Manchester triage system in paediatric emergency care: prospective observational study

doi:10.1136/bmj.a1501

Published 22 September 2008, doi:10.1136/bmj.a1501
Cite this as: BMJ 2008;337:a1501

Research

Manchester triage system in paediatric emergency care: prospective observational study

M van Veen, PhD student¹, Ewout W Steyerberg, professor of medical decision making², Madelon Ruige, paediatrician³, Alfred H J van Meurs, paediatrician³, Jolt Roukema, resident paediatrics ¹, Johan van der Lei, professor of medical informatics⁴, Henriette A Moll, professor of paediatrics¹

¹ Department of Paediatrics, Erasmus Medical Centre, Sophia Children’s Hospital, University Medical Centre Rotterdam, PO Box 2060, 3000 CB Rotterdam, Netherlands, ² Centre for Medical Decision Making, Public Health, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands , ³ Department of Paediatrics, Haga Hospital, Juliana Children’s Hospital, PO Box 60605, 2506 LP, Hague, Netherlands, ⁴ Department of Medical Informatics, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands

Correspondence to: H A Moll h.a.moll{at}erasmusmc.nl

Objective To validate use of the Manchester triage system inpaediatric emergency care.

Design Prospective observational study.

Setting Emergency departments of a university hospital and ateaching hospital in the Netherlands, 2006-7.

Participants 17 600 children (aged <16) visiting an emergencydepartment over 13 months (university hospital) and seven months(teaching hospital).

Intervention Nurses triaged 16 735/17 600 patients (95%) usinga computerised Manchester triage system, which calculated urgencylevels from the selection of discriminators embedded in flowchartsfor presenting problems. Nurses over-ruled the urgency levelin 1714 (10%) children, who were excluded from analysis. Completedata for the reference standard were unavailable in 1467 (9%)children leaving 13 554 patients for analysis.

Main outcome measures Urgency according to the Manchester triagesystem compared with a predefined and independently assessedreference standard for five urgency levels. This reference standardwas based on a combination of vital signs at presentation, potentiallylife threatening conditions, diagnostic resources, therapeuticinterventions, and follow-up. Sensitivity, specificity, andlikelihood ratios for high urgency (immediate and very urgent)and 95% confidence intervals for subgroups based on age, useof flowcharts, and discriminators.

Results The Manchester urgency level agreed with the referencestandard in 4582 of 13 554 (34%) children; 7311 (54%) were over-triagedand 1661 (12%) under-triaged. The likelihood ratio was 3.0 (95%confidence interval 2.8 to 3.2) for high urgency and 0.5 (0.4to 0.5) for low urgency; though the likelihood ratios were lowerfor those presenting with a medical problem (2.3 (2.2 to 2.5)v 12.0 (7.8 to 18.0) for trauma) and in younger children (2.4(1.9 to 2.9) at 0-3 months v 5.4 (4.5 to 6.5) at 8-16 years).

Conclusions The Manchester triage system has moderate validityin paediatric emergency care. It errs on the safe side, withmuch more over-triage than under-triage compared with an independentreference standard for urgency. Triage of patients with a medicalproblem or in younger children is particularly difficult.

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Rapid Responses:

Read all Rapid Responses

But its trauma! Can we measure the impact of over-triage?: James O.M. Plumb
bmj.com, 4 Oct 2008 [Full text]
Re: But its trauma! Can we measure the impact of over-triage?: Mirjam van Veen, et al.
bmj.com, 10 Oct 2008 [Full text]
There's more to triage....: Sue Ieraci
bmj.com, 23 Oct 2008 [Full text]
Re: There's more to triage....: Mirjam van Veen, et al.
bmj.com, 4 Nov 2008 [Full text]
The term "reference standard" is misleading. Triage can be validated against mortality/morbidity: Arravind Pillai, et al.
bmj.com, 4 Dec 2008 [Full text]
Mortality in children is very rare at the emergency department in Western countries: Mirjam van Veen, et al.
bmj.com, 19 Dec 2008 [Full text]