manchester triage system: why, how and...
TRANSCRIPT
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MANCHESTER TRIAGE SYSTEM: why, how and where?
Kevin Mackway-JonesManchester Royal Infirmary
UK
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History
• Observations 1994
• “Surprising” triage decisions• Inconsistent triage decisions
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History
• Question
• How does triage work?
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History
• Answer
• Because it does
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History
• Case26 year old man involved
in pedestrian RTA. Bilateral fractured tibia and fibula. 5 hours in “minor” treatment without treatment
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History
• Local consultation
• Common problem• Wish for common
solution
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History
• Local review
• No consistency
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History
A B C D
First 0 0 0 0
Second <15 10 5-10 <10
Third <120 60 30-60 ~
Fourth <240 120 ~
Fifth ~
Others FGHI
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History
• The Manchester Triage Group 1995
• All local Emergency Physicians• All local Emergency Nurses
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History
Common nomenclature
Common definitions
Common methodology
Common teaching
Common audit
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Triage Group: Nomenclature
• How many priorities?
• What should they be called?
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History
A B C D
First 0 0 0 0
Second <15 10 5-10 <10
Third < 60 30-60
Fourth <120 120
Fifth <240 ~ ~ ~
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Triage Group: Nomenclature
Number Colour Name
First Red Immediate
Second Orange Very urgent
Third Yellow Urgent
Fourth Green Standard
Fifth Blue Non-urgent
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Triage Group: Nomenclature
Number Colour Name
First Red Immediate
Second Orange Very urgent
Third Yellow Urgent
Fourth Green Standard
Fifth Blue Non-urgent
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Triage Group: Nomenclature
Number Colour Name
First Red Immediate
Second Orange Very urgent
Third Yellow Urgent
Fourth Green Standard
Fifth Blue Non-urgent
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Triage Group: Nomenclature
Number Colour Name
First Red Immediate
Second Orange Very urgent
Third Yellow Urgent
Fourth Green Standard
Fifth Blue Non-urgent
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Triage Group: Definitions
• How long is it “safe” to wait
• How long is it “reasonable” to wait
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Triage Group: Target Times
First Second Third Fourth Fifth
0 min10 min
60 min
120 min240 min
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Triage Group: Methodology
• What is triage for?• What is the construct?
• How should triage be performed?
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Triage Group: Methodology
• Triage IS: a professional assessment process that should identify the priority of the patient for clinical intervention
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Triage Group: Methodology
• Triage IS NOT: designed to predict need for admission, resource usage, diagnosis, stream or final destination
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Triage Group: Methodology
• Triage IS NOT: the only factor that affects the MANAGEMENT of the patient by the system
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Triage Group: Methodology
• MTS is Reductive
• All patients “start” as priority 1.
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Triage Group: Methodology
• MTS divides patients into “presentations”
• Recognisable constructs• NOT diagnoses
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Triage Group: Methodology
• MTS uses “discriminators”
• General discriminators for all patients• Specific discriminators depending on
presentation
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Triage Group: Methodology
Presentation
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Triage Group: Methodology
P1Discriminators
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Triage Group: Methodology
P1Discriminators
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Triage Group: Methodology
P1Discriminators
P2Discriminators
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Triage Group: Methodology
P1Discriminators
P2Discriminators
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Triage Group: Methodology
P3Discriminators
P4Discriminators
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Triage Group: Methodology
P1Discriminators
P2Discriminators
P3Discriminators
P4Discriminators
Presentation
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History
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Triage Group: Training
Training box
20 manuals
3 instructor manuals
Instructor materials
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History
• A national solution in the UK
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Triage Group: Audit
• Individual practitioner
• Institution
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Triage Group: Audit
Initial case selection
Random from computer record
Triage Practitioner
Select 2% (min10) records
A Total
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Triage Group: Audit
Assessment of accuracy of presentation selection
Assessment of completeness of information gathering
Assessment of accuracy of discriminator selection
Triage Practitioner
Select 2% (min10) records
Presentationcorrect?
Sufficientinformation?
Discriminatorcorrect?
A Total
B Innacurate
C Incomplete
D Accurate
Yes
No
Yes
No
Yes
No
% Accuracy= 100*D/A
% Void =100*C/A
Check A = B+C+D
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Individual audit: Aims
• 0% episodes incomplete this includes pain scores, documentation, etc
• 95% accuracy
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0
10
20
30
40
50
60
%
1 2 3 4 5
Priority pre MTS
Triage Audit: Showing change
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0
10
20
30
40
50
60
%
1 2 3 4 5
Priority post MTS
Triage Audit: Showing change
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Triage Audit: Institutional
0
10
20
30
40
50
60
70
80
90
100
Accu
racy
(%
11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Study ID
Accuracy by Department
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Progress
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Does the MTS work?
some evidence from the literature
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Construct validity
Does the system identify the patients it sets out to identify?
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Does the Manchester Triage System detect the critically ill?
Cooke MW, Jinks SJ Accid Emerg Med 1999
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Methods
Analysis of triage coding of admissions to critical care areas
Analysis of under-triage Nurse operators MTS
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Conclusions
The MTS is a highly sensitive tool for identifying critically ill patients on arrival at emergency department
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Validation of physiological scoring systems in the A&E Department
Subbe CP, Slater A, Menon D, Gemmell LEmerg Med J, 2006
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Results
Sensitivity at predicting ED-ITU
MTS 96% MEWS 77% ASSIST 22% METS 1%
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Results
Sensitivity at predicting ED-ward-ITU
MTS 65% MEWS 55% ASSIST 8% METS 3%
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Conclusions
MTS is much more sensitive than any physiological score at identifying critically ill patients on arrival at emergency department
Physiological scoring adds little to the MTS in identifying critically ill patients on arrival at emergency department
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Detecting High Risk Patients with Chest Pain
Speake D, Teece S, Mackway-Jones KEmergency Nurse 2003
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Conclusions
Sensitivity 86.8% (78.4 - 92.3)
Specificity 72.4% (61.4 – 81.2)
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Sensitivity and specificity of the Manchester Triage System for patients with acute coronary syndromes
Pinto D, Lunet N, Azevedo ARev Port Cardiol, 2010
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Conclusions
Nurses using MTS are highly sensitive at detecting cardiac chest pain
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The diagnostic utility of triage nurses at recognising pleuritic chest pain
Wright J, Hogg K, Mackway-Jones KEmergency Nurse, 2005
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Conclusions
Sensitivity 69.2% (56.7 - 81.7)
Specificity 92.7% (88.2 – 97.2)
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Predicting admission and mortality with theEmergency Severity Index and the Manchester Triage System: a retrospective observational study
van der Wulp I, Schrivers AJP, van Stell HFEmergency Medicine Journal, 2009
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van der Wulp I et al, 2009
Retrospective database study from 4 EDs, 2006
34,258 patients
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van der Wulp I et al, 2009
Likelihood of admission decreased with decreasing triage category
96.6% of patients who died were priority 1 or 2
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Is Manchester (MTS) more than a triage system? A study of its association with mortality and admission to a large Portuguese hospital
Martins HMG, De Castro Dominguez Cunã LM, Freitas PEmergency Medicine Journal, 2009
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Martins HMG et al, 2009
Retrospective database analysis
321,539 patients (2005 – 2007)
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Martins HMG et al, 2009
Proportion admitted decreased with decreasing priority
Odds of dying 39x higher in P1,2
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Validity of the Manchester Triage System in paediatricemergency care
Roukema J, Steyerberg EW, van Meurs A et alEmergency Medicine Journal, 2006
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Manchester triage system in paediatric emergency care: prospective observational study
van Veen M, Steyerberg EW, Ruige M et alBritish Medical Journal, 2008
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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
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Reproducibility
Do different triage nurses arrive at the same priority when triaging the same patient?
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Observer agreement of the Manchester Triage System and the Emergency Severity Index: a simulation study
Storm-Versloot MN, Ubbink DT, Choi VCA et alEmergency Medicine Journal, 2008
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Reliability and validity of the Manchester Triage System in a general emergency department patient population in the Netherlands: results of a simulation study
van der Wulp I, van Bar ME, Schrivers AJPEmergency Medicine Journal, 2008
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The Manchester triage system provides good reliability in an Australian emergency department
Grouse AI, Bishop RO, Bannon AMEmergency Medicine Journal , 2009
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Manchester Triage in Sweden –Interrater reliability and accuracy
Oloffson P, Gellerstedt M, Carlström EDInternational Journal of Nursing, 2009
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Interrater reproducibility studies
Author Cases Test group
Storm-Vestoot et al, 2008, Netherlands
50 8 nurses from 3 units
van der Wulp et al, 2008, Netherlands
50 48 nurses from 2 units
Grouse et al, 2009, Australia
50 20 nurses from 1 unit
Ollofson et al, 2009, Sweden
13 79 nurses from 7 units
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Interrater reproducibility studies
Author Kappa
Storm-Vestoot et al, 2008
0.76 (0.68 – 0.83)
van der Wulp et al, 2008
0.62 (0.6 – 0.65)
Grouse et al, 2009
0.63
Ollofson et al, 2009
0.61 (0.57 – 0.65)
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Test-retest reproducibility studies
Author Kappa
Storm-Vestoot et al, 2008
0.75 (0.72 – 0.77)
van der Wulp et al, 2008
0.84 (0.73 – 0.94)
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Conclusions
The Manchester Triage System has good inter-rater reproducibility and good to excellent test-retest reproducibility
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Progress
• Increasing usage
• Little criticism
• Increasing evidence
• Some valid comments
• Changing clinical practice
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Second Edition
• Manchester Triage Group
+
• International Reference Group
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Second Edition
• Review of chart titles
• Review of chart contents
• Review of discriminators
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General Discriminators
Airway compromiseInadequate breathing
Exsanguinating haemorrhageShock
Currently fittingUnresponsive child
Severe painUncontrollable major haemorrhage
Altered conscious levelHot child
ColdVery hot adult
Moderate painUncontrollable minor haemorrhage
History of unconsciousnessHot adult
Recent mild painWarmthRecent
RED
ORANGE
YELLOW
GREEN
BLUE
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Second Edition
New chart: Allergy
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Second Edition
New Chart: Palpitations
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Second Edition
New Chart: Falls
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Second Edition
Haematological
D, V now D&V
Nasal problems now Facial Problems
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Progress
Brazil Austria Norway Poland Slovenia
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What is MTS for?
Determining clinical priority
Managing clinical risk
Speaking a common language of urgency
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What is MTS not designed for?
Managing the department
Predicting the need for admission
Identifying resource requirement
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What else can MTS do – the future
Start the process of care
Aid in initial disposition decisions
Telephone triage
Non-professional triage
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Triage and the clinical process
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Decision SupportGuidelines
Patient with cardiacchest pain
Immediate ECG
ImmediateRevascularisation
STEMI
Normal
STchanges
Troponin Tat 12 h +
Time since painonset
LMWH CKMB massstat
> 9 h
0 - 9 h
CKMB massafter 3h
CKMB massafter 6h
Clinical RiskAssessment
High
Low tomoderate
CompleteCDU/011overleaf
DischargeInvestigate as OPAdmit for investigationAdmit to consider
Revascularisation
> 5
> 5
All < 5
< 0.01
> 0.01
> 5Oral
beta blockers
Troponin Tat 12h +
> 0.01
6 ho
urs
of S
T se
gmen
t mon
itorin
g
< 0.01
CompletePDI/010overleaf
CompleteRef/015overleaf
CompleteCDU/014overleaf
CompleteRef/013overleaf
CompleteRef/012overleaf
MTSChestPain
Name______________________AE___/____________ Date___/___/_____
Emergency DepartmentCardiac Chest Pain
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Patient with cardiacchest pain
CompletePDI/010overleaf
MTSChestPain
Cardiac Chest PainWhich Patients?
Over 25 years
Unrelated to trauma
Not pleuritic
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Deciding initial disposition(streaming)
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Presentation-Priority Matrix
There are 50 Charts
There are 5 priorities
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Presentation-Priority Matrix
• There are 250(ish) possible outcomes
• Presentation / Priority pairs
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Presentation-Priority Matrix
BGYOR
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The local mapping process
Identify possibledispositions
Identify localstakeholders
Map each p-p complexto a disposition
Map each p-p complexto a disposition
Map each p-p complexto a disposition
IterationFinal Map
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PPM for MRI
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Telephone Triage
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Triage Group: TTA principles
Now
Soon
Later
Advice
Now
Soon
LaterAdvice
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Telephone charts
Matching format
Same principles
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Non-professional triage
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Severe painMajor bleeding
History of unconsciousnessAcute chemical injury to the eye
Widespread burnsDeformity
Marked distress
Acutely short of breathAbrupt onset headache
Currently fittingOedema of the tongueAltered conscious level
Severe painNon-blanching rash
Chest pain
Early clinicalassessment
Usual clinicalassessment
Acutely short of breathCurrently fitting
Severe painOedema of the tongueFails to react to parents
Non-blanching rashInconsolable by parents
Floppy
Adult
Child
YN
Y
Y
N
N
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The future
Continuous improvement 2e to 3e
Separate edition for children
Separate edition for telephone triage
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Summary
MTS has come a long way in a short time
It will go further
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International Reference Group
Lisbon Hamburg Manchester Graz
Oslo 2012
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MANCHESTER TRIAGE SYSTEM: why, how and where?
Kevin Mackway-JonesManchester Royal Infirmary
UK
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“For all is but a woven web of guesses"
Xenophanes