Manchester triage system in paediatric emergency care: prospective observational study

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.