alexandre Rebelo de Almeida RN, MS (Nurse) c, Tânia Couto Machado Chianca RN, MS, PhD (Nurse, PhD in Nursing, Titular Professor) b, José Carlos Amado Martins RN, MS, PhD (Adjunct Professor, Coordinator, Post-doctoral student (with scholarship of the FCT – Portugal)) d,e,f a
Federal University of the Mucuri and Jequitinhonha Valley, Diamantina, Minas Gerais, Brazil Federal University of Minas Gerais, Minas Gerais, Brazil Centro Hospitalar University of Coimbra, Coimbra, Portugal d Scientific-Pedagogical Unit of Medical-Surgical Nursing, Nursing School of Coimbra, Coimbra, Portugal e Health Sciences Research Unit – Nursing, Coimbra, Portugal f University of São Paulo at Ribeirão Preto College of Nursing/WHO Collaborating Centre for Nursing Research Development, Brazil b c
A R T I C L E
I N F O
Article history: Received 25 January 2014 Received in revised form 19 May 2014 Accepted 14 June 2014 Keywords: Nursing Emergency medical services Triage Risk assessment Manchester triage Manchester protocol
A B S T R A C T
Introduction: The growing number of patients in emergency departments can lead to overcrowding, often adding to organisational problems. Triage aims to predict the severity of disease, with the aim of organising patient flow. The aim of this study was to analyse the efficacy of the Manchester Triage System (MTS) for risk classification of patients. Methods: A systematic review of the literature in Ebscohost, Pubmed and Scielo (2002–2013) was undertaken. Articles were selected independently by two researchers using selection criteria. Twenty-two articles were selected for inclusion in this review. Results: The results support the applicability of the MTS, which has proven validity for use in children, adults, patients with coronary syndrome and patients with acute pulmonary embolism. The MTS was found to be inclusive, and to predict emergency department admission and death in the short term. Conclusion: The majority of studies found that the MTS was useful in triage of patients in emergency departments, but sub-triage and super-triage (i.e. under and over classification of severity, respectively) still occur. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Globally, the number of patients presenting to emergency departments with a wide variety of problems, ranging from high clinical severity to minor injuries, is increasing (Bittencourt and Hortale, 2009). This may lead to overcrowding in emergency deparments which often have other organisational problems, such as assisting patients based on order of arrival as opposed to the severity of their medical conditional (Souza et al., 2011). Triage has emerged as a method to optimise attendance, and to minimise the damage caused by overcrowding, by identifying patients who need immediate care. Patients are classified according to clinical severity, level of suffering and risk to their own health. In this way, triage is defined as a dynamic process of patient clas-
* Corresponding author. Tel.: +55 3835326073. E-mail address: [email protected] (H.M. Guedes).
sification that allows patients to be allocated to the most suitable service for faster treatment (Ganley and Gloster, 2011). Triage scales predict disease severity, mortality rate and required resources, and should be easily understood, applicable and have high interobserver agreement (Christ et al., 2010). Worldwide, various triage scales are used in emergency departments due to functional differences in services. There is a need for a uniform triage scale that is suitable for all services (Christ et al., 2010). There is no infallible measurement instrument, as measurement errors can arise due to personal factors, environmental situations, changes in the method of data collection and cultural adaptation processes (Souza et al., 2011). The Manchester Triage System (MTS) is a classification system of priority and risk prediction for patients seeking emergency care, widely used in the European Union (Cooke and Jinks, 1999; Storm-Versloot et al., 2011). It aims to standardise the service, providing support and emplacement to decision-making when a patient enters the health service, such that patients are seen in order of
http://dx.doi.org/10.1016/j.ienj.2014.06.001 1755-599X/© 2014 Elsevier Ltd. All rights reserved.
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Table 1 Inclusion and exclusion criteria of articles. Inclusion
Exclusion
1-studies published in Portuguese, Spanish or English;
1-congresses and conferences abstracts;
2-studies published in the last ten years;
2-unpublished studies and theses;
3-studies that consider at least a variable related to implementation, evaluation or characterization of the Manchester Triage System;
3-studies that do not address the STM as the main focus of the work and do not respond to the research question.
4-studies who had as a research subject patients or records of risk classification or STM own.
severity of their clinical condition rather than order of arrival at the emergency department (Storm-Versloot et al., 2011). The MTS has a list of 52 pre-defined conditions or presentation flowcharts that are combined with the main complaint reported by the patient and recorded on a form by a nurse. Classification is divided into five colours: red (immediate), orange (very urgent), yellow (urgent), green (standard) and blue (non-urgent) (Speake et al., 2003). Although theoretical and systematised perspectives have addressed the use of the MTS in emergency departments, it is extremely relevant to identify and analyse the scientific publications on the topic, as the MTS has been introduced into practice relatively recently. This will improve understanding of this triage system, and demonstrate the scientific indications for its implementation in different social contexts. As such, the aim of this study was to assess the efficacy of the MTS for the risk classification of patients, and to describe and analyse its use in relevant articles identified. 2. Methods Systematic reviews involve synthesis of the research related to a specific issue, and frequently involve the efficacy of an intervention (Sampaio and Mancini, 2007). This review aimed to reduce the risk of bias by using a rigorous search methodology for study selection, and evaluating the relevance and validity of the research, collection, synthesis and interpretation of data from the surveys (Galvão et al., 2004). This systematic review assessed the level of evidence of each study in accordance with Sampaio and Mancini (2007): I, systematic review of randomised controlled trials with or without meta-analysis; II, randomized controlled trial; III, cohort study; IV, case–control study; V, quasi-experimental study; VI, descriptive study; VII, single case study or case series; and VIII, expert opinion or case report. Starting from the analysis of theoretical assumptions and defining efficacy as the ability of care, at its best, to improve health (Donabedian, 1990), the following research question was asked: “What is the efficacy of the MTS for risk identification in patients seeking a hospital urgency/emergency service?” Table 1 shows the inclusion and exclusion criteria for articles in this review. On 29 January 2013, Pubmed, Scielo and Ebscohost were searched for relevant articles. Ebscohost includes the following databases:
CINAHL Plus with Full Text, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Cochrane Methodology Register, Library, Information Science Technology Abstracts, Nursing and Allied Health Collection: Comprehensive, Health Technology Assessments, MedicLatina, Academic Search Complete, NHS Economic Evaluation Database, Regional Business News, ERIC and Business Source Complete. This search was performed by two researchers who identified the same number of articles. Scientific articles published between 1 January 2002 and the date of the survey (29 January 2013) were eligible for inclusion in this review. The researchers chose to review articles published only within the last 10 years as part of the selection criteria because it limits the studies to a specific time period. In order to identify relevant studies for inclusion in the review, a set of synonyms and related terms were used to restrict the search and meet the study objectives. The combinations of keywords used by both researchers in each database and the search results are shown in Table 2. Initially, articles were selected independently by two researchers after reading the article titles. Disagreements between researchers were resolved by consensus. In total, 56 articles were selected using Inclusion Criteria 1 and 2, and Exclusion Criteria 1 and 2. The abstracts of these 56 articles were read, with 28 articles selected by one investigator and 25 articles selected by the other investigator. Eleven of these studies were not selected by both reviewers, and following discussion, eight were withdrawn and three were retained. As such, 27 studies were selected using Inclusion Criteria 3 and 4, and Exclusion Criterion 3. Information that was not clearly described in the abstract was obtained by reading the full article. Articles were retained or excluded based on consensus between the two reviewers using Inclusion Criterion 4. Ultimately, 22 articles related to the research question were included in this review. For data analysis, articles were read repeatedly, and the most relevant elements of each study were extracted, namely: author(s), country of publication, study design, sample characterisation, level of evidence and conclusion (Table 2). 3. Results Table 3 summarises the study details (author, year of publication and country) and levels of evidence of the articles in this review.
Table 2 Distribution of keywords for database. Palavra-Chave
Ebsco
Pubmed
Scielo
“Manchester Protocol” OR “Manchester system” OR “Manchester Triage” “Manchester Protocol” OR “Manchester system” OR “Manchester Triage” AND “Triage” “Manchester protocol” OR “Manchester System” OR “Manchester Triage” AND “risk assessment” “Manchester protocol” OR “Manchester System” OR “Manchester Triage” AND “emergency service” “Manchester Protocol” OR “Manchester system” OR “Manchester Triage” AND “triage” AND “risk assessment” “Manchester Protocol” OR “Manchester system” OR “Manchester Triage” AND “triage” AND “emergency service” “Manchester protocol” OR “Manchester System” OR “Manchester Triage” AND “risk assessment” AND “emergency service” “Manchester Protocol” OR “Manchester system” OR “Manchester Triage” AND “triage” AND “risk assessment” AND “emergency service”
98 98 26 62 26 62 24 24
70 55 04 35 02 34 02 01
3 02 00 01 00 01 00 00
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Table 3 Articles’ characteristics found. Author, Year and country Objective
Level of evidence
Evaluates the validity, specificity, sensitivity
Specific condition
What is the specific condition
Affirms validity of the MTS
Matias et al. (2008) – Portugal To assess whether the MTS was used effectively in patients admitted to the hospital with a diagnosis of acute coronary syndrome (ACS). Pinto Júnior et al. (2010) – Portugal To assess the sensitivity of the MTS in assigning high priority to patients with acute coronary syndrome, and the sensitivity and specificity of the combinations of flowcharts and discriminators routinely used for triage in the Emergency Department of Hospital de S. João, Porto. Pinto Júnior et al. (2012) – Brazil To assess the predictive validity of the Manchester Triage System implemented in a municipal hospital in Belo Horizonte, MG, Brazil. Souza et al. (2011) – Brazil To assess the level of agreement between an institutional protocol and the Manchester protocol for the risk assessment of patients attended in an emergency room of a public hospital in Belo Horizonte – MG – Brazil. Soler et al. (2010) – Spain Discuss the system of triage integrated in the computerised clinical history and used in the hospital network of Navarre. Martins et al. (2009) – Portugal To determine whether the subgroups created by the application of MTS have different propensities for indirect triage outcomes such as death in the A&E department or being admitted to hospital. Seiger et al. (2011) – The Netherlands To assess the clinical severity of undertriaged patients in the MTS and to define the determinants of undertriage. Roukema et al. (2006) – The Netherlands To assess the validity of the Manchester Triage System in paediatric emergency care, using information on vital signs, resource utilisation and hospitalization. Dann et al. (2005) – England To determine the efficacy of the MTS discriminator ‘pain’ at identifying ‘standard’ and ‘non-urgent’ attenders in emergency departments, and to estabiish a method of assessing pain duration that allows patients with chronic, mild pain to be more appropriately triaged. Storm-Versloot et al. (2011) – The Netherlands To compare the validity of an existing informally structured triage system with the Emergency Severity Index (ESI) and the Manchester Triage System (MTS). van der Wulp et al. (2009) – The Netherlands To compare the degree to which the Emergency Severity Index (ESI) and the Manchester Triage System (MTS) predict admission and mortality. Santos et al. (2014) – Portugal To determine whether the MTS second version is a useful instrument for determining the risk of hospital admission, intrahospital death and resource utilisation in ED and to compare it with the MTS first version. van Veen et al. (2008) – The Netherlands To validate use of the Manchester triage system in paediatric emergency care. Christ et al. (2010) – Germany To identify modern triage instruments and assess their validity and reliability. Speake et al. (2003) – England To assess the ability of nurses using the MTS to identify those patients with chest pain requiring immediate electrocardiogram (ECG) and physician assessment within ten minutes. van Ierland et al. (2013) – The Netherlands To assess whether the flowcharts and discriminators of the Manchester Triage System can be used as indicators of alarming signs of serious febrile illness to predict the risk of hospitalization for febrile children who present at the emergency department. Providência et al. (2011) – Portugal To evaluate the impact of MTS on short-term mortality in acute myocardial infarction and detect potential improvements, and to analyse high-risk groups: diabetic patients, women and older patients. Paiva et al. (2012) – Portugal To assess the appropriateness of MT in this set of patients presenting acutely to the emergency department, and to determine whether it assists in a rapid diagnosis, acts as a protective triage tool and affects short-term mortality. van der Wulp et al. (2008) – The Netherlands To assess the reliability and validity of the Manchester Triage System in a general emergency department patient population. Trigo et al. (2008) – Portugal To evaluate the effectiveness of the MTS in classifying STEMI patients and its effect on IHD. Nijman et al. (2011) – The Netherlands To evaluate the discriminative ability of the MTS to identify serious bacterial infections in children with fever in the emergency department and to study the association between predictors of SBI and discriminators of MTS urgency of care. van der Straten et al. (2012) – The Netherlands To assess the safety and efficiency of triaging low urgent self-referred patients at the emergency department to a general practitioner based on MTS.
VI
N
Y
ACS
Y
VI
Y
Y
ACS
Y
III
Y
N
Y
VI
Y
N
Y
VI
N
N
Y
III
Y
N
Y
III
N
Y
Pediatric
Y
III
Y
Y
Pediatric
Y
VI
Y
Y
Discriminator ‘pain’
Y
III
Y
N
Y
III
Y
N
Y
III
Y
N
Y
III
Y
Y
VI
Y
N
III
Y
Y
Chest pain
Y
III
Y
Y
Pediatric
Y
III
Y
Y
AMI
Y
III
Y
Y
PE
Y
III
Y
N
III
Y
Y
ACS
N
III
Y
Y
Pediatric
N
III
Y
Y
Triaging low urgent selfreferred patients
Y
Pediatric
Y Y
Y
Y-Yes; N-No; ACS-Acute Coronary Syndrome; PE-Acute Pulmonary Embolism; AMI-Acute Myocardial Infarction.
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Evaluation of validity/specificity/sensitivity of the MTS, evaluation of use of the MTS for a specific condition, and affirmation of efficacy of the MTS are also shown (Table 3). Of the 22 studies in this review, nine (40.9%) were from the Netherlands, seven (31.9%) were from Portugal, two (9.1%) were from Brazil, two (9.1%) were from the UK, one (4.5%) was from Germany and one (4.5%) was from Spain. Only three (13.6%) articles did not use validity, specificity and/ or sensitivity to evaluate the efficacy of the MTS. Twenty (90.9%) studies reported that the MTS had good efficacy, and two (9.1%) studies reported that the MTS was not efficacious. Thirteen articles (59%) evaluated the efficacy of the MTS in a specific group of patients, and studies regarding use of the MTS in children were the most common (Nijman et al., 2011; Seiger et al., 2011). Use of the MTS in patients with clinical conditions such as chest pain, acute coronary syndrome and acute pulmonary embolism was also investigated (Dann et al., 2005; van der Straten et al., 2012). Regarding the evidence levels of studies, 72.7% of studies represented Level III evidence and 27.3% represented Level VI evidence (Table 2). 4. Discussion The MTS is used in many countries around the world, and its efficacy has been shown in scientific studies focusing on a specific disease, age group or the general population. The studies in this review were conducted in different contexts and using different methods to assess the efficacy of the MTS. Most studies used a methodological tool to measure the validity, specificity and/or sensitivity of the MTS. Use of structured triage, such as the MTS, by nurses in the emergency department helps to identify patients who are identified as having life-threatening presentations receive the fastest service. It has been suggested that the ideal triage system should allow resource planning, in addition to the identification of patients who need urgent medical care (Christ et al., 2010). Soler et al. (2010) claimed that triage systems should be structured and based on scales with five levels, such as the MTS. The MTS has a standard nomenclature, uses common definitions, has a robust methodology for screening, implements a model of integral formation, and allows the screening method developed to be audited. Studies that evaluated the MTS without focusing on patients with a specific condition (40.9%) found that, in addition to prioritising the care of patients, the MTS was able to predict the evolution of patients during their stay in the institution, as different rating categories had different developments in severity (Pinto Júnior et al., 2012). In addition, the MTS was considered to be more inclusive compared with an institutional protocol, which increased the level of priority when there were disagreements between classifications (Souza et al., 2011). Martins et al. (2009) reported that the MTS was an extremely important tool to distinguish between patients at low and high risk of death in the short term, and to identify patients who would require hospitalisation for at least 24 h before discharge. Santos et al. (2014) reported that the risk for hospital admission was five times greater in high-priority patients (classified as red or orange using the MTS) compared with low-priority patients (classified as yellow, green or blue), and death during hospitalisation was 5.5 times higher in high-priority patients. In addition, the MTS was considered to be a good discriminator for the use of diagnostic tools in the emergency department. Comparison of the Emergency Severity Index (ESI) with the MTS revealed that both tools were predictive of admission to the emergency department. However, the ESI was a better predictor of admission than the MTS. Mortality was associated with urgency category for both triage systems (van der Wulp et al., 2009).
Storm-Versloot et al. (2011) reported similar validity in both the ESI and the MTS, but the ESI had a higher rate of sub-triage (i.e. classification of more-severe cases as less urgent) than the MTS. van der Wulp et al. (2008) reported that sub-triage into orange and yellow categories was a serious problem with the MTS, especially in elderly patients, because symptoms often presented in an atypical way; sensitivity was greater in children. The MTS was also found to have moderate sensitivity for the identification of patients requiring immediate and very urgent care. Four studies in Portugal evaluated the efficacy of the MTS in patients with Acute Coronary Syndrome (Matias et al., 2008; Paiva et al., 2012; Pinto Júnior et al., 2010; Providência et al., 2011). Pinto Júnior et al. (2010) reported that the MTS had high sensitivity for assigning “immediate” and “very urgent” priority levels in these patients, and use of a flowchart/discriminator suggestive of Acute Coronary Syndrome had very high specificity and moderate sensitivity. Therefore, possible evolution towards a more sensitive instrument without loss of specificity or vice versa is dependent on the analysis of cases of acute coronary syndrome who present with atypical symptoms. This was confirmed by Matias et al. (2008), who found that most in-patients with Acute Coronary Syndrome were categorised as orange and yellow, indicating the need for “very urgent” and “urgent” care, respectively. The number of patients who should have been classified as “very urgent” or “urgent”, but were not classified as such, was high (28%). It is probable that the situation and condition of the patient worsened due to the improper classification. This may not have been due to incorrect screening, but the fact that the complaints of the patient and clinical presentation at the time of screening led to screening results indicating a lower level of priority, in addition to clinical deterioration after admission. Providência et al. (2011) reported that the MTS was highly effective for the triage of most patients with acute myocardial infarction, particularly those presenting with typical symptoms, resulting in rapid diagnosis and initiation of therapy. Younger patients seemed to be better protected, as atypical manifestations were more common in elderly patients. Providência et al. (2011) suggested that the disease may not have developed completely at the time of emergency department presentation, and the patient’s condition may deteriorate after screening, as found by Matias et al. (2008). Trigo et al. (2008) reported that the MTS led to the misclassification of patients with Acute Coronary Syndrome with ST segment elevation; these patients were classified as less urgent, resulting in a longer delay before the onset of treatment. Matias et al. (2008) and Providência et al. (2011), found that this failure in the classification of patients with acute myocardial infarction with ST segment elevation by the MTS was not due to the clinical and demographic characteristics of patients in the study. This proves a failure in the classification of MTS. The MTS has been shown to be a sensitive instrument for the classification of patients with chest pain who present at an emergency department. The stratification of chest pain allowed adequate allocation of resources for these patients, but further studies are needed to assess if the training of professionals responsible for screening can be improved (Matias et al., 2008). Paiva et al. (2012) assessed the adequacy of the MTS for use in patients with acute pulmonary embolism. The MTS was found to have high sensitivity for assigning “urgent” priority in patients who presented at an emergency department. Five studies investigated the use of the MTS for paediatric patients. Seiger et al. (2011) found that the MTS was a moderately sensitive and specific instrument in paediatric patients, but supertriage (i.e. classification of less-severe cases as more urgent) was a problem, and was much more common than sub-triage (Roukema et al., 2006; Seiger et al., 2011).
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In addition, the MTS demonstrated moderate validity compared with a referenced standard independent paediatric emergency care, and had sensitivity for “very urgent” classification of 63%, meaning that 37% of patients who should have been seen within 10 min were not categorised as “urgent” (Roukema et al., 2006). The study looked at multiple MTS categories, ranging from emergent to non-urgent. Thus, specific modifications in the MTS should be considered for paediatric patients in order to reduce super-triage, while maintaining sensitivity in more urgent categories (Seiger et al., 2011). Seiger et al. (2011) evaluated sub-triage of the MTS in paediatric patients, and concluded that the number of cases of severe sub-triage was very small (approximately 1%). However, severe subtriage could have serious consequences. A systematic assessment of vital signs in all children was recommended in order to reduce sub-triage. Another paediatric study reported that the MTS had little discriminative ability to predict the presence of serious bacterial infections in children with fever in the emergency department (Nijman et al., 2011). Although important predictors of severe bacterial infection are represented within the MTS, a different role is assigned to them in the classification of urgency. van Ierland et al. (2013) assessed whether the flowcharts and discriminators of the MTS were able to predict the risk of hospitalisation in children with fever, and found that the MTS has the potential to identify children at risk of hospitalisation at the beginning of the care process in the emergency department. However, they recognised that the MTS may not be the ideal tool to recognise the risk of hospitalisation in children. More sophisticated tools, such as decision support systems, are rare for general clinical complaints because their development and implementation are difficult and time consuming, and they require additional clinical features that are not available from triage assessment. Two of the 22 studies in this review did not report good efficacy for the MTS. These studies found that the MTS classified a high percentage of patients with acute coronary syndrome with ST segment elevation as less urgent (Trigo et al., 2008), and the MTS did not predict the presence of severe bacterial infection in children in the emergency department (Nijman et al., 2011). The study selected people with ECG changes as part of the inclusion criteria of the study. 5. Limitations This study had a few limitations. Unpublished manuscripts, books and abstracts were not included, so items with negative results or without positive results may not have been included (Sousa and Ribeiro, 2008). In addition, articles published outside the designated study period were excluded. One of the other limitations of the study was the selection of the study time period that excluded articles published prior to 2002, even though articles were published in the 1990s. 6. Conclusion This review examined the efficacy of the MTS for risk classification of patients. Only two of 22 studies reported unfavourable results for the MTS. The remaining articles generally considered the MTS to be effective for use in children, adults, and people with acute coronary syndrome and acute pulmonary embolism. The MTS was considered to be predictive of admission to the emergency department and short-term death. The articles in this review were performed in different geographical areas of the world, showing high suitability and validity of the MTS. It is suggested that the two studies with unfavourable results should be replicated in other locations.
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