Validity of the Manchester Triage System in patients with sepsis presenting at the ED: a first assessment

Enhancing triage accuracy: The influence of nursing education on risk prediction

AIM

This study aimed to compare the performance in risk prediction of various outcomes between specially trained triage nurses and the Manchester Triage System (MTS).

DESIGN

Prospective observational study.

METHODS

The study was conducted from June 1st to December 31st, 2023, at the Emergency Department of Merano Hospital. Triage nurses underwent continuous training through dedicated courses and daily audits. We compared the risk stratification performed by expert nurses with that of MTS on various outcomes such as mortality, hospitalisation, and urgency defined by the physicians. Comparisons were made using the Areas Under the Receiver Operating Characteristic curve (AUROC).

RESULTS

The agreement in code classification between the MTS and the expert nurse was very low. The AUROC curve analysis showed that the expert nurse outperformed the MTS in all outcomes. The triage nurse's experience led to statistically significant better stratification in admission rates, ICU admissions, and all outcomes based on the physician's assessment.

CONCLUSIONS

The continuous training of nurses enables them to achieve better risk prediction compared to standardized triage systems like MTS, emphasizing the utility and necessity of implementing continuous training pathways for these highly specialised personnel.

Study about the Manchester Triage System subtriage in patients that visited the Emergency Department due to headache

INTRODUCTION

Headache is a frequent cause of consultation; it is important to detect patients with secondary headache, particularly high-risk secondary headache. Such systems as the Manchester Triage System (MTS) are used for this purpose. This study aims to evaluate the frequency of sub-triage in patients attending the emergency department due to headache.

MATERIAL AND METHODS

We studied a series of consecutive patients who came to the emergency department with headache and presenting some warning sign, defined as the presence of signs leading the physician to request an emergency neuroimaging study and/or assessment by the on-call neurologist. The reference diagnosis was established by neurologists. We evaluated the MTS triage level assigned and the presence of warning signs that may imply a higher level than that assigned.

RESULTS

We registered a total of 1120 emergency department visits due to headache, and 248 patients (22.8%) were eligible for study inclusion. Secondary headache was diagnosed in 126 cases (50.8% of the sample; 11.2% of the total), with 60 cases presenting high-risk secondary headache (24.2%; 5.4%). According to the MTS, 2 patients were classified as immediate (0.8%), 26 as very urgent (10.5%), 147 as urgent (59.3%), 68 as normal (27.4%), and 5 as not urgent (2%). The percentage of patients under-triaged was 85.1% in the very urgent classification level and 23.3% in the urgent level.

CONCLUSION

During the study period, at least one in 10 patients attending the emergency department due to headache had secondary headache; one in 20 had high-risk secondary headache. The MTS under-triaged most patients with warning signs suggesting a potential emergency.

Audit of a computerized version of the Manchester triage system and a SIRS-based system for the detection of sepsis at triage in the emergency department

BACKGROUND AND IMPORTANCE

Different triage systems can be used to screen for sepsis and are often incorporated into local electronic health records. Often the design and interface of these digitalizations are not audited, possibly leading to deleterious effects on screening test performance.

OBJECTIVE

To audit a digital version of the MTS for detection of sepsis during triage in the ED.

DESIGN

A single-center retrospective study SETTINGS AND PARTICIPANTS: Patients (n=29766) presenting to an ED of a tertiary-care center who received formal triage were included.

OUTCOME MEASURES AND ANALYSIS

Calculated performance measures included sensitivity, specificity, likelihood ratios, and AUC for the detection of sepsis. Errors in the application of the specific sepsis discriminator of the MTS were recorded.

MAIN RESULTS

A total of 189 (0.7%) subjects met the Sepsis-3 criteria, with 47 cases meeting the criteria for septic shock. The MTS had a low sensitivity of 47.6% (95% CI 40.3 to 55.0) for allocating sepsis patients to the correct triage category. However, specificity was high at 99.4% (95% CI 99.3 to 99.5).

Decision support-tools for early detection of infection in older people (aged> 65 years): a scoping review

Background

Infection is more frequent, and serious in people aged > 65 as they experience non-specific signs and symptoms delaying diagnosis and prompt treatment. Monitoring signs and symptoms using decision support tools (DST) is one approach that could help improve early detection ensuring timely treatment and effective care.

Objective

To identify and analyse decision support tools available to support detection of infection in older people (> 65 years).

Methods

A scoping review of the literature 2010–2021 following Arksey and O’Malley (2005) framework and PRISMA-ScR guidelines. A search of MEDLINE, Cochrane, EMBASE, PubMed, CINAHL, Scopus and PsycINFO using terms to identify decision support tools for detection of infection in people > 65 years was conducted, supplemented with manual searches.

Results

Seventeen papers, reporting varying stages of development of different DSTs were analysed. DSTs largely focussed on specific types of infection i.e. urine, respiratory, sepsis and were frequently hospital based (n = 9) for use by physicians. Four DSTs had been developed in nursing homes and one a care home, two of which explored detection of non- specific infection.

Conclusions

DSTs provide an opportunity to ensure a consistent approach to early detection of infection supporting prompt action and treatment, thus avoiding emergency hospital admissions. A lack of consideration regarding their implementation in practice means that any attempt to create an optimal validated and tested DST for infection detection will be impeded. This absence may ultimately affect the ability of the workforce to provide more effective and timely care, particularly during the current covid-19 pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03218-w.

The Manchester Triage System's performance in clinical risk prioritisation of patients presenting with headache in emergency department: A retrospective observational study

OBJECTIVE

Non-traumatic headache is a frequent reason for visits to the emergency department (ED). We evaluated the performance of the Manchester Triage System (MTS) in prioritising patients presenting to the ED with non-traumatic headache.

METHODS

In this single-centre observational retrospective study, we compared the association of MTS priority classification codes with a final diagnosis of a severe neurological condition requiring timely management (ischaemic or haemorrhagic stroke, subarachnoid haemorrhage, cerebral sinus venous thrombosis, central nervous system infection or brain tumour). The study was conducted and reported according to the STROBE statement. The overall prioritisation accuracy of MTS was estimated by the area under the receiver operating characteristic (ROC) curve. The correctness of triage prediction was estimated based on the "very urgent" MTS grouping. An undertriage was defined as a patient with an urgent and severe neurological who received a low priority/urgency MTS code (green/yellow).

RESULTS

Over 30 months, 3002 triage evaluations of non-traumatic headache occurred (1.7% of ED visits). Of these, 2.3% (68/3002) were eventually diagnosed with an urgent and severe neurological condition. The MTS had an acceptable prioritisation accuracy, with an area under the ROC curve of 0.734 (95% CI 0.668-0.799). The sensitivity of the MTS for urgent codes (yellow, orange and red) was 79.4% (95% CI 74.5-84.3), with a specificity of 54.1% (95% CI 52.9-55.3). The triage prediction was incorrect in only 6.3% (190/3002) of patients with headache.

CONCLUSION

The MTS is a safe and accurate tool for prioritising patients with non-traumatic headache in the ED. However, MTS may need further specific tools for evaluating the more complicated symptoms and for correctly identifying patients with urgent and severe underlying pathologies.

RELEVANCE TO CLINICAL PRACTICE

The triage nurse using MTS may need additional tools to improve the assessment of patients with headache, although MTS provides a good safety profile.

Mortality risk for different presenting complaints amongst older patients assessed with the Manchester triage system

PURPOSE

Older people often present to the Emergency Department with nonspecific complaints. We aimed (1) to examine characteristics of older patients presenting to the ED triaged with the presentational flowchart 'unwell adult' of the Manchester triage system (MTS) and (2) to assess the different mortality and admission rates among triage categories.

METHODS

Retrospective cohort study including all consecutive patients aged 70 years and older who visited the ED of a tertiary care hospital in the Netherlands during a 1-year period. The primary outcome was 30-day mortality. Secondary outcomes were 7-day mortality, hospital admission and ED length of stay.

RESULTS

4255 patients were included in this study. Mean age was 78 years (IQR 73.9-83.4) and 2098 were male (49.3%). The MTS presentational flowchart 'unwell adult' was the most commonly used flowchart (n = 815, 19.3%). After the infrequent flowchart 'major trauma' (n = 9, 13.8%), 'unwell adult' had the highest 30-day mortality (n = 88, 10.8%). When compared to all other flowcharts, patients assigned as 'unwell adult' have significantly higher 30-day mortality rates (OR 1.89 (95%CI 1.46-2.46), p =  < 0.001), also when adjusted for age, gender and triage priority (OR 1.75 (95%CI 1.32-2.31), p =  < 0.001). Patients from the 'unwell adult' flowchart had the highest hospital admission rate (n = 540, 66.3%), and had among the longest ED length of stay.

CONCLUSIONS

Older ED patients are most commonly assigned the presentational flowchart 'unwell adult' when using the MTS. Patients in this category have the highest non-trauma mortality and highest hospital admission rates when compared to other presenting complaints.

Mortality benefit of crystalloids administered in 1-6 hours in septic adults in the ED: systematic review with narrative synthesis

BACKGROUND

Based on the 2018 update of the Surviving Sepsis Campaign, the Committee for Quality Improvement of the NHSs of England recommended the instigation of the elements of the 'Sepsis-6 bundle' within 1 hour to adult patients screened positive for sepsis. This bundle includes a bolus infusion of 30 mL/kg crystalloids in the ED. Besides the UK, both in the USA and Australia, compliance with similar 1-hour targets became an important quality indicator. However, the supporting evidence may neither be contemporaneous nor necessarily valid for emergency medicine settings.

METHOD

A systematic review was designed and registered at PROSPERO to assess available emergency medicine/prehospital evidence published between 2012 and 2020, investigating the clinical benefits associated with a bolus infusion of a minimum 30 mL/kg crystalloids within 1 hour to adult patients screened positive for sepsis. Due to the small number of papers that addressed this volume of fluids in 1 hour, we expanded the search to include studies looking at 1-6 hours.

RESULTS

Seven full-text articles were identified, which investigated various aspects of the fluid resuscitation in adult sepsis. However, none answered completely to the original research question aimed to determine either the effect of time-to-crystalloids or the optimal fluid volume of resuscitation. Our findings demonstrated that in the USA/UK/Australia/Canada, adult ED septic patients receive 23-43 mL/kg of crystalloids during the first 6 hours of resuscitation without significant differences either in mortality or in adverse effects.

CONCLUSION

This systematic review did not find high-quality evidence supporting the administration of 30 mL/kg crystalloid bolus to adult septic patients within 1 hour of presentation in the ED. Future research must investigate both the benefits and the potential harms of the recommended intervention.

Acute abdominal pain in triage: A retrospective observational study of the Manchester triage system's validity

OBJECTIVE

Roughly 5% to 10% of patients admitted to the emergency department suffer from acute abdominal pain. Triage plays a key role in patient stratification, identifying patients who need prompt treatment versus those who can safely wait. In this regard, the aim of this study was to estimate the performance of the Manchester Triage System in classifying patients with acute abdominal pain.

METHODS

A total of 9,851 patients admitted at the Emergency Department of the Merano Hospital with acute abdominal pain were retrospectively enrolled between 1 January 2017 and 30 June 2019. The study was conducted and reported according to the STROBE statement. The sensitivity and specificity of the Manchester Triage System were estimated by verifying the triage classification received by the patients and their survival at seven days or the need for acute surgery within 72 h after emergency department access.

RESULTS

Among the patients with acute abdominal pain (median age 50 years), 0.4% died within seven days and 8.9% required surgery within 72 hours. The sensitivity was 44.7% (29.9-61.5), specificity was 95.4% (94.9-95.8), and negative predictive value was 99.7% (99.2-100) in relation to death at seven days.

CONCLUSIONS

The Manchester Triage System shows good specificity and negative predictive value. However, its sensitivity was low due to the amount of incorrect triage prediction in patients with high-priority codes (red/orange), suggesting overtriage in relation to seven-day mortality. This may be a protective measure for the patient. In contrast, the need for acute surgery within 72 h was affected by under-triage.

RELEVANCE TO CLINICAL PRACTICE

The triage nurse using Manchester Triage System can correctly prioritise the majority of patients with acute abdominal pain, especially in low acuity patients. The Manchester Triage System is safe and does not underestimate the severity of the patients.

Study about the Manchester Triage System subtriage in patients that visited the Emergency Department due to headache

INTRODUCTION

Headache is a frequent cause of consultation; it is important to detect patients with secondary headache, particularly high-risk secondary headache. Such systems as the Manchester Triage System (MTS) are used for this purpose. This study aims to evaluate the frequency of sub-triage in patients attending the Emergency Department due to headache.

MATERIAL AND METHODS

We studied a series of consecutive patients who came to the Emergency Department with headache and presenting some warning sign, defined as the presence of signs leading the physician to request an emergency neuroimaging study and/or assessment by the on-call neurologist. The reference diagnosis was established by neurologists. We evaluated the MTS triage level assigned and the presence of warning signs that may imply a higher level than that assigned.

RESULTS

We registered a total of 1,120 emergency department visits due to headache, and 248 patients (22.8%) were eligible for study inclusion. Secondary headache was diagnosed in 126 cases (50.8% of the sample; 11.2% of the total), with 60 cases presenting high-risk secondary headache (24.2%; 5.4%). According to the MTS, two patients were classified as immediate (0.8%), 26 as very urgent (10.5%), 147 as urgent (59.3%), 68 as normal (27.4%), and five as not urgent (2%). The percentage of patients under-triaged was 85.1% in the very urgent classification level and 23.3% in the urgent level.

CONCLUSION

During the study period, at least one in 10 patients attending the Emergency Department due to headache had secondary headache; one in 20 had high-risk secondary headache. The MTS under-triaged most patients with warning signs suggesting a potential emergency.

Evaluation of a new rapid assessment and treatment (RAT) tablet app for Emergency Department (ED) nurses: Is earlier identification of investigations and treatments feasible?

Although doctor-led RAT has advantages, serial processing (triage - investigation - treatment) still predominates in UK EDs. We have designed a RAT decision-support app to assist ED nurses to select investigations and treatments at initial patient assessment and aid acuity scoring.

METHODS

Test nurses accompanied triage ('control') nurses in an observational study of 529 adult patients. Investigations, treatments and procedures, selected using the app, were compared with those selected later by ED clinicians. Acuities set by both nurses were re-evaluated blind by a consultant panel.

RESULTS

Data capture and decision making using RAT-support took a median of 1.43 min (IQR 1.13-2.07). Odds ratios are reported for matching of test versus control investigation and treatment orders. The ability to predict, within minutes, control investigations which were ordered at median of 50 min (IQR 21-99) is encouraging. Median times to order treatments (analgesia 88 min, IV antibiotics 112 min) were also reduced. Acuity scores versus the consultant panel gave weighted kappa of 0.54 (CI 0.48-0.61) for study nurses and for controls 0.45 (CI 0.36-0.53).

CONCLUSIONS

We conclude that nurse-led RAT for use in initial assessment is feasible given decision support. We also identified improvements required for the app.

Geriatric Screening, Triage Urgency, and 30-Day Mortality in Older Emergency Department Patients

BACKGROUND

Urgency triage in the emergency department (ED) is important for early identification of potentially lethal conditions and extensive resource utilization. However, in older patients, urgency triage systems could be improved by taking geriatric vulnerability into account. We investigated the association of geriatric vulnerability screening in addition to triage urgency levels with 30‐day mortality in older ED patients.

DESIGN

Secondary analysis of the observational multicenter Acutely Presenting Older Patient (APOP) study.

SETTING

EDs within four Dutch hospitals.

PARTICIPANTS

Consecutive patients, aged 70 years or older, who were prospectively included.

MEASUREMENTS

Patients were triaged using the Manchester Triage System (MTS). In addition, the APOP screener was used as a geriatric screening tool. The primary outcome was 30‐day mortality. Comparison was made between mortality within the geriatric high‐ and low‐risk screened patients in every urgency triage category. We calculated the difference in explained variance of mortality by adding the geriatric screener (APOP) to triage urgency (MTS) by calculating Nagelkerke R².

RESULTS

We included 2,608 patients with a median age of 79 (interquartile range = 74‐84) years, of whom 521 (20.0%) patients were categorized as high risk according to geriatric screening. Patients were triaged on urgency as standard (27.2%), urgent (58.5%), and very urgent (14.3%). In total, 132 (5.1%) patients were deceased within a period of 30 days. Within every urgency triage category, 30‐day mortality was threefold higher in geriatric high‐risk compared to low‐risk patients (overall = 11.7% vs 3.4%; P < .001). The explained variance of 30‐day mortality with triage urgency was 1.0% and increased to 6.3% by adding the geriatric screener.

CONCLUSION

Combining triage urgency with geriatric screening has the potential to improve triage, which may help clinicians to deliver early appropriate care to older ED patients. J Am Geriatr Soc 68:1755‐1762, 2020.

Effectiveness of Manchester Triage System in risk prioritisation of patients with pulmonary embolism who present dyspnoea, chest pain or collapse

BACKGROUND

Recognising patients with pulmonary embolism continues to be a clinical challenge. In the Emergency Department, up to 50% of patients with pulmonary embolism can be delayed or even misdiagnosed. The ability of a triage system to correctly prioritise suspected embolism in these patients is fundamental for determining diagnostic-therapeutic procedures.

AIM

To verify the effectiveness of the Manchester Triage System in risk prioritisation of patients with pulmonary embolism who present with dyspnoea, chest pain, or collapse.

METHODS

In this observational, retrospective, study the sensitivity, specificity, and positive and negative predictive values of the Manchester Triage System were calculated using the triage classification for these patients, and their established diagnoses. The analysis included baseline characteristics and triage evaluations.

RESULTS

During the two-year study period, 7055 patients were enrolled. Pulmonary embolism episodes were 2.1% of all cases, while severe pulmonary embolisms were 0.8%. The estimated specificity of the Manchester Triage System was 72.5% (CI 95%, 71.5-73.6), and the negative predictive value was 98.1% (CI 95%, 97.7-98.5). The results suggest that clinical characteristics leading to a high Manchester Triage System priority are similar to those characterising a pulmonary embolism episode.

CONCLUSIONS

Although pulmonary embolism is difficult to diagnose, the Manchester Triage System is an effective tool for prioritising patients with symptoms of this disease.

Prevalence of palliative care patients in emergency departments

BACKGROUND

Emergency departments (ED) serve as a contact point for critically ill patients. According to experience, a fraction of patients visiting ED present with palliative symptoms and require palliative care; however, the prevalence of these patients has not been determined in Austria so far.

METHODS

In the ED of a tertiary care medical centre in Carinthia all adult patients presenting between 8 January 2018 and 17 January 2018 were classified on arrival with the Manchester triage system (MTS) and were afterwards assessed with a validated 2‑tier screening tool for palliative care. Patient records were screened in April 2018 to find out whether they received palliative care.

RESULTS

In total 1277 patients visited the ED during the investigation period. Of these patients 1096 were screened and 145 of these patients (13.2%) showed palliative symptoms and needed a goal-oriented therapy. Of these 145 patients 10.9% were assessed by MTS as emergency, 2.7% as very urgent, 34.7% as urgent, 51% as normal, and 0.7% as not urgent. Only 8 (5.5%) of the patients with palliative medical symptoms actually received palliative care consultation.

CONCLUSIONS

More than 1 in 10 patients attending an ED suffered from palliative symptoms. Hence it is to be expected that healthcare providers in an ED in Austria will frequently encounter patients with palliative symptoms in emergency admissions. Therefore, it is necessary to develop suitable structures to provide these patients with the best possible care.

Triage Performance in Emergency Medicine: A Systematic Review

STUDY OBJECTIVE

Rapid growth in emergency department (ED) triage literature has been accompanied by diversity in study design, methodology, and outcome assessment. We aim to synthesize existing ED triage literature by using a framework that enables performance comparisons and benchmarking across triage systems, with respect to clinical outcomes and reliability.

METHODS

PubMed, EMBASE, Scopus, and Web of Science were systematically searched for studies of adult ED triage systems through 2016. Studies evaluating triage systems with evidence of widespread adoption (Australian Triage Scale, Canadian Triage and Acuity Scale, Emergency Severity Index, Manchester Triage Scale, and South African Triage Scale) were cataloged and compared for performance in identifying patients at risk for mortality, critical illness and hospitalization, and interrater reliability. This study was performed and reported in adherence to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

RESULTS

A total of 6,160 publications were identified, with 182 meeting eligibility criteria and 50 with sufficient data for inclusion in comparative analysis. The Canadian Triage and Acuity Scale (32 studies), Emergency Severity Index (43), and Manchester Triage Scale (38) were the most frequently studied triage scales, and all demonstrated similar performance. Most studies (6 of 8) reported high sensitivity (>90%) of triage scales for identifying patients with ED mortality as high acuity at triage. However, sensitivity was low (<80%) for identification of patients who had critical illness outcomes and those who died within days of the ED visit or during the index hospitalization. Sensitivity varied by critical illness and was lower for severe sepsis (36% to 74%), pulmonary embolism (54%), and non-ST-segment elevation myocardial infarction (44% to 85%) compared with ST-segment elevation myocardial infarction (56% to 92%) and general outcomes of ICU admission (58% to 100%) and lifesaving intervention (77% to 98%). Some proportion of hospitalized patients (3% to 45%) were triaged to low acuity (level 4 to 5) in all studies. Reliability measures (κ) were variable across evaluations, with only a minority (11 of 42) reporting κ above 0.8.

CONCLUSION

We found that a substantial proportion of ED patients who die postencounter or are critically ill are not designated as high acuity at triage. Opportunity to improve interrater reliability and triage performance in identifying patients at risk of adverse outcome exists.