Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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But its trauma! Can we measure the impact of over-triage?
- James O.M. Plumb (4 October 2008)
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Re: But its trauma! Can we measure the impact of over-triage?
- Mirjam van Veen, Henriette A. Moll (10 October 2008)
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There's more to triage....
- Sue Ieraci (23 October 2008)
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Re: There's more to triage....
- Mirjam van Veen, Henriette A. Moll (4 November 2008)
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The term "reference standard" is misleading. Triage can be validated against mortality/morbidity
- Arravind Pillai, Samiksha Manchanda manchandasami@yahoo.com, St.Stephen's Hospital,Tiz Hazari,Delhi (4 December 2008)
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Mortality in children is very rare at the emergency department in Western countries
- Mirjam van Veen, Henriette A. Moll (19 December 2008)
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James O.M. Plumb, CT1 Paediatric Emergency Medicine Nottingham University Hospitals Trust Queen's Medical Centre Campus Derby Rd Nottingham NG7 2UH
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I read with great interest the article by Van Veen et al.1 I commend the study, which highlights some interesting points about this relevant and important topic. The authors recognise the considerable limitations of their study particularly with regard to their devised reference standard but have still highlighted a pertinent problem: the potential under-triage of medical patients and over-triage of trauma patients. As commented on in the editorial by Maconochie and Dawood the key requirement of any triage system is that an experienced clinician undertakes triage.2 The Manchester system works by the applying a pathway approach based on structured questions. Does the system allow for the experience of the nurse, the time of the day, the position of the shift the nurse happens to be on or their current mental well being? I think not. In my experience the numbers attributed are based on observations and common sense rather than using any of the 52 flow pathways. On the whole the system works rather well. Does it affect the time in which a patient is seen? Sometimes it does, but in a busy department with limited numbers of doctors a category 2 could often wait more than 10 minutes to be seen. Mistakes will always be made with the appropriate categorisation of patients presenting in the acute phase of illness or injury because human error can never be eliminated. The point of systems such as the Manchester triage system is to try to eliminate human error by creating a structured approach. Any system designed in this way will be limited and will always get things wrong. In the case of the aforementioned study it is suggested that patients are more often over-triaged. One only has to work for one week in a UK emergency department to see the effects of over-triage on the telephone by NHS direct. The government admit that walk in centres and NHS direct have failed to reduce emergency department attendance.3 But is this actually problematic? Well I would argue that it is. In the department in which I work any child who is called through on the ‘red phone’ is automatically seen in the resuscitation room regardless of the nature of the problem, not a bad idea I here you cry? In principle this is a very safe way to approach the care of the potentially unwell paediatric patient. However I have recently seem a small nail in a girl’s toe, and a trivial abrasion to a boy’s leg, oh and not to mention the ‘anaphylaxis’ that comes in beaming at you and talking away happily. The point is that 2 nurses and 1 doctor are taken away from the paediatric emergency department to deal with the incoming call which at night leaves one nurse to see and triage any one else coming through the department. The under-triaged medical patient may then wait longer than they should have done to be seen. This may be the fault of the ambulance service but the principle is seen throughout the department. The over-triage of the trauma patient is well recognised by this observational study and in my experience this behaviour and culture amongst emergency department nursing staff is a very real phenomenon. I will often be asked to ‘check over’ or perform a ‘primary survey’ on a well child who has fallen off their bike but has been put into category 2 due to the mechanism of injury. There appears to be a heightened awareness to the importance of ‘that missed ruptured spleen'. The old chestnut of the 4 hour wait becomes important in any discussion about triage categories as children who have fallen off their bike but come in collard and taped are often seen quickly to avoid time wasted that they may have to spend in x-ray and to get them off an uncomfortable spinal board, again good in principle but is it putting patients in lower triage categories at risk? This question is difficult to answer as noted by the authors, as it is hard to relate morbidity to longer waiting times. The problem will not disappear. Unwell children will unfortunately continue to sometimes be missed. Whilst the Manchester system has value modification appears to be needed. 1. Van Veen M et al, BMJ 2008;337:a1501 2. Maconochie I, Dawood M, BMJ 2008;337:a1507 3. Longwoods review Towards Faster Treatment: Reducing Attendance and Waits at Emergency Departments. A Briefing Paper from the U.K. National Coordinating Centre for NHS Service Delivery and Organization Research and Development. Vol. 4 No. 1 2006 http://www.longwoods.com/product.php?productid=18130&cat=439&page=1 Competing interests: None declared |
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Mirjam van Veen, PhD student Erasmus Medical Center-Sophia Children's Hospital, 3000CB, Rotterdam, The Netherlands, Henriette A. Moll
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With interest we read the reaction by James Plumb ‘But its trauma! Can we measure the impact of over-triage?’(1) on our article on the validity of the Manchester Triage System (MTS) in paediatric emergency care. (2) Mr Plumb wrote that in his experience urgencies are based on observations and common sense, rather than using any of the 52 flowcharts. Applying the system correctly, is a minimum requirement of the MTS to work properly. In our study and in our current practice, we used and use a digital application of the MTS. For nurses it provides all 52 flowcharts and their discriminators, which is very useful since the MTS contains many flowcharts and discriminators. Secondly, since triage characteristics (chosen flowchart and discriminator) have to be documented, nurses are forced to use the MTS correctly. Because all data is easily available, compliance can be controlled and discussed with the nurses afterwards. Since a triage system can never predict urgency 100% correctly, it must be seen as a guideline and experienced triage nurses always have to use their own expertise in their triage decisions as well. As was illustrated by Plumb, if patients are over-triaged, it will be favorable for the particular patient but real high urgency patients have to wait longer. Under-triaged patients are placed in a too low urgency category and will be seen too late by a physician. We argue that triage must be based primarily on medical criteria instead of social criteria, as Plumb showed in his example. For a patient who presents with a minor injury and who needs diagnostics, it will be pleasant for the patient if the X-ray is taken directly, so his total stay at the ED will be shorter. Although, this patient will not be harmed when he has to wait for more than one hour, he does take the place of a high urgency patient who may be harmed. Over-triage and under-triage will always be present in triage systems. However, by validating triage systems with a prognostic reference standard, we are able to develop modifications in order to reduce over- and under-triage. 1.Plumb J. But its trauma! Can we measure the impact of over-triage? Bmj. 2008; Rapid Response 4 okt. 2.van Veen M, Steyerberg EW, Ruige M, et al. Manchester triage system in paediatric emergency care: prospective observational study. Bmj. 2008;337:a1501. Competing interests: None declared |
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Sue Ieraci, senior consultant emergency medicine Bankstown Hospital NSW Australia
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Neither the Van Veen paper nor the accompanying editorial appeared to be aware of the Australasian work that produced the first published five- point triage scale in 1993 (Australasian College for Emergency Medicine). Following a study of over 11,000 occasions of triage by Whitby et al, a groupd of clinical descriptors was linked to the scale, and it was updated and published as the Australasian Triage Scale (ATS) in 2000. The descriptors can be found at http://www.acem.org.au/media/policies_and_guidelines/G24_Implementation__ATS.pdf, with an accompanying paper at http://www.acem.org.au/media/policies_and_guidelines/G24_Implementation__ATS.pdf. This work formed the basis of subsequent five-point scales, including both Manchester and CTAS. The clinical descriptors were found to be significantly correlated with the categories. There are specific descriptors for paediatric presentations. Although it has proven impossible to show that triage categorisation affects clinical outcome (because of the difficulty in controlling - or even knowing - the time of onset), the categories have been shown to correlate with admission rates to hospital. It is puzzling to see a study that attempts to validate the Manchester scale against the standard of a local, less-validated scale, and puzzling that the standard was not precisely described in the published study. Can the authors give us more information about their standard and how it was derived? How has the local standard been validated? The main purpose of a triage scale is not to be 100% predictive of outcome, but to ensure that more urgent cases are seen faster. This really only becomes a problem when the scale starts to be used as a performance measure, with waiting time targets. In Australia, the target of 30 mins for ATS Category 3 patients is becoming very difficult to meet. It is yet to be shown whether the 30 min target is clinically valid, with methods of linking to clinical outcomes for far being elusive. Competing interests: None declared |
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Mirjam van Veen, PhD student Erasmus Medical Center-Sophia Children's Hospital, 3000 CB, Rotterdam, The Netherlands, Henriette A. Moll
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With interest we read the reaction by Dr. Sue Leraci ‘There’s more to triage’ (1) on our paper on the validity of the Manchester Triage System (MTS) in paediatric emergency care.(2) Although, we are aware of the Australasian Triage Scale (ATS), we did not discuss the system since our paper focused on the validity of triage systems in paediatric emergency care. We did not find any publications on the validity of the ATS for the specific paediatric population, in the emergency care setting. Our aim was to validate the MTS in paediatric emergency care. The reference standard for urgency has to be a proxy for severity of outcome. Therefore, our reference standard was based on vital signs and potentially life threatening diseases for the highest urgency categories, according to the literature. The reference standard for the lowest urgency categories was based on hospitalization and resource use, as applied for validation of other triage systems. (3-5) Experts combined these items to define our reference standard for urgency level 3,4 and 5. The standard is described in detail in the appendixes 1 and 2, which are published along with the paper on BMJ.com. (http://www.bmj.com/cgi/content/full/337/sep22_1/a1501/DC1) We agree that a standard based on the literature and expert opinion is a relative low grade of evidence-based medicine. However, our study is the first, which validated all urgency categories of the MTS for paediatric patients and did not only focus on a specific emergent diagnosis or intensive care admission as outcome. The reference standard defines five different urgency classes and can be applied in other settings as well, which allow for comparison between different triage systems in different settings. Since a golden standard of urgency does not exist, the independent reference standard is the best available proxy for severity of outcome. We applied the methodology of diagnostic research on triage research and are able to modify the MTS based on the individualized data. We agree that the goal of triage is not to be 100% predictive for all urgency outcome levels, but to identify high urgent cases that need immediate attention and those low urgent patients who can safely wait. Over-triage will be present in every triage system to allow a safe urgency classification. 1. Leraci S. There's more to triage.. BMJ 2008; Rapid response 23 Okt. 2. van Veen M, Steyerberg EW, Ruige M, van Meurs AH, Roukema J, van der Lei J, et al. Manchester triage system in paediatric emergency care: prospective observational study. Bmj 2008;337:a1501. 3. Baumann MR, Strout TD. Evaluation of the Emergency Severity Index (version 3) triage algorithm in pediatric patients. Acad Emerg Med 2005;12(3):219-24. 4. Gouin S, Gravel J, Amre DK, Bergeron S. Evaluation of the Paediatric Canadian Triage and Acuity Scale in a pediatric ED. Am J Emerg Med 2005;23(3):243-7. 5. Maningas PA, Hime DA, Parker DE. The use of the Soterion Rapid Triage System in children presenting to the Emergency Department. J Emerg Med 2006;31(4):353-9. Competing interests: None declared |
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Arravind Pillai, Medical student St.Stephen's Hospital,Tiz Hazari,Delhi, Samiksha Manchanda manchandasami@yahoo.com, St.Stephen's Hospital,Tiz Hazari,Delhi
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We read with great interest, the paper entitled Manchester Triage System in Paediatric Emergency Care(1). We are surprised by the conclusion drawn from the study both in the article and the editorial(2). The Manchester Traige System has been validated in a number of circumstances(3,4,5). The present authors compared an unvalidated triage system (misleadingly called ‘Reference Standard’ by the authors) against the Manchester Triage System and found little agreement between the two systems. The inference could well be that the Reference standard triage is not valid. However the authors conclude that Manchester Triage System is at fault and is not valid. Triage can be validated against mortality. It requires a large sample. The WHO has developed Emergency Triage And Treatment (ETAT) score(6). This was validated against the mortality in each score. At our institution, we have recently developed a triage system utilising the abnormal physical variables of the systemic inflamatory response syndrome(7,8). This too has been validated against mortality in the UK and India(9). Thus, although mortality is low, a good triage system will exibit a calibrated increase in mortality with increase in score if the sample size is large enough. Mortality will perhaps be the best gold standard against which traige scores can be evaluated. Morbidity may also be an objective index against which such triage scores can be measured. 1.Veen MV, Steyerberg E W, Ruige M, van Meurs A,Roukema J, van der Lei J, Moll HA. Manchester triage system in paediatric emergency care:prospective observational study BMJ 2008;337:792-795 2.Mannconochie I, Dawood M. Manchester triage system in paediatric emergency care BMJ 2008;337:767-768 3.Roukema J, Steyerberg EW, van Meurs A, Ruige M, van der Lei J, Moll HA. Validity of Manchester triage system in paediatric emergency care Emergency Med J 2006:23:906-910 4.Cronin JG. The introduction of Manchester triage scale to an emergency department in Republic of Ireland Accid Emerg Nurse 2003;11:121-125 5.Cooke M W, Jinks S. Does the Manchester triage system detect the critically ill? J Accid Emerg Med 1999;16:179-181 6.Robertson MA, Molyneux EM. Description of cause of serious illness and outcome in patients identified using ETAT guidelines in urban Malawi Arch Dis Child 2001;85:214-217 7.Kumar N, Thomas N, Singhal D, Puliyel J M, Sreenivas V.Triage score for severity of illness Indian Pediatrics 2003;40:204-210 8.Bhal S, Tyagi V, Kumar N, Sreenivas V, Puliyel JM J Postgrad Med 2006;52:102-105 9.Gupta MA, Sahni M, Puliyel JM, Rangasami J, Chakrabarti A, Halstead R, Green DA, Puliyel A,Sreenivas V.International collaboration validity SICK score: a non-invasive severity of illness assesment Arch Dis Child 2008;93 supl 1:A10 Competing interests: None declared |
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Mirjam van Veen, PhD student Erasmus Medical Center-Sophia Children's Hospital, 3000 CB, Rotterdam, The Netherlands, Henriette A. Moll
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In reaction to the rapid response of Pillai et al (1) on our paper on the validity of the Manchester Triage System (MTS) in paediatric emergency care (2) we have some important comments. To validate the MTS for children, we used a reference standard for urgency as outcome measure, which is a proxy for morbidity. This standard is not a triage system. It consists of items, which are gathered at presentation and at the end of ED consultation, independent of the triage urgency level. These items were based on literature and combined by an expert panel. The reference standard aimed to determine “real “ urgency. Secondly, the authors argue that mortality can be used as an outcome measure and refer to the study on the ETAT guidelines performed in Malawi. Secondly they refer to a study evaluating the SICK score. (3,4) The hospital in Malawi at which the ETAT guidelines were studied has an in patient mortality in the paediatric population of 10%. The mortality of our study population at the emergency department was 0.07% (n=17,600). The congress abstract describing the evaluation of the SICK score used the mortality of admitted patients as outcome measure. This score was not applied to all emergency care patients. Furthermore, the mortality was not provided in the abstract. (3) If mortality is used as an outcome measure to study triage decisions in children, it must preferably concern mortality at the emergency department and not the total in hospital mortality. The total in hospital mortality is influenced by many other factors besides the triage decision. Mortality can be used as outcome measure to study triage systems, in settings with a high mortality. Mortality in children is very rare at emergency departments in West European countries. 1. Pillai A, Manchanda S. The term "reference standard" is misleading. Triage can be validated against mortality/morbidity. BMJ 2008;Rapid Response 4 December 2008. 2. van Veen M, Steyerberg EW, Ruige M, van Meurs AH, Roukema J, van der Lei J, et al. Manchester triage system in paediatric emergency care: prospective observational study. Bmj 2008;337:a1501. 3. Gupta M, Sahni M, Rangasami J, Chakrabarti A, Halstead R, Green D, et al. International Collaboration validating Sick score: a non-invasive severity of illness assessment, RCPCH abstract. Arch Dis Child 2008;93 supl; A10. 4. Robertson MA, Molyneux EM. Description of cause of serious illness and outcome in patients identified using ETAT guidelines in urban Malawi. Arch Dis Child 2001;85(3):214-7. Competing interests: None declared |
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