Effectiveness of the Manchester Triage System on time to treatment in the emergency department: a systematic review

The Effects of Displaying the Time Targets of the Manchester Triage System to Emergency Department Personnel: Prospective Crossover Study

BACKGROUND

The use of triage systems such as the Manchester Triage System (MTS) is a standard procedure to determine the sequence of treatment in emergency departments (EDs). When using the MTS, time targets for treatment are determined. These are commonly displayed in the ED information system (EDIS) to ED staff. Using measurements as targets has been associated with a decline in meeting those targets.

OBJECTIVE

This study investigated the impact of displaying time targets for treatment to physicians on processing times in the ED.

METHODS

We analyzed the effects of displaying time targets to ED staff on waiting times in a prospective crossover study, during the introduction of a new EDIS in a large regional hospital in Germany. The old information system version used a module that showed the time target determined by the MTS, while the new system version used a priority list instead. Evaluation was based on 35,167 routinely collected electronic health records from the preintervention period and 10,655 records from the postintervention period. Electronic health records were extracted from the EDIS, and data were analyzed using descriptive statistics and generalized additive models. We evaluated the effects of the intervention on waiting times and the odds of achieving timely treatment according to the time targets set by the MTS.

RESULTS

The average ED length of stay and waiting times increased when the EDIS that did not display time targets was used (average time from admission to treatment: preintervention phase=median 15, IQR 6-39 min; postintervention phase=median 11, IQR 5-23 min). However, severe cases with high acuity (as indicated by the triage score) benefited from lower waiting times (0.15 times as high as in the preintervention period for MTS1, only 0.49 as high for MTS2). Furthermore, these patients were less likely to receive delayed treatment, and we observed reduced odds of late treatment when crowding occurred.

CONCLUSIONS

Our results suggest that it is beneficial to use a priority list instead of displaying time targets to ED personnel. These time targets may lead to false incentives. Our work highlights that working better is not the same as working faster.

Quality of fluid balance charting and interventions to improve it: a systematic review

INTRODUCTION

Fluid balance monitoring is pivotal to patients' health. Thus, fluid balance charting is an essential part of clinical nursing documentation. This systematic review aimed to investigate and describe the quality of fluid balance monitoring in medical, surgical and intensive care units, with an emphasis on the completeness of charting data, calculation errors and accuracy, and to evaluate methods used to improve fluid balance charting.

MATERIALS AND METHODS

Quantitative studies involving adult patients and reporting data on fluid balance monitoring were included in the review. We searched MEDLINE, Embase, CINAHL and the Cochrane Library. The risk of bias in the included studies was assessed using tools developed by the Joanna Briggs Institute.

RESULTS

We included a total of 23 studies, which involved 6649 participants. The studies were quasi-experimental, cohort or prevalence studies, and every third study was of low quality. Definitions of 'completeness' varied, as well as patient categories and time of evaluation. Eighteen studies reported the prevalence of patients with complete fluid balance charts; of those, 10 reported that not more than 50% of fluid balance charts were complete. Studies addressing calculation errors found them in 25%-35% of charts, including omissions of, for example, intravenous medications. The reported interventions consisted of various components such as policies, education, equipment, visual aids, surveillance and dissemination of results. Among studies evaluating interventions, only 38% (5 of 13) achieved compliance with at least 75% of complete fluid balance charts. Due to the heterogeneity of the studies, a meta-analysis was not possible.

CONCLUSION

The quality of fluid balance charting is inadequate in most studies, and calculation errors influence quality. Interventions included several components, and the impact on the completion of fluid balance charts varied.

Effect of In-Situation Versus Manchester Triage System-Based Initial Case Management on Hospital-Based Mortality: A Before and After Study

OBJECTIVE

To compare mortality and treatment-initiation time pre- and post introduction of Manchester Triage System (MTS) in patients of age group 1 mo to 15 y admitted in a tertiary care hospital in India.

METHODS

Pre- and post intervention study conducted on a prospective cohort of patients hospitalized over a period of 6 mo, who were triaged using MTS and compared with a retrospective cohort, who were not formally triaged using any system and were admitted to the hospital during the past 6 mo, prior to commencement of the study. Intervention was training of resident doctors for five MTS urgencies using flowcharts and discriminators and displaying them in the emergency room. Data on clinical and outcome variables were abstracted from hospital case record sheets in both the cohorts.

RESULTS

The present study was conducted from May 2019 to April 2020 including 450 patients hospitalized from August 2019 to January 2020 in a prospective cohort and a retrospective cohort of 450 patients hospitalized from January 2019 to June 2019. Overall mortality in pre-MTS group was 26.2% (118/450) as compared to 20.9% (94/450) in post-MTS group (p value = 0.021). Average treatment time was reduced from 30 to 10 min after implementation of MTS (p value = 0.001).

CONCLUSION

Implementation of MTS in pediatric emergency leads to statistically significant reduction of mortality and average treatment-initiation time.

Implementing a new emergency medical triage tool in one health region in Norway: some lessons learned

BACKGROUND

Acutely sick or injured patients depend on ambulance and emergency department personnel performing an accurate initial assessment and prioritisation (triage) to effectively identify patients in need of immediate treatment. Triage also ensures that each patient receives fair initial assessment. To improve the patient safety, quality of care, and communication about a patient's medical condition, we implemented a new triage tool (the South African Triage Scale Norway (SATS-N) in all the ambulance services and emergency departments in one health region in Norway. This article describes the lessons we learnt during this implementation process.

METHODS

The main framework in this quality improvement (QI) work was the plan-do-study-act cycle. Additional process sources were 'The Institute for Healthcare Improvement Model for improvement' and the Norwegian Patient Safety Programme.

RESULTS

Based on the QI process as a whole, we defined subjects influencing this work to be successful, such as identifying areas for improvement, establishing multidisciplinary teams, coaching, implementing measurements and securing sustainability. After these subjects were connected to the relevant challenges and desired effects, we described the lessons we learnt during this comprehensive QI process.

CONCLUSION

We learnt the importance of following a structured framework for QI process during the implementation of the SATS-N triage tool. Furthermore, securing anchoring at all levels, from the managements to the medical professionals in direct patient-orientated work, was relevant important. Moreover, establishing multidisciplinary teams with ambulance personnel, emergency department nurses and doctors with various medical specialties provided ownership to the participants. Meanwhile, coaching provided necessary security for the staff directly involved in caring for patients. Keeping the spirit and perseverance high were important factors in completing the implementation. Establishment of the regional network group was found to be important for sustainability and further improvements.