Improving the prioritization of children at the emergency department: Updating the Manchester Triage System using vital signs

Abstract

Background Vital signs are used in emergency care settings in the first assessment of children to identify those that need immediate attention. We aimed to develop and validate vital sign based Manchester Triage System (MTS) discriminators to improve triage of children at the emergency department. Methods and findings The TrIAGE project is a prospective observational study based on electronic health record data from five European EDs (Netherlands (n = 2), United Kingdom, Austria, and Portugal). In the current study, we included 117,438 consecutive children <16 years presenting to the ED during the study period (2012–2015). We derived new discriminators based on heart rate, respiratory rate, and/or capillary refill time for specific subgroups of MTS flowcharts. Moreover, we determined the optimal cut-off value for each vital sign. The main outcome measure was a previously developed 3-category reference standard (high, intermediate, low urgency) for the required urgency of care, based on mortality at the ED, immediate lifesaving interventions, disposition and resource use. We determined six new discriminators for children <1 year and ≥1 year: “Very abnormal respiratory rate”, “Abnormal heart rate”, and “Abnormal respiratory rate”, with optimal cut-offs, and specific subgroups of flowcharts. Application of the modified MTS reclassified 744 patients (2.5%). Sensitivity increased from 0.66 (95%CI 0.60–0.72) to 0.71 (0.66–0.75) for high urgency patients and from 0.67 (0.54–0.76) to 0.70 (0.58–0.80) for high and intermediate urgency patients. Specificity decreased from 0.90 (0.86–0.93) to 0.89 (0.85–0.92) for high and 0.66 (0.52–0.78) to 0.63 (0.50–0.75) for high and intermediate urgency patients. These differences were statistically significant. Overall performance improved (R2 0.199 versus 0.204). Conclusions Six new discriminators based on vital signs lead to a small but relevant increase in performance and should be implemented in the MTS.

Using the Delphi method to establish pediatric emergency triage criteria in a grade A tertiary women’s and children’s hospital in China

“…Many triage nurses in China evaluate patient conditions based on their own intuition and experience, not a standardized objective indicators. Vital signs have been proved to be an important part in triage assessment [ 18 ] and an important predictor of disease progression [ 19 ]. The results of Zachariasse et al [ 18 ] have shown that the determining cut-off values of vital signs for patients of different age groups can help nurses triage the patients.…”

“…Vital signs have been proved to be an important part in triage assessment [ 18 ] and an important predictor of disease progression [ 19 ]. The results of Zachariasse et al [ 18 ] have shown that the determining cut-off values of vital signs for patients of different age groups can help nurses triage the patients. However, Zachariasse et al did not elaborate on age group classification.…”

Characteristics of pediatric emergency department frequent visitors and their risk of a return visit: A large observational study using electronic health record data

“…For clinical relevance and given the low numbers in the ’immediate group’ and non-urgent category, we combined immediate/very urgent and standard/non-urgent, resulting in a three-level triage urgency variable. Severity of an ED visit was determined based on type of management during the entire ED visit similar to the approach in the TrIAGE project [ 18 , 19 ] ( S1 Table ), and included the levels not severe, severe and very severe.…”

A practical approach to establishing a critical care outreach service: An expert panel research design

“…10,38 Lack of an international EWS is likely related to the view that an EWS in one hospital may not be applicable in another owing to different patient characteristics, which suggests one single EWS may not meet the needs of unique patient populations. 40,42 This is reflected in hospitals that have developed their own EWS, such as a paediatric EWS, 43 or a modified EWS. 44…”