The term "reference standard" is misleading. Triage can be validated against mortality/morbidity
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
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
Competing interests: No competing interests