Manchester Triage System in Paediatric Emergency Care

Report By: Dr Gemma Macey - Foundation Year 2 Trainee, A&E
Search checked by Mr John Sloan - Consultant in Emergency Medicine
Institution: Countess of Chester Hospital
Date Submitted: 11th December 2008
Last Modified: 8th January 2009
Status: Blue (submitted but not checked)

Three Part Question

In [children presenting to emergency care], is [the Manchester Triage System] able to [accurately triage patients].

Clinical Scenario

Triage of paediatric patients in the emergency department has long presented a problem as although several triage systems exist and can be applied to children, there is very little evidence for their validity. The Manchester Triage System is the most common method of triage in hospitals across Europe but little is known about its true correlation with actual illness severity in paediatric patients.

Search Strategy

Ovid Medline 1950-2008

Search terms: “Paediatric” OR “pediatric” AND “emergency” AND “Manchester triage”
Limited to English language papers

Search Outcome

4 papers found of which 2 were irrelevant or of insufficient quality. The remaining 2 papers are shown in the table below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results
Veen et al 2008 Netherlands	17 600 children aged <16 visiting an emergency department (3181 excluded from analysis)	Prospective observational study	Sensitivity (for high urgency patients)	Sensitivity 63%
			Specificity	Specificity 79%
			Accuracy of triage category (compared with an independent reference standard)	Accurate triage 34%, Over-triage 54%, Under-triage 12%
Roukema et al 2006 Netherlands	1065 children aged <16 visiting an emergency department (65 excluded from analysis)	Retrospective observational study	Sensitivity (for high urgency patients)	Sensitivity 63%
			Specificity	Specificity 78%
			Accuracy of triage category (compared with an independent reference standard)	Accurate triage 45%, Over-triage 40%, Under-triage 15%

Comment(s)

Whilst the Manchester Triage System includes six specific paediatric flowcharts, it has not previously been validated for use in a paediatric setting. Both studies show that the MTS has poor sensitivity and only moderate specificity, tending to err on the side of caution, causing over-triage of a significant number of patients into the ‘very urgent’ group, and with accurate triage in less than half. A lower validity was noted in children presenting with medical problems compared to those presenting with trauma in the larger study.

Clinical Bottom Line

The Manchester Triage System has limited value when applied to paediatric emergency care. Further studies are required to confirm these results and assess any modifications which could be applied to reduce over-triage rates and improve validity.

References

van Veen M. Steyerberg EW. Ruige M. van Meurs AH. Roukema J. van der Lei J. Moll HA. Manchester triage system in paediatric emergency care: prospective observational study. BMJ. 2008; 337:a1501.
Roukema J. Steyerberg EW. van Meurs A. Ruige M. van der Lei J. Moll HA. Validity of the Manchester Triage System in paediatric emergency care. Emergency Medicine Journal. 2006; 23(12):906-10 .