MANCHESTER TRIAGE SYSTEM: why, how and where?

Kevin Mackway-Jones Manchester Royal Infirmary UK

History
Observations 1994
Surprising triage decisions Inconsistent triage decisions

History
Question
How does triage work?

History
Answer
Because it does

History
Case 26 year old man involved in pedestrian RTA. Bilateral fractured tibia and fibula. 5 hours in minor treatment without treatment

History
Local consultation
Common problem Wish for common

solution

History
Local review
No consistency

History
A First Second Third Fourth Fifth Others 0 <15 <120 <240 B 0 10 60 120 ~ FGHI C 0 5-10 30-60 ~ D 0 <10 ~

History
The Manchester Triage Group

1995

All local Emergency Physicians All local Emergency Nurses

History

Common nomenclature Common definitions Common methodology Common teaching Common audit

Triage Group: Nomenclature

How many priorities?

What should they be called?

History
A First Second Third Fourth Fifth 0 <15 < <120 <240 B 0 10 60 120 ~ ~ ~ C 0 5-10 30-60 D 0 <10

Triage Group: Nomenclature

Number First Second Third Fourth Fifth Red Orange Yellow Green Blue Colour Name Immediate Very urgent Urgent Standard Non-urgent

Triage Group: Nomenclature

Number First Second Third Fourth Fifth Red Orange Yellow Green Blue Colour Name Immediate Very urgent Urgent Standard Non-urgent

Triage Group: Nomenclature

Number First Second Third Fourth Fifth Red Orange Yellow Green Blue Colour Name Immediate Very urgent Urgent Standard Non-urgent

Triage Group: Nomenclature

Number First Second Third Fourth Fifth Red Orange Yellow Green Blue Colour Name Immediate Very urgent Urgent Standard Non-urgent

Triage Group: Definitions

How long is it safe to wait How long is it reasonable to wait

Triage Group: Target Times

First Second Third Fourth Fifth

10 min 60 min

0 min

120 min 240 min

Triage Group: Methodology

What is triage for? What is the construct? How should triage be performed?

Triage Group: Methodology

Triage IS: a professional

assessment process that should identify the priority of the patient for clinical intervention

Triage Group: Methodology

Triage IS NOT: designed to predict

need for admission, resource usage, diagnosis, stream or final destination

Triage Group: Methodology

Triage IS NOT: the only factor that

affects the MANAGEMENT of the patient by the system

Triage Group: Methodology

MTS is Reductive
All patients start as priority 1.

Triage Group: Methodology

MTS divides patients into

presentations

Recognisable constructs NOT diagnoses

Triage Group: Methodology

MTS uses discriminators

General discriminators for all patients Specific discriminators depending on

presentation

Triage Group: Methodology

Presentation

Triage Group: Methodology

P1 Discriminators

Triage Group: Methodology

P1 Discriminators

Triage Group: Methodology

P1 Discriminators

P2 Discriminators

Triage Group: Methodology

P1 Discriminators

P2 Discriminators

Triage Group: Methodology

P3 Discriminators

P4 Discriminators

Triage Group: Methodology

P1 Discriminators

Presentation

P2 Discriminators

P3 Discriminators

P4 Discriminators

History

Triage Group: Training

Training box 20 manuals 3 instructor manuals Instructor materials

History

A national solution

in the UK

Triage Group: Audit

Individual practitioner Institution

Triage Group: Audit

Triage Practitioner

Initial case selection Random from computer record

Select 2% (min 10) records

Total

Triage Group: Audit

Triage Practitioner Select 2% (min 10) records

Total

Presentation correct? No B Innacurate % Void = 100*C/A Yes

Incomplete

No

Sufficient information?

No

Yes

Check A = B+C+D

Discriminator correct?

Assessment of accuracy of presentation selection Assessment of completeness of information gathering Assessment of accuracy of discriminator selection

Yes

Accurate

% Accuracy = 100*D/A

Individual audit: Aims

0% episodes

incomplete this includes pain scores, documentation, etc

95% accuracy

Triage Audit: Showing change

60 50 % 40 30 20 10 0 1 2 3 4 5

Priority pre MTS

Triage Audit: Showing change

60 50 % 40 30 20 10 0 1 2 3 4 5

Priority post MTS

Triage Audit: Institutional

Accuracy by Department
100

90 80

70

Accuracy (%

60

50

40

30 20

10

0 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Study ID

Progress

Does the MTS work?

some evidence from the literature

Construct validity

Does the system identify the patients it sets out to identify?

Does the Manchester Triage System detect the critically ill?

Cooke MW, Jinks S J Accid Emerg Med 1999

Methods
Analysis of triage coding of admissions to critical care areas Analysis of under-triage

Nurse operators MTS

Conclusions

The MTS is a highly sensitive tool for identifying critically ill patients on arrival at emergency department

Validation of physiological scoring systems in the A&E Department

Subbe CP, Slater A, Menon D, Gemmell L Emerg Med J, 2006

Results
Sensitivity at predicting ED-ITU

MTS MEWS ASSIST METS

96% 77% 22% 1%

Results

Sensitivity at predicting ED-ward-ITU

MTS MEWS ASSIST METS

65% 55% 8% 3%

Conclusions

MTS is much more sensitive than any physiological score at identifying critically ill patients on arrival at emergency department Physiological scoring adds little to the MTS in identifying critically ill patients on arrival at emergency department

Detecting High Risk Patients with Chest Pain

Speake D, Teece S, Mackway-Jones K Emergency Nurse 2003

Conclusions

Sensitivity 86.8% (78.4 - 92.3)

Specificity 72.4% (61.4 81.2)

Sensitivity and specificity of the Manchester Triage System for patients with acute coronary syndromes

Pinto D, Lunet N, Azevedo A Rev Port Cardiol, 2010

Conclusions

Nurses using MTS are highly sensitive at detecting cardiac chest pain

The diagnostic utility of triage nurses at recognising pleuritic chest pain

Wright J, Hogg K, Mackway-Jones K Emergency Nurse, 2005

Conclusions
Sensitivity 69.2% (56.7 - 81.7)

Specificity 92.7% (88.2 97.2)

Predicting admission and mortality with the Emergency Severity Index and the Manchester Triage System: a retrospective observational study

van der Wulp I, Schrivers AJP, van Stell HF Emergency Medicine Journal, 2009

van der Wulp I et al, 2009

Retrospective database study from 4 EDs, 2006

34,258 patients

van der Wulp I et al, 2009

Likelihood of admission decreased with decreasing triage category 96.6% of patients who died were priority 1 or 2

Is Manchester (MTS) more than a triage system? A study of its association with mortality and admission to a large Portuguese hospital

Martins HMG, De Castro Dominguez Cun LM, Freitas P Emergency Medicine Journal, 2009

Martins HMG et al, 2009

Retrospective database analysis

321,539 patients (2005 2007)

Martins HMG et al, 2009

Proportion admitted decreased with decreasing priority Odds of dying 39x higher in P1,2

Validity of the Manchester Triage System in paediatric emergency care

Roukema J, Steyerberg EW, van Meurs A et al Emergency Medicine Journal, 2006

Manchester triage system in paediatric emergency care: prospective observational study

van Veen M, Steyerberg EW, Ruige M et al British Medical Journal, 2008

Conclusions

The Manchester triage system has moderate validity in paediatric emergency care. It errs on the safe side, with much more over-triage than under-triage

Reproducibility

Do different triage nurses arrive at the same priority when triaging the same patient?

Observer agreement of the Manchester Triage System and the Emergency Severity Index: a simulation study

Storm-Versloot MN, Ubbink DT, Choi VCA et al Emergency Medicine Journal, 2008

Reliability and validity of the Manchester Triage System in a general emergency department patient population in the Netherlands: results of a simulation study

van der Wulp I, van Bar ME, Schrivers AJP Emergency Medicine Journal, 2008

The Manchester triage system provides good reliability in an Australian emergency department

Grouse AI, Bishop RO, Bannon AM Emergency Medicine Journal , 2009

Manchester Triage in Sweden Interrater reliability and accuracy

Oloffson P, Gellerstedt M, Carlstrm ED International Journal of Nursing, 2009

Interrater reproducibility studies

Author
Storm-Vestoot et al, 2008, Netherlands van der Wulp et al, 2008, Netherlands Grouse et al, 2009, Australia Ollofson et al, 2009, Sweden

Cases
50 50 50 13

Test group
8 nurses from 3 units 48 nurses from 2 units 20 nurses from 1 unit 79 nurses from 7 units

Interrater reproducibility studies

Author
Storm-Vestoot et al, 2008 van der Wulp et al, 2008 Grouse et al, 2009 Ollofson et al, 2009

Kappa
0.76 (0.68 0.83) 0.62 (0.6 0.65) 0.63 0.61 (0.57 0.65)

Test-retest reproducibility studies

Author
Storm-Vestoot et al, 2008 van der Wulp et al, 2008

Kappa
0.75 (0.72 0.77) 0.84 (0.73 0.94)

Conclusions

The Manchester Triage System has good inter-rater reproducibility and good to excellent test-retest reproducibility

Progress
Increasing usage Little criticism Increasing Changing clinical Some valid

comments

evidence

practice

Second Edition

Manchester Triage Group

+
International Reference Group

Second Edition
Review of chart titles Review of chart contents Review of discriminators

General Discriminators
Airway compromise Inadequate breathing Exsanguinating haemorrhage Shock Currently fitting Unresponsive child

RED

Severe pain Uncontrollable major haemorrhage Altered conscious level Hot child Cold Very hot adult

ORANGE

Moderate pain Uncontrollable minor haemorrhage History of unconsciousness Hot adult

YELLOW

Recent mild pain Warmth Recent

GREEN

BLUE

Second Edition

New chart: Allergy

Second Edition

New Chart: Palpitations

Second Edition

New Chart: Falls

Second Edition

Haematological D, V now D&V Nasal problems now Facial Problems

Progress

Brazil Austria Norway Poland Slovenia

What is MTS for?

Determining clinical priority Managing clinical risk Speaking a common language of urgency

What is MTS not designed for?

Managing the department Predicting the need for admission Identifying resource requirement

What else can MTS do the future

Start the process of care Aid in initial disposition decisions Telephone triage Non-professional triage

Triage and the clinical process

MTS Chest Pain

Emergency Department

Cardiac Chest Pain

Patient with cardiac chest pain

Decision Support Guidelines

Name______________________ AE___/____________

Date___/___/_____

Complete PDI/010 overleaf

Normal Immediate ECG Clinical Risk Assessment

Complete CDU/011 overleaf

Low to moderate

STEMI

ST changes High

Time since pain onset >9h

Complete Ref/012 overleaf LMWH >5 6 hours of ST segment monitoring

0-9h

CKMB mass stat

Oral beta blockers

>5

CKMB mass after 3h

>5

CKMB mass after 6h

Troponin T at 12 h + Complete Ref/013 overleaf Complete CDU/014 overleaf Immediate Revascularisation Admit to consider Revascularisation

< 0.01

Troponin T at 12h +

< 0.01

All < 5 > 0.01 > 0.01 Complete Ref/015 overleaf Discharge Investigate as OP

Admit for investigation

Cardiac Chest Pain

Which Patients?

Over 25 years Unrelated to trauma Not pleuritic

MTS Chest Pain Patient with cardiac chest pain

Complete PDI/010 overleaf

Deciding initial disposition (streaming)

Presentation-Priority Matrix
There There

are 50 Charts are 5 priorities

Presentation-Priority Matrix

There are 250(ish) possible

outcomes

Presentation / Priority pairs

Presentation-Priority Matrix

The local mapping process

Identify possible dispositions

Map each p-p complex to a disposition

Identify local stakeholders

Map each p-p complex to a disposition

Iteration

Final Map

Map each p-p complex to a disposition

PPM for MRI

Telephone Triage

Triage Group: TTA principles

Now
Now

Soon Later

Soon

Later

Advice

Advice

Telephone charts

Matching format

Same principles

Non-professional triage

Child

Acutely short of breath Currently fitting Severe pain Oedema of the tongue Fails to react to parents Non-blanching rash Inconsolable by parents Floppy

Usual clinical assessment

Severe pain Major bleeding History of unconsciousness Acute chemical injury to the eye Widespread burns Deformity Marked distress

Early clinical assessment

Adult

Acutely short of breath Abrupt onset headache Currently fitting Oedema of the tongue Altered conscious level Severe pain Non-blanching rash Chest pain

The future
Continuous improvement 2e to 3e Separate edition for children Separate edition for telephone triage

Summary
MTS has come a long way in a short time It will go further

International Reference Group

Lisbon Hamburg Manchester Graz Oslo 2012

MANCHESTER TRIAGE SYSTEM: why, how and where?

Kevin Mackway-Jones Manchester Royal Infirmary UK

For all is but a woven web of guesses"

Xenophanes