Manchester triage system in paediatric emergency care: prospective observational study

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