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Manchester triage system in paediatric emergency care: prospective observational study

BMJ 2008; 337 doi: (Published 22 September 2008) Cite this as: BMJ 2008;337:a1501
  1. M van Veen, PhD student1,
  2. Ewout W Steyerberg, professor of medical decision making2,
  3. Madelon Ruige, paediatrician3,
  4. Alfred H J van Meurs, paediatrician3,
  5. Jolt Roukema, resident paediatrics 1,
  6. Johan van der Lei, professor of medical informatics4,
  7. Henriette A Moll, professor of paediatrics1
  1. 1Department of Paediatrics, Erasmus Medical Centre, Sophia Children’s Hospital, University Medical Centre Rotterdam, PO Box 2060, 3000 CB Rotterdam, Netherlands
  2. 2Centre for Medical Decision Making, Public Health, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
  3. 3Department of Paediatrics, Haga Hospital, Juliana Children’s Hospital, PO Box 60605, 2506 LP, Hague, Netherlands
  4. 4Department of Medical Informatics, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
  1. Correspondence to: H A Moll h.a.moll{at}
  • Accepted 22 July 2008


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

Design Prospective observational study.

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

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

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

Main outcome measures Urgency according to the Manchester triage system compared with a predefined and independently assessed reference standard for five urgency levels. This reference standard was based on a combination of vital signs at presentation, potentially life threatening conditions, diagnostic resources, therapeutic interventions, and follow-up. Sensitivity, specificity, and likelihood ratios for high urgency (immediate and very urgent) and 95% confidence intervals for subgroups based on age, use of flowcharts, and discriminators.

Results The Manchester urgency level agreed with the reference standard in 4582 of 13 554 (34%) children; 7311 (54%) were over-triaged and 1661 (12%) under-triaged. The likelihood ratio was 3.0 (95% confidence interval 2.8 to 3.2) for high urgency and 0.5 (0.4 to 0.5) for low urgency; though the likelihood ratios were lower for 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 validity in paediatric emergency care. It errs on the safe side, with much more over-triage than under-triage compared with an independent reference standard for urgency. Triage of patients with a medical problem or in younger children is particularly difficult.


  • We thank Kevin Mackway-Jones, professor of emergency medicine, Manchester Royal Infirmary, for critical comments on the manuscript, and Marcel de Wilde, department of medical informatics, Erasmus University Medical Centre, Rotterdam, Netherlands, for technical support.

  • Contributors: All authors substantially contributed to the conception and design of the study. MvV, EWS, JvdL, MR, AHJvM, and HAM contributed to the data analysis. MvV, HAM, EWS, and JvdL drafted the article and analysed the data. All authors revised it critically for important intellectual content and gave their approval of the final version. HAM is guarantor.

  • Funding: Netherlands Organization for Health Research and Development (ZonMw), and Erasmus University Medical Centre, Rotterdam, Netherlands.

  • Competing interests: None declared.

  • Ethical approval: Institutional medical ethics committee; the requirement for informed consent was waived.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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