the manchester triage system telephone triage workshop

THE MANCHESTER TRIAGE SYSTEM

Telephone triage workshop

Copyright belongs to The Manchester Triage Group

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any other means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without prior permission of the publisher Blackwell Publishing Ltd.

History

1994 a local problem

History

1995 a local group

History

1996 a local

solution

Triage Group: Nomenclature

Number Colour Name

First Red Immediate

Second Orange Very urgent

Third Yellow Urgent

Fourth Green Standard

Fifth Blue Non-urgent

Triage Group: Target Times

First Second Third Fourth Fifth

0 min10 min

60 min

120 min

240 min

Discriminators

Y

Discriminators

Discriminators Discriminators

RED

ORANGE

YELLOW GREEN

BLUE

Y

Y

Y

N

NN

N

PRESENTATIONALFlow Chart

Triage Group: MethodologyTriage Group: Methodology

History

1997 a publication

History

1998 a national

solution

History

1999 an international

solution

Key Features

Designed by practitioners

Based on presentation (not diagnosis) 50 presentational charts

Reductive

Pain at the centre of assessment

Easy documentation

Key Features

FIT FOR PURPOSE

CLINICAL RISK MANAGEMENT TOOL

History

2005 2nd edition

Chart format For example…

Allergy

Allergy Discriminators

Defined in discriminator dictionary Vital part of system - the discriminator is used in a

consistant way

Standard ABCD

Allergy

Discriminators appear at the same point on every relevant chart

Allergy

Allergy

Current or recent (occurring within the past 7 days)

Another one…

Palpitations

Palpitations

Usual ABC

Palpitations Chest pain History of overdose or poisoning Abnormal pulse

Palpitations

Current palpitation History of unconsciousness Significant cardiac history

Palpitations

Discriminator definitions…

Example - “Inappropriate History”:

“When the history (story) does not explain the physical findings then the history is termed inappropriate. This is important as it is a marker of non-accidental injury in vulnerable children and adults and may be the sentinel for abuse”

Discriminator definitions…

“Significant respiratory history”

“A history of previous life-threatening episodes of a respiratory condition (eg COPD) is significant as is brittle asthma”

Discriminator definitions… “Acute neurological deficit”

“Any loss of neurological function that has come on within the previous 24 hours. This might include altered loss of sensation, weakness of the limbs (either transiently or permanently) and alterations of bladder and bowel function”

Translating Manchester Triage

- into…..Telephone Triage and Advice

History

1998 Local use over

telephone

Triage Group: TTA principles

Now

Soon

Later

Advice

Now

Soon

Later

Advice

Telephone charts

Matching format

Same principles

The Triage Event

How to perform an effective triage assessment

The purpose

MTS is designed to guide the triage practitioner’s decision making and assign a clinical priority rapidly to each patient.

To make the most effective use of this patient interaction the practitioner must be competent to perform a triage consultation.

The triage assessment must be systematic All elements of the assessment are pieced

together to give a complete picture of the patient’s presenting problem

For effective triage practitioners should have sufficient experience of emergency care and the inter-personal skills to communicate effectively with patients and their families.

Triage is a Pit Stop not an MOT!

Triage is a rapid, focused assessment and allocation of priority

Slowing of the process occurs when tasks other than prioritisation are carried out

A rapid face to face triage intervention can take as little as 30-60 seconds

Telephone triage should be expected to take longer as you do not have a patient in front of you

A framework for the triage consultationAssessment component

Greeting the patient

Triage activity Listen to voice Ascertain whether

patient or other

The patient history

Ask the patient what the problem is

This is a short, concise, subjective history and tells you about the patients injury / illness / health related problem

The presenting complaint

A patients presenting complaint can be established from the subjective history they provide.

This leads the triage practitioner to choose the most appropriate presentation flowchart.

Focused questions This is where the triage practitioners knowledge

and skills are most evident. Application of anatomical knowledge, pattern

recognition of presenting complaints and the ability to react effectively to life threatening situations are all the domain of the triage practitioner.

Focused questions can be used to obtain more detail if required e.g. duration of the problem, mechanism of injury, current medications, etc.

The format of these questions will be directed by the discriminators in the chosen presentation flow chart

Physical examination & assessment of physical

parameters Possible at face to face, less so on the end

of a phone but…some questions can be asked such as…..

What things sound like – do they make a gurgling sound when they breathe?

What things look like –does the limb look a different colour when you compare it to the other side?

What effect the problem is having – is your vision blurred or strange?

Pain assessment

An integral part of the MTS Pain assessment in telephone triage

is difficult so pain has been revised to be Severe pain (face to face now) Unresolved pain – (pain which has not

resolved despite the use of appropriate analgesia)in the absence of any other discriminator (face to face later)

Priority / plan of care

Priority assigned using the highest discriminator applicable to the patient

Relevant advice given.

Documentation Record information

to an agreed format; clear, concise and relevant to presenting complaint.

Include a record (subject to local requirements) of:

Allergies Current medications Relevant past

medical history Advice given

Legible Signature

An effective triage event By following this

systematic process, facilitated by the triage methodology, to guide decision-making the patient assessment can be performed rapidly and confidently to reach an appropriate clinical priority.

General Discriminators


95 year old lady found lying unresponsive on the bedroom floor by her daughter

Cyanosed RR fast Responding only to pain


24 month old boy, mum tells you he has been unwell for the past 5 days

Seen GP on 2 occasions advised analgesia and antipyretics

Today crying and listless Refusing food and fluids Temp 40oc

General Discriminators A 22-year-old man had a tooth removed

yesterday. He is registered with a dentist, but it is

sunday Increasing pain today & facial swelling

and bleeding He has been biting onto a cotton wool

ball as instructed, but it won’t stop bleeding

Painful


53 year old man complains of being hit on the leg with a metal bar

Felt faint 5 minutes after the event No LOC No bruising, contusions or wounds Painful Fully mobilising

Workshops

Making safe, reproducible triage decisions

Illness workshop 1Case 1

A 33-year-old woman is brought in from home. She is 16/40 weeks pregnant with her first baby

She complains of severe abdominal cramps and heavy PV blood loss

She complains of nausea


A 22-year-old woman who has collapsed in a supermarket She had apparently approached an assistant and asked if there was anywhere where she could sit as she did not feel well. The assistant had gone to get a chair for her and on returning had found her lying on the floor and "shaking all over". She had wet herself.

She is slightly drowsy but can converse normally. She complains of a headache.

She says she must have banged her head. She has a large lump on the back of her head

lllness workshop 1Case 4 A 22-year-old known migraine sufferer

complaining pain in her head and the back of the neck.

The patient is unable to say whether the headache is similar to her previous migraines. She points out that she usually has flashing lights in front of her eyes and she certainly does not have them this time. She is surprised that the headache came on suddenly because usually she gets a prodromal period before the headache starts.

She has photophobia and a stiff neck.


A 53-year-old woman complaining of diarrhoea and vomiting.

She says she has been unwell for two days

This morning she complains of a headache and has vomited once

She still has pain

Injury workshop 1Case 1

A 3-year-old child was playing in the kitchen and accidentally pulled on the handle of a saucepan which was being used to boil an egg. The saucepan fell and the hot water splashed over her left shoulder and back.

You can hear her screaming in the background.

Her grandmother says that there are no burns to her face.


It is 2.00 am on Saturday morning and the clubs have just shut. A 21 year old man has been assaulted. They state that he had not "been looking for trouble" when he had been set upon by three men.

The patient can talk to his friends.There is no obvious external bleeding. His friends say that he was punched and kicked.

They say that he was not unconscious. Patient complains that his "head hurts a bit".


A 33-year-old woman has been involved in a road traffic accident. She was a pedestrian crossing the road she was struck by a transit van moving at approximately 30 mph and has sustained a head injury.

She was knocked to the ground and banged her head. She was able to walk at the scene.

She says that her "head throbs". She was apparently unconscious at the scene for two to three minutes. She does not seem to be bleeding

Injury workshop 1Case 4 A 20 year-old-man who has been involved in

motorbike accident. He was hit by an oncoming car as he turned at

a junction and was thrown from the bike, which is severely damaged.

He is conscious but unable to remember the car hitting him.

He appears to be in severe pain, particularly in his hip and thigh


A 96-year-old man lives with his son who reports that his father fell this morning and hit his chest on the side of the bath. There is no obvious bruising.

Normally district nurses bathe the elderly gentleman, but he had been incontinent of faeces and his son says he could not stand the smell any longer.

There is no sign of external bleeding and he is not short of breath.


A 16-year-old girl had been sitting on a bus on her way home from college with a group of other students when they all noticed a strange smell. Shortly afterwards she noticed burning in her throat. Three other passengers had similar complaints.

There is no history regarding the nature of the chemical involved. The student is alert and orientated and her breathing ‘sounds ok’.

She thinks her tongue is slightly swollen her face feels puffy.


It is 10 o'clock in the morning. A 69-year-old man phones 999 for the eighth day in a row complaining of breathing problems.

He says that he has been trying to see his GP but the receptionist refuses to give him an appointment.

He is talking normally and does not appear to have difficulty breathing or any complaints of chest pain.

He has no history of chest infection or injury. He does not have a wheeze.

He complains he has now had the symptoms for six weeks.


A 76-year-old man says that he has vomited some blood.

He has vomited on six occasions in the previous two hours and he saw some blood streaks on the final occasion. He vomits once more while you are talking to him – he can’t see any blood this time.

He complains of severe spasms of pain in his upper abdomen.


It is September and the first week of the university term in the local town. A new first-year student phones and says that he does not have a GP and that he has a sore throat and feels unwell. He says he is "hot and bothered".

He says that he has just returned from Russia where he has been travelling in the summer holidays.

Temp 38.5 0c. He has no rash or blistering. He says his symptoms

came on gradually. He states that he had a splenectomy at the age of 16 following trauma.


A 74-year-old man’s GP phones 999. The patient has a 2 week history of

central/lower abdominal pain which comes in waves and settles. He has been aware of pain radiating into lower back. No vomiting but some constipation.

GP states ‘abdomen soft with prominent abdominal aorta – pulsatile and tender on palpation. No bruits, femoral pulses easily palpable’.

The patient is alert and orientated and walked into the surgery


A 55-year-old man is has an accident at work. It appears that he is a band-saw operator who has slipped while fitting a new blade to the saw. His ankle has gone underneath him and he says he heard a loud crack.

The ankle is obviously very deformed and the first aider says that there is a great deal of swelling.

On closer questioning, the first aider says that there is a piece of bone poking through the skin.


An 8-year-old child has apparently suffered an insect bite. His mum says that he is intermittently sobbing.

The mother states that the child has "never been stung by an insect before". She is very worried because her other son is allergic to wasp stings and his grandad was allergic to penicillin.

She says that he is breathing normally and she cannot see any swelling around his face. There is a 2 cm raised area on the left thigh with what appears to be a sting visible centrally.


A 50-year-old man who has slipped and fallen down three stairs this morning at. His speech is slightly slurred and he says that he was out drinking last night

During the fall he banged the back of his neck but does not know if he has been unconscious.

He says that he has pain in his neck which radiates down his right arm.

He has an unpleasant sensation like ‘ice cold water being poured down his back and legs’.


A 17 year-old young man suffers a head-to-head collision with another player during a game of football. No LOC witnessed.

He is bleeding a lot from his nose and his mouth and he has lost a tooth which is embedded in his upper lip

He is distressed but can communicate and clear his mouth of blood by spitting

His mouth and nose are swollen and he says his vision is OK

Illness workshop 3Case 1 An 19-year-old female university

student’s friend reports that she is feeling unwell. She is an insulin-controlled diabetic.

She says that she has been feeling unwell for a couple of days but today she has vomited several times.

Her blood glucose reading is 26.8 mmol A glucose stick test shows ++++ of

ketones in her urine. Temp 39.4 0c


A 55 year woman is having a palpitation She has a long standing history of

palpitations for which she takes medication - flecainide 200mgs BD

She has no chest pain or shortness of breath but her pulse rate feels very fast

She feels panicky and frightened and complains that her mouth feels very dry

lllness workshop 3Case 3 An 48 year-old lady phones with ear pain. She has had mastoid surgery 29 years ago, nil

problems since but advised not to get water in the ear.

Today she has got water in the ear and now complains of pain and that the ear feels swollen.

She has already consulted her GP today who prescribed regular paracetamol and antibiotics.

She complains of severe pain


A 42-year-old man complains of blurred vision.

His left eye is red. He states that his eye is not exactly painful - it is more of a "discomfort".

He says that the vision in that eye is very blurred


A 16-year-old girl who has been sent home from school unwell. Her mother phones She has been asthmatic for five years and her current medication is steroid inhaler, two puffs twice a day, and salbutamol inhaler, two puffs PRN.

She says that she has been increasingly breathless for two days.

She has never been in hospital before with her asthma.

She says that she has increased her salbutamol inhaler to two puffs every two hours but the shortness of breath does not improve.

Children workshopCase 1

A 5-year-old child is was well until the day before yesterday when she developed a slight fever. Today she is complaining of pain in her left knee and is unable to walk properly.

Mum has noticed no rash. The child feels slightly warm

The child has told her mum that her left leg is "pretty sore". She says that the pain gets worse when she moves her hip. Her left knee is hot to touch compared with the other knee.


An eleven month old girl was seen by her GP two days ago after presenting with a blanching rash. The GP diagnosed Chicken Pox.

She is crying and restless, temperature 37.9oc Today the child has a widespread rash and

blistering which includes the inside of her mouth.

Her mum says her face is not swollen but.. She is unable to take food or drink due to the

discomfort in her mouth


A 6-year-old child is is unwell at school. Apparently he had not been particularly well first thing in the morning and by mid morning break his class teacher had been concerned about him. He appeared to be unable to do anything other than walk without panting badly. He was not known to be on medication.

The boy can speak to the teacher in short sentences and is alert. There is no history of injury. The school have no record of medicines or puffers He is coughing intermittently.


It is 3 o'clock in the morning when the parents of a 6 month old baby phone. They say the child has been crying since midday the day before and they just do not know what to do.

He feels very warm to touch but his dad says that his temperature is OK using a tempadot. The parents have looked carefully all over the child and there is no sign of a rash.

Apparently the baby cried intermittently to start with, but has been crying non-stop since 10 o'clock that night. The child does not stop crying at all during the phone call The child has not had any paracetamol elixir, since it will not take anything by mouth.


A 5-year-old boy complains of pain in his tummy.

He is not vomiting and has had no episodes of diarrhoea.

He says his pain is not there all the time but it makes him want to curl up as it comes and goes and but he describes the pain as ‘OK really’

Behaviour workshopCase 1

A 51-year-old man is waiting for an ambulance having been found lying by the roadside apparently intoxicated.

No obvious signs of injury. The police say that he is slurring his words

and smells of alcohol. He responds to their voice. He has a confirmed history of alcohol

abuse.


A 32 year-old woman’s friend states that she has attempted to cut her wrists.

There is considerable bleeding from the right wrist. No attempts to control haemorrhage have been made as yet.

Following the application of a pressure dressing the haemorrhage ceases. She states that she is not in severe pain but that her arm "stings".

She keeps saying she is sorry and won’t hurt herself again. She is sobbing in the background


A 15-year-old girl is at a a residential children's home has drunk two mouthfuls of bleach.

She has vomited three times in the past 20 minutes and has a burning sensation in the back of her throat.

She has taken an overdose of paracetamol on two previous occasions

She says drank the bleach because she wanted to die.


The husband of a 27-year-old woman phones He states that over the previous two days she has started running around the house closing all the windows and locking the doors. She has used six bottles of bleach down the lavatory and states repeatedly that she will "probably catch it now".

She is alert orientated and denies taking any tablets or medicines. She has told her husband that that if she had any antibiotics she would certainly take them and that might save her. Her partner states that she has never been under psychiatric care.

She expresses no ideas of harming other people or of harming herself. She shows no signs of head injury and her partner states that she is physically the same as ever.

the manchester triage system telephone triage workshop

Documents

telephone slide

publication slide

methodology slide

abuse slide

days slide

local group slide

local problem slide

local solution slide