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A MEASUREMENT OF THE RELIABILITY
AND VALIDITY OF THE MANCHESTER
TRIAGE SYSTEM IN AN IRISH
HEALTHCARE CENTRE
By
Kenneth Folliard
A thesis submitted in partial fulfilment of the
requirements for
Degree of Master of Science in Nursing Studies
(Clinical Practice)
University College Dublin
2006
i
TABLE OF CONTENTS
Declaration .......................................................................................................... v
Dedication .......................................................................................................... vi
Acknowledgments ............................................................................................ vii
Abstract ............................................................................................................ viii
List of figures ..................................................................................................... x
1. Chapter 1 .......................................................................................................
The research objective
1.1. Introduction to problem ........................................................................ 1
1.2. Rationale for the project ......................................................................... 2
2. Chapter 2 .......................................................................................................
Literature review
2.1. Introduction ........................................................................................... 4
2.2. Literature search ................................................................................... 6
2.3. Definition of triage ................................................................................. 7
2.4. Historical origins of triage .................................................................... 7
2.5. Principles of triage ................................................................................ 9
2.6. Types of triage ........................................................................................ 9
2.7. Triage scales ......................................................................................... 11
2.7.1. Australasian Triage Scale and National Triage Scale .............. 11
2.7.2. Canadian Triage Acuity Scale .................................................. 12
2.7.3. Emergency Severity Index ........................................................ 13
ii
2.7.4. Manchester Triage Scale........................................................... 14
2.7.5. Cape Triage System ................................................................. 14
2.8. Consistency of triage scales ................................................................ 16
2.9. Use of triage scales as predictors of acuity and admission rates ........ 17
2.10 Discussion / Conclusion .................................................................... 18
3. Chapter 3 .......................................................................................................
Methodology
3.1. Study design ........................................................................................ 20
3.2. Location/Setting .................................................................................. 20
3.3. Sample ................................................................................................ 21
3.4. Data collection ..................................................................................... 22
3.5. Patient scenarios .................................................................................. 23
3.6. Data analysis......................................................................................... 23
3.7. Inter rater agreement ........................................................................... 24
3.8. Intraclass correlation ............................................................................ 26
3.9. Ethical considerations ......................................................................... 27
3.10 Project outline ..................................................................................... 28
4. Chapter 4 .......................................................................................................
Results
4.1. Introduction ......................................................................................... 29
4.2. Demographic details of sample ........................................................... 30
4.3. Educational qualifications of participants .......................................... 32
4.4. MTS training ....................................................................................... 33
iii
4.5. Questionnaire responses ....................................................................... 34
4.6. Over and under triage of scenarios ...................................................... 36
4.7. Modal score .......................................................................................... 38
4.8. Interrater reliability .............................................................................. 39
4.9. Intraclass correlation ........................................................................... 40
4.10 Conclusion .......................................................................................... 41
5. Chapter 5 ........................................................................................................
Discussion
5.1 Introduction .............................................................................................. 42
5.2 Sampling ................................................................................................ 42
5.3 Questionnaires ........................................................................................ 43
5.4 Answers to scenarios ............................................................................... 44
5.5 Modal responses ..................................................................................... 46
5.6 Interrater agreement ................................................................................ 46
5.7 Limitations .............................................................................................. 47
5.8 Conclusions/implications for practice ..................................................... 47
6. Chapter 6 .......................................................................................................
Summary
6.1 Summary ............................................................................................... 49
6.2 Recommendations for practice ............................................................... 50
6.3 Recommendations for research ............................................................. 51
6.4 Conclusion ............................................................................................. 51
iv
References ........................................................................................................ 53
Appendix 1
Questionnaire .................................................................................................... 61
Appendix 2
Letter to participants .......................................................................................... 72
Appendix 3
Letter to Clinical Director .................................................................................. 75
Appendix 4
Letter to Director of Nursing ............................................................................ 77
Appendix 5
Ethical Approval application ............................................................................. 79
Appendix 6
Letter of ethical approval ................................................................................... 91
Appendix 7
Letter of approval Clinical Director .................................................................. 93
Appendix 8
Letter of approval Director of Nursing ............................................................. 95
Appendix 9
Approval to reproduce MTS table .................................................................. 97
Appendix 10
Scenarios from MTS with ‘Correct’ Answers .................................................. 99
v
DECLARATION
This dissertation is submitted to University College Dublin as part fulfilment of the
requirement for the Degree of Master of Science in Nursing Studies (Clinical Practice).
It has not been submitted to for a degree at this or any other University. I declare that
the content is my own work unless otherwise stated.
I give permission to University College Dublin to lend or copy this thesis upon request.
This permission covers single copies made for study purposes and subject to normal
conditions of acknowledgment
_______________________________
Kenneth Folliard.
vi
DEDICATION
To my parents:
Who both made me who I am and gave me the ability to strive to achieve my
goals.
vii
ACKNOWLEDGMENTS
The author wishes to thank the following for their help and support in completing this
thesis:
Jonathon Drennan, for all his help and words of encouragement throughout the whole
project particularly when it came to kappa statistics.
Julian O Brien, for his invaluable advice on inter-rater reliability and intraclass
correlation
Clinical Director of the Emergency Directorate in St James Hospital Una Geary
Acting Director of Nursing St James Hospital Catherine Carey
All the nurse managers, staff nurses and nurse practitioners in the Emergency
Department of St James Hospital
My colleagues, Gerry, Mary, Josephine, Joan Frieda, Marie, Mary and Niall who went
through this experience with me
And finally to Declan, for his patience and understanding, and whose constant support
and encouragement particularly when stress levels were high helped to keep my feet
on the ground.
viii
UNIVERSITY COLLEGE DUBLIN
ABSTRACT
A MEASUREMENT OF THE
RELIABILITY AND VALIDITY OF THE
MANCHESTER TRIAGE SYSTEM IN AN
IRISH HEALTHCARE SETTING
By
Kenneth Folliard
Purpose: The purpose of this study is to measure the validity and reliability of the
Manchester Triage System (MTS) in an Irish healthcare setting.
Design: The design used is that of a methodological nature which is aimed at
determining the level of interrater reliability or levels of agreement amongst nurses
using the MTS.
Setting: The setting used the emergency department of an inner city centre teaching
hospital in Dublin, with an average attendance of 46000 patients per annum where the
MTS has been in use since 1998.
Sample: The sample consisted of 31 nurses who work within the emergency
department, have had formal training in the use of the MTS and who use it on a regular
basis.
Data Collection: All participants were given a questionnaire by the researcher which
they have to complete. The questionnaire was divided into two sections; the first
contained 15-20 patient scenarios which the participants will be asked to assign a
triage category to each, the second section contained demographic questions about the
individual participant.
ix
Data Analysis: the data was analysed using the Kappa statistic, to determine the level
of agreement between the individual nurses responses, descriptive statistics are used to
outline the characteristics of the sample chosen.
Results: The interrater reliability of the MTS in this project was determined as
moderate (k=0.45 p<0.0001). Only one scenario received the correct answer by all
participants, of all the answers received approximately 15% (n=141) were ‘over
triaged’ and 17% (n=155) were ‘under triaged’. The correlation of the modal scores
with the correct answers was approx 90% with a difference of only 1 category between
any of the scores.
Conclusion: These results demonstrate that the MTS has a moderate level of interrater
reliability when used within an Irish healthcare setting; however the discrepancies that
were found namely the percentages of ‘over’ and ‘under’ triaging could have
detrimental effects for patient outcomes. The conclusions that arise from this project
are that further educational strategies need to be put into place in order to reduce the
number of patients that are triaged incorrectly and that further reliability and validity
studies are required in the area of the MTS.
x
LIST OF TABLES AND FIGURES
Table 4.2 Demographic characteristics of the participants……………………...……31
Table 4.3 Educational qualifications of the participants……………………...………32
Figure 4.4 Year of MTS training …………………………………………………….33
Figure 4.5 Variance of scenario answers ………………………………….…………34
Table 4.5 Frequencies of scenario answers…………………………….……………. 35
Table 4.6 Frequencies of over and under triage …………………...…………………37
Table 4.7 Modal responses ………………………………………….……………….38
Table 4.8 Kappa values and strength of agreement ………………….………………39
Table 4.9 Intraclass correlation coefficients ……………… ……………………….40
1
C h a p t e r 1
THE RESEARCH OBJECTIVE
1.1 Introduction
The underlying principle of any triage scale is that a patient should be able to present
to any emergency department, be triaged by any triage nurse at any time of the day
with a specific problem and be allocated the same triage category each time (Considine
et al 2000). In order to achieve this any triage scale in use must stand up to the rigours
of testing and be deemed reliable. The consequences of utilising an unreliable scale
can have detrimental effects on patient outcomes. If patients with serious or life
threatening illnesses or injuries are allocated a triage category below that of which is
warranted by them they can then face longer waits to receive treatment, this can lead to
a deterioration in their condition which in some cases could be life threatening. If
patients with relatively minor problems receive a triage category above that of which
they should, they will certainly access treatment quicker, but this could be to the
detriment of more ill patients, as resources, staff and time are used for patients with
less urgent conditions while other patients with more serious conditions have to wait
longer. This ‘over’ and ‘under’ triage is often as a direct result of the triage scale in use
not haven been proven either reliable or valid (Hollis & Sprivulis 1996). There are also
wider implications in the use of an unreliable triage scale. The current developments in
the evolution of healthcare in Ireland with a greater emphasis on financial planning,
reduction in working time hours and effective resource utilisation has led to the use of
2
triage scales not only for the prioritisation of patients according to their level of acuity,
but also to aid in decision making in issues such as staffing levels, funding and other
administration and managerial matters. The Report of the National Task Force on
Medical Staffing (Government of Ireland 2003) in its recommendations included that
EDs “utilise a uniform triage scale that produce comparable and comprehensive
information on patient attendance and acuity” and that patients should be directed to
triage as the first point of contact with the Emergency Department. The Report on
Nurse Staffing Levels in Emergency Departments (Healthcare Consultancy Ltd.2003)
used triage codes as a means of calculating the number of nurses required on a shift so
the importance of triage and accurate triage has a direct impact on staffing levels
within an ED. This is corroborated at local level in the setting for this project where the
triage codes of patients are used to imply to the acuity of the department (St James
Hospital 2003 p 45).
1.2 Rationale for the project
The background rationale for this project is the introduction of the Manchester Triage
System into numerous emergency departments (EDs) in Ireland and yet there is no
published research which has demonstrated its reliability internationally, or any
documented evidence of it effectiveness within the Irish healthcare setting. There is
also contradictory evidence in relation to interrater agreement amongst nurses and
doctors and some research to suggest that triage scales are not a good predictor of
either department acuity or admission rates. (Brillman et al 1996)
3
The project is particularly relevant at present, where evidence based practice is
advocated in all settings and a system has been introduced which has not as of yet been
independently validated.
4
C h a p t e r 2
LITERATURE REVIEW
2.1 Introduction
Triage is accepted as an integral part of the emergency department (ED) patient
assessment. It has become important to the safe and efficient operation of the ED by
allowing for the prioritization of patients based on acuity. The purpose of this literature
review is to examine the most relevant literature pertaining to triage with particular
reference to the Manchester Triage System (MTS) and its usefulness in the Irish health
system. The key role of triage is to assign a treatment priority to patients to ensure that
those needing urgent care, access care first (Murray 2003). As deduced from a short
telephone audit of emergency departments, the principle triage system utilised in the
Irish healthcare system is the Manchester Triage Scale (MTS). The Report of the
National Task Force on Medical Staffing in its recommendations included that EDs
utilise a uniform triage scale that produces comparable and comprehensive information
on patient attendance and acuity and that patients should be directed to triage as the
first point of contact with the Emergency Department (Government of Ireland 2003).
The introduction of formal triage in the mid-eighties put nurses where they should be,
in the front line of emergency care, and undid the injustice of patients having their
potentially life threatening needs assessed by well meaning but unqualified
receptionists (Blythin 1988). It provided full recognition of the pivotal role ED nurses
had always played in the assessment and management of patients and paved the way
5
for other autonomous roles such as those of nurse practitioner. Nursing authors saw
triage as an opportunity to realise the caring aspirations of emergency nursing,
possessing outcomes in its own right. The espoused benefits were numerous and have
included: the assessment and prioritisation of patients, reduction in waiting times, the
control of the flow of patients by assigning the appropriate area for treatment and
balancing the workload with resources, the increase in infection control measures, the
implementation of crisis intervention, reduction of aggression and the provision of
information (Turner 1981, Rausch 1981, Molitor 1985, Nuttall 1986, Blythin 1988,
Jones 1988). These were further described as an extension of the caring role with early
identification health promotion needs, the provision of a safe environment and
continual re-assessment of patients, opportunistic screening for health risk, such as
alcohol abuse, domestic violence, suicide risk and the early initiation of investigations.
(Williams 1992, Rosenzweig 1992, Gray 1991). Realising these aspirations in
practice, however, remains largely unsubstantiated, the evidence for the efficacy of
nurse triage being both minimal and weak. This has caused some to argue that triage
has become little more than the operating of a multiple queuing system, even going so
far as to question whether triage is an appropriate nursing role (Redmond 1998).
The evidence that does exist has arisen from studies that have focused on two main
aspects, the accuracy of nurse triage and triage as a means of reducing waiting times.
Research into the accuracy of nurse triage has generally involved single centre studies
comparing nurses’ prioritisation of the presenting problem with the retrospective or
prospective judgment of a senior medical clinician (Zwicke et al 1982, Parmer 1985,
Rausch 1981). Variations in the number and type of categories used and the criteria for
allocating patients to them, along with the differences in demography and
organisational structure, makes generalisations across EDs impossible.
6
Furthermore, while most investigations have concluded that nurses were safe and
effective in identifying potential risk, the emphasis on comparative studies has,
paradoxically, only served to reinforce medical dominance. Several studies have
claimed to demonstrate the effectiveness of triage in reducing waiting times. However,
on closer examination, it can be seen that these reductions came about when triage was
combined with other extended roles, notably X-ray requesting, the initiation of
treatment or structural changes in the department, rather than as a result of triage per se
(Wong et al 1994, Burgess 1992, Jones 1986,)
2.2 Literature Search
The following databases were searched:
PubMed
CINAHL (Cumulative Index to Nursing and Allied Healthcare Literature)
Medline
Proquest
Terms used to focus the search included Triage, Manchester Triage, and Validity of
Triage In addition a search of medical and nursing journals such as Annals of
Emergency Medicine, Journal of Advanced Nursing, Accident and Emergency
Nursing and Emergency Nurse resulted in the identification of other research pertinent
to the subject concerned. Other sources searched included the Department of Health
and Children and Government of Ireland websites for publications relating to triage
and emergency care.
7
2.3 Definition of Triage
Triage may be defined as the process of prioritising sick or injured people for treatment
according to the seriousness of their condition or injury.
The Oxford English Dictionary (2004) has defined triage as ‘The assignment of
degrees of urgency to wounds or illnesses in order to decide the order or suitability of
treatment’, from a nursing point of view Gerdtz and Bucknall (1999) defined triage as
a “dynamic decision-making process that prioritises a patient’s need for medical care”
on arrival at an ED. It is usually performed by nursing staff trained in a recognised
triage system. Woolwich (1999) outlined a number of types of nurse triage including
non-professional, basic and advanced. Fundamentally triage aims to ensure that
patients who present to the ED treated in the order of their clinical urgency.
2.4 Historical origins of triage
The word triage comes from the French word 'trier', which means "to sort" (Dolan and
Holt 2000). Much of the credit for modern day triage has been attributed to
Dominique Jean Larrey (1766 –1842 ), a famous French surgeon in Napoleon's army
who devised a method to quickly evaluate and categorize the wounded in battle and
then evacuate those requiring the most urgent medical attention (Blaine 1997).
Surgical triage developed from the need to prioritize the care of injured soldiers in
battlefield settings. The concept of prioritizing patients and providing immediate care
to the most seriously injured was practiced in France in the early 1800s. Over the next
8
century, this practice was further developed in armies throughout the world. As a
result, many injured persons whose surgery might have been delayed received critical
care earlier. During World War I, improved outcomes of some battle injuries were
credited to appropriate triage. Thus, triage is one of the first applications of medical
care after first aid.
Triage in emergency departments (EDs) occurred sporadically in the early 1900s in
crowded inner-city hospital dispensaries; however, it was not widely adapted in EDs
until the latter half of the century, when organized departments with on-duty ED
physicians became standard (Derlet 2004) . Although initially triage was a concept
associated with the military and war, over the past 20 years it has been adopted
worldwide into hospitals and acute care settings. The need for the introduction of a
triage system has been attributed to the rapidly increasing numbers of patients coming
to hospital ED over the past decade, especially those with non-urgent problems. Triage
has evolved to become a critically important part of the ED, as long waits to see the
ED physician require timely detection at triage of those patients with high-risk
conditions.
9
2.5 Principles of triage
The main principles of triage have been summarized by Murray (2003):
‘To rapidly identify patients with urgent, life threatening conditions.
To determine the most appropriate treatment area for patients presenting to the
ED.
To decrease congestion in emergency treatment areas.
To provide ongoing assessment of patients.
To provide information to patients and families regarding services expected care
and waiting times.
To contribute information that helps to define departmental acuity.’
It must also be noted that the decisions made at triage by the nurse may have profound
effect on the eventual outcome of all patients presenting to the department (Doolan
2005) and that the role of the triage nurse extends further than just initial assessment
but incorporates reassessment and continuous reassessment
2.6 Types of triage
Triage can be performed in various settings, including disaster triage, military triage,
ED triage and telephone triage (Grossman 2003, Gilboy et al 2003). In examining
disaster triage and ED triage, there are differences in the aim of triage as well as the
way it is carried out.
10
In ED triage, each individual is assessed and prioritized according to the individuals’
clinical needs, while in disaster triage the triage category allocated is also dependent on
the limited resources as a consequence of the disaster, as well as the other casualties.
The majority of disaster triage models use a three or four level scale to quickly identify
victims who have life threatening injuries but who can be saved, “to do the best you
can for the most you can” (START 2001, Manchester Triage Group 2006), whereas
most ED triage scales use five level scales and the main priority is to identify the
sickest patients and ensure that they receive care first.
Disaster triage deals with extreme situations, and where the majority of casualties are
likely to have more severe conditions. However, the importance of a correct triage
decision is as great in any kind of triage, because it is about making sure that the
patient in need of immediate attention will be prioritized, before patients with less
urgent conditions.
When an obviously ill person enters the ED, the triage decision is often relatively easy
because the person needs immediate attention. Persons seeking health care with non-
urgent chief complaints may also be easily triaged, but a large proportion of ED
patients belong to neither of these extremes, and thus the triage decision for such
patients becomes more difficult. Telephone triage is a relatively new concept in the
healthcare system and as it does not involve patients within the department therefore
has been excluded from this review of the literature.
11
2.7 Triage Scales
To assist in the appropriate triage of patients presenting to the ED a number of scales
have been developed. The first five-level scale to be developed was the Ipswich Triage
scale (Fitzgerald 1989) from which all others have been adapted. The National Triage
Scale which then became the Australasian Triage scale, the Canadian Triage Acuity
scale, the Emergency Severity Index, the Manchester Triage Scale and the most recent
scale to be introduced the Cape Triage Scale. . Each scale comprises of a number of
categories to which a patient may be assigned. This category is dependant on a number
of factors namely the patients presenting complaint, vital signs, and past medical
history and determines how long the patient may safely wait prior to the
implementation of treatment. These scales were developed primarily to provide a
consistent approach to triage so that any patient may present at any time, to any ED
with a specific problem and be allocated the same triage priority, a principle identified
by Considine et al (2000) as the underlying ethos of any triage scale.
2.7.1 Australasian Triage Scale (ATS) and National Triage Scale (NTS)
The NTS was first developed by the Australian College for Emergency Medicine
(ACEM) in 1993 by adapting an original five-point scale from Ipswich General
Hospital and validated for use in Australia in the 1980s by Fitzgerald and Jelinek,
(Fitzgerald 1996) in an attempt to standardise the triage process in Australia
(Considine et al 2001). The ATS which was introduced in 2000 was primarily a
revision of the NTS with the main difference being the description of each of the
12
categories. These descriptions have evolved into immediately life threatening,
imminently life threatening, potentially life threatening, potentially serious and less
urgent. The basic responsibility of any triage scale it that regardless of who is triaging
the patient and regardless of location or events the same patient presenting for triage
will be allocated the most appropriate category for the nature and severity of their
condition (Doolan 2005). There were varying degrees of consistency in the application
of the ATS in Australia which led to the publication of The Consistency of Triage in
Victoria’s Emergency Departments Project (Le Vasseur et al 2001). The main
objective of the project was to improve the consistency of triage through the
development of physiological discriminators, which would allow for the use of
objective as well as subjective data to be utilised in the triage decision-making process.
These discriminators were developed in collaboration with clinicians, managers and
educators, and are divided into adult and paediatric. They cover life threat topics and
follow a format of a primary survey incorporating airway breathing and circulation
with the inclusion of risk factors for serious illness or injury such as age, mechanism of
injury, cardiac risk factors and presence of co-morbidities. These discriminators once
incorporated have had great effects on the reliability of the ATS (Dilley & Standen
1998)
2.7.2 Canadian Triage Acuity Scale
The Canadian Triage Acuity Scale (CTAS) was developed and introduced in 1995 as a
result of a recommendation by the Canadian Association of Emergency Physicians
(CAEP) to use one national five–level triage scale. Prior to this Canadian EDs used a
13
three point scale ranging from emergent, urgent and deferrable as a means of triaging
patients. The CTAS prioritises patients according to clinical condition and assigns each
patient to a particular level, ranging from level I, resuscitation who need to be seen
immediately, level 2 emergent, to be seen within 15 mins, level 3 urgent, to be seen
within 30 mins, level 4 semi-urgent, to be seen within 1 hour down to level 5 non-
urgent, to be seen within 2 hours.
2.7.3 Emergency Severity Index.
The Emergency Severity Index (ESI) is predominately in use in the United States of
America. It was originally developed as a replacement to a three level scale which was
in use which classified patient into emergent, urgent and non-urgent. It emerged from
work by Wuertz et al (1998) that the three level scale wasn’t very reliable in either
classifying patients or reflecting department acuity with interrater agreement between
triage staff and expert panels of poor to fair, kappa scores ranging from 0.19 to 0.39
(Wuertz et al 1998). The five level scale which replaced it; the ESI, classifies patients
into five categories ranging from category 1 or most urgent to category 5 least urgent.
It has been validated as providing a more accurate scale and which also more closely
represents department acuity and the use of resources.
14
2.7.3 Manchester Triage Scale
The Manchester Triage scale is also based on a five level scale with category 1 or red
being the most urgent down to category 5 or blue the least urgent. The waiting times
for each category range from immediate for category 1 to four hours for category 5
(appendix 1). It was developed in 1996 by the Manchester triage Group with the aim
of achieving consensus among senior emergency clinicians and nurses about triage
standards. There are fifty presenting complaint flow charts ranging alphabetically from
abdominal pain to wounds, one of which is chosen for each patient. Each flow chart
then comprises of a five-level decision making framework from which a triage
decision is made. There are general discriminators which cover life threat topics such
as airway, haemorrhage and pain which relate to every flow chart and then others
which are presentation specific such as peak flow measurement in shortness of breath
or signs of meningitis in headache. The MTS also has specific flow charts for use
during a mass casualty or major incident. The MTS has been adopted for use
throughout the United Kingdom as well as Ireland, Portugal and Holland (Manchester
Triage Group 2006).
2.74 Cape Triage System
The most recent scale to be developed is the Cape Triage System (CTS) which was
developed in South Africa by the South African Triage Group (SATG). The system
was intended to address the issues of prolonged waiting times, poor management of
clinical risk and increased morbidity and mortality. The Cape Triage Group (CTG)
15
was convened in April 2004 by the Joint Emergency Medicine Division, Universities
of Cape Town and Stellenbosch, in order to design a triage system suitable for local
use. The South African Triage Group (SATG) was convened in June 2005 following
the successful implementation of the Cape Triage Score (CTS) in Western Cape public
sector emergency units. The SATG is multidisciplinary and comprises doctors, nurses
and paramedics representing the state and private sectors. The SATG set goals that
included defining vital sign parameters, while ensuring that the triage system remained
user-friendly in order to enable rapid and accurate sorting of emergency patients.
The SATG has designed a triage tool intended for utilisation in both the pre-hospital
and ED settings, it is a five tiered system but instead of numbers or categories the
system utilises colours which indicate the urgency of each patient, red: immediate
priority, orange: very urgent, yellow: urgent, green: delayed priority and blue: dead.
The CTS derivation process has been through both expert opinion and in-hospital
prospective studies. Three versions have been developed, based on a prospective study
of the SATS on 22,500 patients in a public hospital setting, and 2,000 patients in
private hospitals. The adult version is intended for those over 12 years of age the child
version has been developed for those 3 - 12 years old, and the infant version for those
under 95 cm or less than 3 years of age. The pre-hospital use of the CTS still requires
validation.
A two-tiered approach to triaging is utilised, using both a physiological scoring system
and a series of discriminators. The adult, child and infant version vary with slightly
different discriminators. The CTS has used the following discriminators: Mechanism
of injury has been limited to high energy transfer. Presentation: his includes symptoms
such as chest pain and abdominal pain; it also includes ‘eyeball diagnoses’ such as
seizures and dislocations, which are clear at triage
16
Pain: As with many triage scores, pain is regarded as an important indicator of priority.
It is recorded as severe, moderate, or mild. Experienced health care professionals can
also improve the triage process by adding their opinion to other parameters. In the
SATG protocol, a senior health care professional may alter the triage coding, either up-
or downgrading the triage status. The waiting times for the CTS are the same as the
MTS.
2.8 Consistency of international scales
Internationally there has been much work carried out in examining the reliability and
validity of different triage scales, with both positive and negative results. The negative
results focus mainly on poor inter-rater agreement between triage nurses and also
demonstrate incongruity between nurses and physicians (Brillman et al 1996). Other
research has focused on the use of three level scales in comparison to five level scales
(Wuertz et al 1999, Travers et al 2002). These papers have supported the use of a five
level scale as more reliable and valid than the previously used three level scales. The
ATS has had many validation studies carried out (Doolan 2005, Crellin ad Johnson
2003, Standen 1998, Jelinek & Little 1996, Doherty 1996) and found varying degrees
of consistency and interrater reliability ranging from kappa scores 0.24- 0.37. From
the Canadian perspective the earlier three point scale that was in place prior to the
CTAS being implemented had never been examined for either reliability or validity
(Murray 2003). The CTAS was proven to be more to be more valid and was seen to
better allocate the resources available in the department to patient need and was
supported by the work of Wuertz et al (1998).
17
There are very few studies carried out to examine the consistency of the MTS. In
searching MEDLINE, CINAHL and Proquest databases there are no studies
investigating the validity or reliability of the MTS what has been examined is the
detection of critically ill patients (Cooke 1999) and the assessment of pain using the
MTS pain ruler (Lyon 2005). In the detection of critically ill patients Cooke (1999)
stated that the MTS was a sensitive tool for detecting those who subsequently need
critical care and are ill on arrival in the ED, yet in their results stated that 67% of
patient who were admitted to the critical care area received a triage category of 1 or 2,
and that 18 others should have received a code of 1 or 2 but claimed that this was
down to nurse error rather than the system.
In the convergent validity of the MTS pain ruler (Lyon 2005), the correlation between
the MTS pain ruler for children and the Oucher scale was examined, good correlation
scores were reported but no studies to date have examined the pain ruler for its validity
in adults.
2.9 Use of triage scales as predictors of departmental acuity and admission rates
As stated previously The Report on Nurse Staffing Levels in Emergency Departments
(Healthcare Consultancy Ltd. 2003) use triage codes as a means of calculating the
number of nurses required on a shift so the importance of triage and accurate triage has
a direct impact on staffing levels within an Emergency Department (ED). This is true
at local level in the setting of this study where the triage codes of patients are used to
imply the acuity of the department (St James Hospital 2003 p 45). A study carried out
18
by Brillman et al (1996) examined triage coding and hospital admission rates and
found there to be little conclusive evidence that triage codes can predict hospital
admission or even the need for emergent care. They cited examples such as
hypoglycaemia, chest pain and allergic reaction which require urgent medical
intervention and a high triage category but are not admitted to the hospital or use as
many resources as a patient with abdominal pain who would be given a lower triage
priority but may have an ectopic pregnancy or appendicitis and require hospital
admission as well as laboratory, radiology and theatre resources. Conversely Jiminez et
al (2003) carried out a study on the CTAS and found a very strong correlation (p<0.01)
between triage category, admission rates and laboratory utilization.
However they did not formally evaluate inter-rater triage reliability; nor were able to
comment on inter-hospital reliability and external validity.
2.10 Discussion/ Conclusion
Since the early Eighties, triage has become an accepted formalised role in EDs. This
has happened despite little substantive evidence in support of its espoused benefits. By
tracing its history, it has been shown that far from being a unified concept, triage
incorporates conflicting ideologies and agendas, and the consequences of the way in
which it has been implemented, the original spirit of nurse triage has been lost and the
benefits for patients have become questionable.
The MTS has been introduced into the Irish healthcare system since the late 1990s and
as of yet there are no studies evaluating its value in improving the service provided to
19
patients who present to Irish EDs. There is also a distinct lack of international literature
in analysing the reliability or validity of the MTS in any population. The studies that
have been carried out have focused on the reliability of the MTS in detecting critically
ill patients which have proven that it is a sensitive tool in detecting critical illness but
no studies have examined its use in the vast majority of patients who present to EDs
with illness or injury which falls between the two extremes of critically ill and non-
urgent.
This literature review has highlighted a major gap in the research surrounding the MTS
which must be addressed as the MTS has been so widely introduced into so many EDs
throughout Ireland and its results are having effects on the waiting times of patients as
well as a direct affect on budgets, department resources and staffing levels with the
Irish healthcare system.
20
C h a p t e r 3
METHODOLOGY
3.1 Study design
The design that used is one of non-experimental quantitative technique which
determines the validity and reliability of measurement or assessment scales by
examination of the level of inter-rater agreement between nurses. In asking the
question what is the measurement of reliability and validity of the MTS in an Irish
healthcare setting. The MTS is viewed as an instrument which must stand up to the
rigours of testing, this research design was used as the MTS is essentially an
assessment scale whereby patients are categorised according to the severity of their
illness (MTG 1996). This type of research also employs psychometrics which allows
the researcher a more controlled and rigorous method of assessing these criterion
which is essential in any quantitative research (Polit et al 2001)
3.2 Location / Setting
The setting for this project is the ED of a large teaching hospital in the city centre of
Dublin, Ireland. It has approx 44500 new attendances per annum, with an admission
rate of approx 26% (St James Hospital 2004). The MTS has been in operation within
21
the department since 1998. There are approximately 65 nurses working in the
department with 51 trained in the use of MTS. Permission was sought from the
Director of Nursing of the hospital (Appendix 4) as well as from the Clinical Director
of the department (Appendix 3).
3.3 Sample
Sampling within research is a process of selecting subjects who are representative of a
specific population in order to make generalizations about that population in a given
situation (LoBiondo-Wood & Haber 2002). A convenience sample was taken as the
participants must have had training in the MTS in order to be able to complete the
questionnaire. The participants are all nurses working within the ED, who have had
training in the Manchester triage system and who use it on a regular basis
approximately 50 in total. Inclusion criteria are that nurses must have had training in
the Manchester triage system and have been working in emergency nursing for a
minimum of six months. Excluded were nurses who did have not had training the
Manchester triage system.
22
3.4 Data collection
Data was collected by the use of a questionnaire as derived from the literature review.
The questionnaire contained two parts. The first part contained sample patient
scenarios which the respondents were asked to assign a triage category to. The second
contained a demographic section which enquired to the personal characteristics of the
respondents such as educational level, years qualified etc. this information allowed the
researcher to build up a profile of the respondents and allow for correlation of these
characteristics with the item being studied.
There are limitations to the use of questionnaires, the main problem being poor
response rates (Burns and Grove 2001) but in comparison to other methods of data
collection which were considered: simultaneous triage by nurse and researcher or
retrospective chart audit, it was deemed the most appropriate. The use of a
questionnaire in this type of study is also supported by its use in similar studies in
examining the reliability and validity of other triage systems (Dilley & Standen 1998,
Bergeron et al 2002, Crellin 2003). The issue of poor response rates was addressed by
the implementation of strategies outlined by Edwards et al (2005) such as the use of
colour in the questionnaire, advance notice, a letter was sent to each nurse who
satisfied the inclusion and exclusion criteria (Appendix 2), follow-up contact, posters
were put up in the department advertising the project and reminding staff to fill in the
questionnaires, and the assurance of confidentiality.
23
3.5 Patient scenarios
The patient scenarios were obtained from the Manchester Triage group and all have
‘expected’ answers and have been validated through a panel of experts in emergency
care (appendix 10) both for content validity and for the accuracy by which each
scenario reflects the triage category they have been designed for (Manchester Triage
Group 2006). Although paper scenarios have been described as having limitations as
they do not provide the nurse with the visual, audible and verbal cues used to make
triage decisions (Jelinek & Little 1996, Dilley & Standen 1998), the use of actual
patients would have substantial ethical implications for patient confidentiality.
3.6 Data analysis
To determine the type of statistical analysis appropriate for this study the level of
measurement must be identified, as the higher the level of measurement the greater the
amount of information that may be obtained (LoBiondo-Wood 2002). The
questionnaire variables were predominately at ordinal and nominal level which allow
for descriptive and frequency statistics to be used i.e. means standard deviations and
percentages for the demographic section and modes for the scenarios section. As a
research design of this kind does not investigate a relationship between independent
and dependant variables but is concerned with the reliability and validity of the MTS
as seen through the inter rater agreement of the respondents, an element of
psychometric analysis was employed. The test of choice was Cohen’s Kappa. A
chance corrected measure introduced by Scott (1955) and extended by Cohen (1960)
24
which has become known as Cohen’s Kappa. It has been generalised many times since
Cohen (1968) Fleiss (1971) Landis and Koch (1977) Kraemer (1979, 1980) Fleiss and
Cuzick (1979) Conger (1980) Craig (1981) Davies and Fleiss (1982) O Connell and
Dobson (1984). Cohen’s Kappa coefficient measures the degree of agreement between
raters using multiple categories in classifying the same group of subjects. The Kappa
coefficient ranges from +1 (complete agreement) to -1 (complete disagreement) with a
score nearer to +1 indicating a higher level of agreement (Barker et al 2002). Although
there is some controversy surrounding the use of kappa statistics in determining inter
rater agreement (section 3.7) it was deemed appropriate for this study in its use by
other similar studies (Jelinek & Little 1998, Dilley & Standen 1998 and Considine et al
2000). The other means of calculating the level of agreement between the participants’
answers is the use of another statistical test called intraclass correlation. Intraclass
correlation assesses rating reliability by comparing the variability of different ratings of
the same subject to the total variation across all ratings and all subjects; it is computed
using SPSS (SPSS 2001).
3.7 Inter rater agreement
Cohen’s kappa was first described by Cohen in 1960 (Altman 1991), the earliest and
simplest version of the kappa (k) statistic is that of the unweighted kappa coefficient
which was used for two raters and gave a kappa score, beyond the level expected by
chance when the categories are nominal. Fleiss' kappa is a variant of Cohen's kappa, a
statistical measure of inter-rater reliability. Cohen's kappa works for only two raters,
Fleiss' kappa works for any constant number of raters. It is a measure of the degree of
25
agreement that can be expected above chance. Agreement can be thought of as
follows, if a fixed number of people assign numerical ratings to a number of items then
the kappa will give a measure for how consistent the ratings are. A further
development to the kappa statistic is the use of a weighted kappa (Cohen 1968, Fleiss
1973). The weighting of the kappa statistic is more useful in ordinal level data because
a “weight” can be applied where there is not total agreement but if the raters are one or
two categories away from each other. Therefore a higher kappa score will be
calculated if two raters rate an item on an ordinal scale one category away from each
other and a lower score will be obtained if they rate the item two categories away from
each other. This weighting system gives a more accurate reflection of inter rater
agreement then the unweighted version which simply gives a score of agreement or not
and does not take into account the degree of variance in the raters answers. The
negative issues to do with calculating the kappa statistic namely include the fact that is
a general level of agreement and does not make distinctions among various types and
sources of disagreement, it is influenced by distribution and base-rate and as a result,
kappa’s are seldom comparable across studies, procedures, or populations (Thompson
& Walter, 1988; Feinstein & Cicchetti, 1990). Kappa may be low even though there
are high levels of agreement and even though individual ratings are accurate. (Maclure
& Willet, 1987). Whether a given kappa value implies a good or a bad rating system or
diagnostic method depends on what model one assumes about the decision making of
raters (Uebersax, 1988). Kappa requires that two rater/procedures use the same rating
categories. There are situations where one is interested in measuring the consistency of
ratings for raters that use different categories (e.g., one uses a scale of 1 to 3, another
uses a scale of 1 to 5). However kappa remains one of only a few inter rater
26
coefficients available at present and coupling this with its widespread use in other
published studies it was deemed appropriate for use in this study.
3.8 Intraclass correlation
The intraclass correlation (ICC) assesses rating reliability by comparing the variability
of different ratings of the same subject to the total variation across all ratings and all
subjects (Muller 1994). It is scored similar to the kappa statistic in that it ranges from
-1 to +1 with a score nearer to +1 denoting a closer correlation between the raters. This
statistic was computed using SPSS (SPSS 2001) which offers five different
combinations of options: 1) one way random model with measures of absolute
agreement; 2) two way random model with measures of consistency; 3) two way
random model with measures of absolute agreement; 4) two way mixed model with
measures of consistency; 5) two way mixed model with measures of absolute
agreement. Each of the five possible sets of output includes two different ICC
estimates: one for the reliability of a single rating, and one for the reliability for the
mean or sum of ratings. The appropriate measure to use depends on whether reliance is
placed on a single rating or a combination of ratings. Combining multiple ratings
generally produces more reliable measurements. The interpretations under the two
models are different, as are the assumptions. Since treating the data matrix as a two
way design leaves only one case per cell, there is no way to disentangle potential
interactions among raters from errors of measurement. The practical implications of
this are that when raters are treated as fixed in the mixed model, the ICC estimates (for
either consistency or absolute agreement) for the combination of ratings require the
27
assumption of no rater interactions. The estimates for the reliability of a single rating
under the mixed model and all estimates under the random model are the same
regardless of whether interactions are assumed (McGraw & Wong 1996). The model
used for this sample of data is the two-way mixed model with measures of consistency,
and two-way mixed model for absolute agreement.
3.9 Ethical Considerations.
The Declaration of Helsinki, issued by the World Medical Association in 1964, is the
fundamental document in the field of ethics in biomedical research and has influenced
the formulation of international, regional and national legislation and codes of conduct.
The Declaration, most recently amended in 2004 (WMA 2004) is a comprehensive
international statement of the ethics of research involving human subjects. It sets out
ethical guidelines for physicians engaged in both clinical and non clinical biomedical
research. In keeping with in line with international guidelines, ethical approval was
sought from the Joint Research and Ethics Committee of St James Hospital; a
Consultant in Emergency Medicine agreed to act as clinical supervisor and supervised
the project to ensure no aspect of ethical approval was breached.
The questionnaires were left in the staff room of the department and signs indicating
that the project had commenced. No obligation was placed on participants to fill out
the questionnaire. A separate consent form was not included as consent was implied by
way of the return of a completed questionnaire. However a letter was included with the
research questionnaire which clearly outlined the purpose of the study, the data
collection methods and re-iterated confidentiality and anonymity to all participants.
28
Participants were asked not to write their name anywhere on the questionnaire. Each
questionnaire contained a numerical code for data collection purposes, a list of these
codes was kept by the researcher in a locked press and destroyed when data analysis
was completed.
3.10 Project Outline
The scenarios used were available from the Manchester Triage group in April 2006.
Data collection began during the first week in May for a period of six weeks with a
period of seven weeks for data analysis. This left a period of approx nine weeks for
completion of project.
29
C h a p t e r 4
RESULTS
4. 1 Introduction
This chapter reports the results of the statistical analysis of all data derived from the
questionnaires. Firstly the demographic data is analysed followed by the educational
qualifications of the participants. The third section reports the length of time since the
participants had training on the MTS. The fourth section outlines the responses of the
participants to the scenarios, the modal responses and percentages of correct responses.
The final section of this chapter reports the results of the primary objective of this
study, the inter rater reliability.
In determining the inter rater reliability of the MTS in an Irish healthcare setting the
data obtained from the questionnaires was analysed using SPSS (Statistical Package
for Social Sciences) version 11.0 for windows (SPSS 2001) and Stats Direct software
version 2.5.6 (Stats Direct 2003). There were 51 questionnaires sent out to all
participants who met the inclusion/exclusion criteria and 31 were returned giving a
response rate of approx 60%.
30
4.2 Demographic profile of the sample
The first step in analysing the data was to create a table of demographic characteristics
of the participants (Table 4.2). Values for the continuous variables such as age and
years experience are presented in mean/standard deviation, whereas nominal variables
are presented as frequencies or percentages. There were a greater number of female
respondents (n=24) in comparison to male (n=4) with the majority employed as staff
nurses (n=16, 51.6%) within the department. Length of service varied from 4-30 years
with a mean length of years of 13.6. In relation to experience in emergency care the
majority of participants had less than 10yrs experience with 5 having > 15 years the
mean length of experience was 8.8 yrs. The majority of nurses who participated in the
study were between the ages of 31-40 (n=15 48.4%) with only 5 over the age of 40
(19.3%).
31
Table 4.2 Demographic characteristics of participants
Item Measurement
Gender
Male (n) (%) 7 (22.6%)
Female (n) (%) 24 (77.4%)
Experience in Emergency Nursing M (SD) (min- max) 8.8 (6.1) (2-24)
Years Qualified M(SD) (min-max) 13.6 (7.3) (4-30)
Age
21-30 (n) (%) 10 (32.3%)
31-40 (n) (%) 15 (48.4%)
41-50 (n) (%) 5 (16.1%)
Position
Staff nurse (n) (%) 16 (51.6%)
CNM 1 (n) (%) 7 (22.6%)
CNM 2 (n) (%) 5 (16.1%)
ANP (n) (%) 3 (9.7%)
32
4.3 Educational qualifications
Table 4.3 outlines the educational qualifications of the participants. Only 5 participants
had a dual qualification with midwifery (n=2), psychiatric (n=2) and sick children
(n=1). The most common additional academic qualification that the respondents held
was a higher/postgraduate diploma (n=22 71%), with 9 (29%) having a bachelors
degree and 4 (12.9%) having completed a masters degree.
Table 4.3
Education Qualifications* Measurement Certificate
17 (54.8%)
Diploma
13 (41.9%)
Higher Diploma
22 (71.0%)
Bachelors Degree
9 (29.0%)
Masters Degree 4 (12.9%)
Professional Qualifications*
RGN 31 (100%)
RM 2 (6.5%)
RPN 2 (6.5%)
RSCN 1 (3.2%)
RMHN 0
PHN
0
*totals will not equal 100% as participants may hold more than one qualification
33
4.4 MTS training
The figure below (figure 4.4) outlines when the participants received training in the
MTS the dates vary from 1997 to 2006, with the highest number receiving training in
2000 (20%, n=6) followed by 2006 (16.7%, n=5).
Figure 4.4 Year of MTS Training
MTS Training (year)
2006200520042003200220012000199919981997
Num
ber
7
6
5
4
3
2
1
0
34
4.5 Questionnaire responses
The next step in analysing the data is to examine the answers given by each participant
for each of the scenarios. The frequencies of these answers are displayed in table 4.5.
The table displays a wide variation in the answers given for some of the scenarios.
Only 1 scenario (scenario 7) received the same category by all participants there were
5 scenarios which received answers ranging over 2 categories, 21 of the scenarios have
scores ranging over three categories and finally 3 scenarios (scenario 11, 26 & 28)
received answers ranging over 4 categories, it should also be noted that not all
participants answered all the scenarios. The figure 4.5 displays the overall variance of
answers from the correct answer, overall 68% (n=630) of the scores given matched the
correct answer with 30% (n=278) of responses being 1 category away from the correct
and 2% (n=18) being 2 categories away from the correct
Figure 4.5 Variance of answers
0 10 20 30 40 50 60 70
Correct
1 Away
2 Away
35
Table 4.5 Frequencies of scenario answers
Scenario Number Cat 1 Cat 2 Cat 3 Cat 4 Cat 5 TOTAL
Scenario 1 0 1 21 9 0 31
Scenario 2 0 14 16 1 0 31
Scenario 3 0 30 1 0 0 31
Scenario 4 0 2 23 5 0 30*
Scenario 5 1 29 1 0 0 31
Scenario 6 0 9 20 2 0 31
Scenario 7 0 31 0 0 0 31
Scenario 8 0 27 4 0 0 31
Scenario 9 0 0 21 10 0 31
Scenario 10 0 3 19 9 0 31
Scenario 11 1 7 19 3 0 30*
Scenario 12 4 23 4 0 0 31
Scenario 13 0 21 7 3 0 31
Scenario 14 0 23 7 1 0 31
Scenario 15 0 0 3 17 11 31
Scenario 16 0 22 8 1 0 31
Scenario 17 0 13 18 0 0 31
Scenario 18 0 25 5 1 0 31
Scenario 19 0 2 2 27 0 31
Scenario 20 3 26 2 0 0 31
Scenario 21 1 15 15 0 0 31
Scenario 22 0 8 20 3 0 31
Scenario 23 1 29 1 0 0 31
Scenario 24 0 21 10 0 0 31
Scenario 25 0 5 14 12 0 31
Scenario 26 0 7 17 5 1 30*
Scenario 27 0 7 22 1 0 30*
Scenario 28 0 1 16 12 2 31
Scenario 29 0 5 21 5 0 31
Scenario 30 1 21 9 0 0 31
* Not all participants responded to this scenario
36
4.6 Over and under triage of scenarios
The participants’ allocation of triage categories for each scenario were further
examined and compared to the gold standard or “expected” answers which were
supplied by the Manchester Triage Group, the participants’ answers were coded as
correct, over triaged or under triaged (Table 4.6 ). The implications of having patients
over triaged are not as adverse as having a patient under triaged. The over triage of a
patient may have an impact on the departments resources but from the patients’ point
of view it means they will be seen quicker. The under triaging of a patient is more
serious and could have detrimental effects on patient outcome, whereby a patient with
a serious or life threatening problem may be left to wait longer to be seen and have
their condition deteriorate in that time . The only scenario which all participants
allocated the correct triage category to was scenario 7, which outlined an 81 yr old
male patient with a presenting complaint of chest pain which all participants correctly
identified as cardiac chest pain which denotes a triage category of 2. There were a total
of 15.2% (n=141) responses over triaged with the highest being scenario 4 which
detailed a 27 yr old female patient with signs of abnormal behaviour without any
intent to cause self harm. There were 16.8% (n= 155) of the scenarios under triaged,
the scenario which received the most under triage scores (48.4%, n=15) was scenario
21 which detailed a 50yr old male patient who smelled of stale alcohol and had fallen
down 3 stairs and sustained a bang to his head, he is alert but doesn’t remember all the
events surrounding his injury and due to the fact of him having altered sensation down
his back and legs, the correct triage category for this patient is category 2.
37
Table 4.6 Frequencies of under and over triage
*Not all participants responded to this scenario
Correct (n) (%) Over triaged (n) (%) Under triaged (n) (%) Total
Scenario 1 21 (67.7%) 1 (3.2%) 9 (29.0%) 31
Scenario 2 16 (51.6%) 14 (45.2%) 1 (3.2%) 31
Scenario 3 30 (96.8%) 0 (0.0%) 1 (3.2%) 31
Scenario 4 5 (16.7%) 25 (83.3%) 0 (0.0%) 30*
Scenario 5 29 (93.5%) 1 (3.2%) 1 (3.2%) 31
Scenario 6 20 (64.5%) 9 (29.0%) 2 (6.5%) 31
Scenario 7 31 (100.0%) 0 (0.0%) 0 (0.0%) 31
Scenario 8 27 (87.1%) 0 (0.0%) 4 (12.9%) 31
Scenario 9 21 (67.7%) 0 (0.0%) 10 (32.3%) 31
Scenario 10 19(61.3%) 3 (9.7%) 9 (29.0%) 31
Scenario 11 19 (63.3%) 8 (26.7%) 3 (10.0%) 30*
Scenario 12 23 (74.2%) 4 (12.9%) 4 (12.9%) 31
Scenario 13 21 (67.7%) 0 (0.0%) 10 (32.3%) 31
Scenario 14 23 (74.2%) 0 (0.0%) 8 (25.8%) 31
Scenario 15 11 (35.5%) 20 (64.5%) 0 (0.0%) 31
Scenario 16 22 (71.0%) 0 (0.0%) 9 (29.0%) 31
Scenario 17 18 (58.1%) 13 (41.9%) 0 (0.0%) 31
Scenario 18 25 (80.6%) 0 (0.0%) 6 (19.4%) 31
Scenario 19 27 (87.1%) 4 (12.9%) 0 (0.0%) 31
Scenario 20 26 (83.9%) 3 (9.7%) 2 (6.5%) 31
Scenario 21 15 (48.4%) 1 (3.2%) 15 (48.4%) 31
Scenario 22 20 (64.5%) 8 (25.8%) 3 (9.7%) 31
Scenario 23 29 (93.5%) 1 (3.2%) 1 (3.2%) 31
Scenario 24 21 (67.7%) 0 (0.0%) 10 (32.3%) 31
Scenario 25 14 (45.2%) 5 (16.1%) 12 (38.7%) 31
Scenario 26 17 (56.7%) 7 (23.3%) 6 (20.0%) 30*
Scenario 27 22 (73.3%) 7 (23.3%) 1 (3.3%) 30*
Scenario 28 16 (51.6%) 1 (3.2%) 14 (45.2%) 31
Scenario 29 21 (67.7%) 5 (16.1%) 5 (16.1%) 31
Scenario 30 21 (67.7%) 1 (3.2%) 9 (29.0%) 31
Totals Total Correct 630 (68.0%)
Total Over triage 141 (15.2%)
Total Under triage 155 (16.8%)
38
4.7 Modal Scores
The modal scores for each scenario are outlined in table 4.7; the overall agreement of
the modal scores with the correct scores is 90%, using Stats Direct software version
2.5.6 (Stats Direct 2003) the modal scores and correct scores were treated as two raters
and analysed for levels of absolute agreement, this gave an unweighted kappa score of
0.9 (p<0.001). There was a difference of only one category between the modal scores
and the correct scores
Table 4.7 Modal responses for scenarios
Triage Scenario Correct Response Modal Response Agree (1=yes, 0= no) Scenario 1 3 3 1 Scenario 2 3 3 1 Scenario 3 2 2 1 Scenario 4 4 3 0 Scenario 5 2 2 1 Scenario 6 3 3 1 Scenario 7 2 2 1 Scenario 8 2 2 1 Scenario 9 3 3 1 Scenario 10 3 3 1 Scenario 11 3 3 1 Scenario 12 2 2 1 Scenario 13 2 2 1 Scenario 14 2 2 1 Scenario 15 5 4 0 Scenario 16 2 2 1 Scenario 17 3 3 1 Scenario 18 2 2 1 Scenario 19 4 4 1 Scenario 20 2 2 1 Scenario 21 2 3 0 Scenario 22 3 3 1 Scenario 23 2 2 1 Scenario 24 2 2 1 Scenario 25 3 3 1 Scenario 26 3 3 1 Scenario 27 3 3 1 Scenario 28 3 3 1 Scenario 29 3 3 1 Scenario 30 2 2 1
39
4. 8 Interrater reliability
The main objective of this study was to determine the level of reliability of the MTS
within an Irish healthcare setting; this was achieved by analysing the level of interrater
agreement between the raters who triaged the patient scenarios. The kappa scores and
the corresponding strength of agreement are shown in table 4.8 below. The overall
kappa coefficient for the interrater reliability of this project was determined using Stats
direct (2003) as moderate (k = 0.45 p<0.001).
Table 4.8 Kappa Value and strength of agreement
Kappa Strength of agreement
<0.2 Poor
0.21- 0.40 Fair
0.41-0.60 Moderate
0.61-0.80 Good
0.81-1.0 Very Good
(Barker et al 2002)
40
4.9 Intraclass Correlation
The intraclass correlation coefficient was calculated using SPSS version 11.0 (SPSS
2001). It was determined by means of a two way mixed model for levels of
consistency, and for absolute agreement (chapter 3). The results are outlined in table
4.9 below.
Table 4.9 Intraclass Correlation
Model ICC score min-max Significance
Two way mixed model (Absolute
agreement definition )
Single measure of ICC 0.05 0.03-0.12 p<0.001
Average measure of ICC
0.66 0.47-0.80 p<0.001
Two way mixed model (Consistency
definition)
Single measure of ICC 0.13 0.07-0.24 p<0.001
Average measure of ICC 0.82 0.71-0.90 P<0.001
41
4.10 Conclusion
The main objective of the MTS and of any triage system is the consistent allocation of
triage categories to patients who present to emergency departments, regardless of who
triages the patient. The results from this study indicate that only one scenario was
correctly triaged by all respondents, with approximately 15% (n=141) allocated a
triage category above the correct one and 17% (n=155) receiving a triage category
below that of the correct one. The modal responses when compared with the correct
responses had a 90% agreement, the modal scores which did not agree with the correct
answer were one category away, of all the answers given 68% (n=) were correct
Despite the discrepancies found in some of the results this project found a moderate
level of agreement amongst nurses using the MTS to assign a triage category to
patients. The intraclass correlation coefficient at 0.60 for absolute agreement and 0.80
for consistency agreement backs up the kappa score
42
C h a p t e r 5
DISCUSSION
5.1 Introduction
The purpose of this study was to measure the reliability and validity of the Manchester
Triage System in an Irish healthcare setting, as well as exploring some of the
implications of triage variations in practice. The literature review outlined in chapter 2
demonstrates that unlike other triage systems namely the Australasian Triage System
and the Canadian Triage Acuity Scale, there are no international published studies
examining the reliability or the validity of the MTS and therefore no studies which can
be used for comparison of results. The results of this study then are compared to
similar studies which have examined the reliability and validity of other triage systems
This chapter discusses the main findings of this research study, as presented in chapter
4 within the context of the main objectives of the study, the literature reviewed and the
limitations of the study.
5.2 Sampling
In relation to the sampling technique and number of responses the response rate to the
questionnaires was 60% (n=31) of the total of 51 that were sent out. There were
methods utilised to increase response rates such as advanced notification, each
43
participant was sent an introduction letter approx 2 weeks prior to the commencement
of the project. The questionnaires also contained a colour front page and posters were
put up in the department informing all staff when the project was underway, these
posters also served as a constant reminder to staff to fill in the questionnaire
5.3 Questionnaires
One of the main limitations of this study is the use of written paper scenarios which
have been cited by many as a disadvantage as they do not provide the nurse with the
visual and aural cues that may lead to more accurate triage decisions (Jelinek & Little
1996, Dilley & Standen 1998). The decision to use written scenarios was taken on the
basis of their use in similar studies in examining triage interrater reliability (Jelinek &
Little 1998, Dilley & Standen 1998 and Considine et al 2000) and also by their ease of
development and administration (Considine et al 2000). There are opinions that on-line
or computer based triage systems lead to more accurate triage decisions (MTS 2006)
but as computer based systems are not presently in use at the site of this study paper
based scenarios were decided to be the most appropriate a view also supported by
Landis et al. (1989) who determined that paper scenarios were effective in determining
triage consistency.
44
5.4 Answers to scenarios
In relation to the answers given by each of the participants there are a number of
discrepancies noted, namely the over and under triage of the scenarios. The fact that all
participants received the exact information the variance of the answers received is a
cause for concern. The under triage of patients can lead to increased waiting times and
to adverse patient outcomes (Maningas 2006). The two scenarios which were under
triaged by the highest number of participants’ scenarios 21 and 28. The details in
scenario 21 outlined a 50-year-old man, who had slipped and fallen down three stairs
this morning at and smells of stale alcohol. He banged the back of his head but does
not know if he was unconscious, he continually complained of pain in his neck, which
radiates down his right arm and had an unpleasant sensation like ‘ice cold water is
being poured down his back and legs. The respondents were almost divided in half in
allocating a category to this patient 48% (n=15) assigned a correct category of 3 to this
scenario but an equal amount 48% (n=15) assigned a lower category of 4 which would
allow this patient with a suspected spinal injury wait 2hrs for treatment. The issue of a
smell of stale alcohol may have an effect in the triage of this patient as it has been
noted that alcohol consumption by patients can lead to clinician decision making bias
(Klein 2005). This point is corroborated by the responses to scenario 28 which outlines
a 51-year-old man, having been found lying by the roadside apparently intoxicated. No
obvious sign of injury. He was slurring his words and smells of alcohol. A glucose
stick test shows a blood glucose level of 4.3 mmols per litre. He responds to voice. He
has a confirmed history of alcohol abuse. The correct category for this scenario is
category 3 but 45 %( n=12) allocated a category of 4 and 6 %( n=2) allocated a
category of 5. In relation to the over triage of patients the two scenarios over triaged by
45
the most participants was scenario 4 and 15. Scenario 4 outlined a patient complaining
of pain in his left lower leg. He fell the previous evening whilst out drinking with
friends and woke this morning in pain. He uses the pain ruler and indicates his pain
score is 8. He is observed limping into the department and laughing with friends in the
waiting room, scenario 15 detailed a 69-year-old man who presented to the department
for the eighth day in a row complaining of breathing problems. He stated 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.
02 sats 98% on air He complains he has now had the symptoms for six weeks. It could
be argued that it is safer to increase the priority of the patient rather than decrease it but
the issue with both of these scenarios being over triaged leads to inappropriate pressure
put on the departments resources, and possibly utilises these resources at the expense
of patients who are correctly assigned to a higher triage category (Maningas 2006, San
Pedro et al 2005, Kilner 2006).
In relation to other studies which have examined similar triage systems, several
reasons have been cited for the variance of under and over triage of patients. Considine
et al (2000) stated that junior nurses may be more inclined to over triage in comparison
to their more senior colleagues; they outlined factors such as increased caution, less
experience of triage and less knowledge of certain illnesses or injuries. Although not
within the remit of this study, the mean years of experience in emergency nursing in
this study was 8.8yrs (SD 6.1) which does not indicate a very junior sample. Other
studies have examined the relationship between demographic variables (Jelinek &
Little 1996) and found no relationship between length of experience and triage
responses.
46
5.5 Modal Responses
The modal responses in this study are similar to those found by Jelinek & Little (1996)
in that 100% of the modal responses were within one category of the correct answer.
This is an improvement on the work carried out by both Doherty (1996) and Dilley &
Standen (1998) who found varying degrees of incorrect answers ranging from 83%
spread over three categories to 90% spread over two categories respectively.
5.6 Inter rater agreement
The main purpose of this study was to measure the reliability and validity of the MTS
within an Irish healthcare setting through the measurement of the level of interrater
agreement of the nurses who participated in the study. This method of reliability
testing has been used internationally to examine the consistency of various triage
scales. As there are no other studies of this kind carried out on the MTS there are no
other results to compare these findings to except those of similar triage scales namely
the CTAS and the ATS. The overall level of interrater agreement in this study was
deemed to be moderate (k=0.45 p<0.001). in relation to international studies on other
systems Wuertz et al (1998) found kappa scores ranging from 0.34 to 0.80 for the three
and five point scales in the USA and Beveridge et al. (1999) found scores of 0.84 for
the CTAS. The ATS has been examined by Doolan (2005), Crellin & Johnson 2003
and Dilley & Standen (1998) and found scores ranging from ‘fair’ to ‘good’ with
kappa scores ranging from 0.24 to 0.51. Although the results of this study cannot be
compared to other studies on the MTS the results found are similar to those of other
47
triage systems and may be used in the future for other studies on the MTS to compare
to.
5.7 Limitations
The main limitations of this study are the use of paper based scenarios which have
been discussed earlier, the small sample size and the fact that the study was limited to
only one institution. The tight inclusion and exclusion criteria left a small amount of
nurses to represent the population so convenience sampling was the only method
available for use. This means that the findings may not be generalised to any other
similar population.
5.8 Conclusions/implications for practice
Although the overall level of agreement was deemed to be moderate (k 0.45, p<0.001)
there were varying degrees of inaccuracy in the triage answers which indicate a need
for improvement in the practice of triage. Of particular worry are the number of
responses to the scenarios which were ‘under’ triaged (17% n=155) which could have
detrimental effects on patient outcomes if patients are incorrectly given a lower
category and have to wait longer for treatment. The ‘over’ triage of scenarios (15%
n=141) may also have a negative effect on the utilisation of departmental resources and
cause undue delay for patients who are appropriately allocated a higher category. The
reasons for over and under triage may be due to the level of experience as stated by
48
Considine et al (2000), and although outside this study there may have been an element
of caution exercised in the placing of patients in a higher category in uncertain
situations rather than utilising the MTS flowcharts.
Implications for practice arising out of this study indicate that education strategies need
to be employed around the practice of triage. In particular, the utilisation of the
flowcharts to aid decision making which would reduce the amount of discrepancies
and thereby increase the reliability and validity of the MTS. Other implications include
the need to increase triage nurses’ knowledge in disease processes and injuries which
they are not regularly exposed to; one example at local level in the setting of this study
is the area of eye injuries as the hospital does not have many ophthalmic presentations
due to the close proximity of a dedicated eye and ear hospital
49
C h a p t e r 6
SUMMARY
6.1 Summary
The principle objective of this study was to examine the reliability and validity of the
Manchester Triage system in an Irish healthcare setting. The background for this study
was the introduction of the MTS into the study setting without any either national or
international validation. The review of the literature has demonstrated that all other
international triage scales have been validated except for the MTS. The implications of
using a scale which is not valid are wider than just the inaccurate or inconsistent
allocation of triage categories to patients but also include fiscal, staffing and resource
management issues. The results of this study demonstrated a moderate level of
agreement (k=0.45, p<0.001) amongst the sample of nurses who took part. These
results although not comparable to any others carried out on the MTS do compare to
similar studies which have examined the validity and reliability of other international
triage systems such as the ATS (Dilley & Standen 1998).
Arising out of this study in order to improve the application of the MTS and increase
the level of interrater agreement amongst the nurses using the system a number of
recommendations for both practice and research are suggested.
50
6.2 Recommendations for practice
It is recommended that:
Educational strategies be utilised to enhance nurses’ knowledge of the MTS,
particularly focusing on the use of the flow charts to guide decision making.
Training in the MTS by accredited MTS trainers is mandatory for all nurses who
undertake the role of triage.
Funding and dedicated study time is allocated for the training of nurses’ in the MTS.
Competency assessment is carried out on triage nurses’ by accredited MTS trainers to
identify individual nurse educational needs.
Regular study days are provided to update nurses on the MTS and triage work
practices to maintain nurses’ knowledge.
Regular audits of both triage accuracy and triage times are carried out and results fed
back to the staff, and that staff who undertake the role of triage be involved in carrying
out these audits.
Nurses’ who undertake triage receive increased exposure to areas of practice in which
they are unfamiliar i.e. ophthalmic presentations, through educational strategies such
as dedicated lectures or short term placements.
51
6.3 Recommendations for research
As this is the first study of its kind it is recommended that this study be replicated and
similar studies be carried out in order to corroborate or refute the results found.
It is also suggested that other studies should be undertaken with emphasis on
demographic variables such as length of experience and educational qualifications and
triage decision making, to examine if there is any correlation between them.
6.4 Conclusion
The primary objective of the MTS or any triage scale is the consistent allocation of a
triage category to a patient regardless of who triages the patient. Triage scales are also
used as a means to infer the acuity of the department and therefore as a means of
resource utilisation, staff allocation and a predictor of admission rates. In order to
achieve these objectives the triage scale in use must be reliable and valid for the
population that it serves.
From the literature review in this study it has been demonstrated that five level systems
such as the MTS are more reliable than other three level scales. The rationale of
undertaking this study was the introduction of the MTS into the Irish health system
without any published research to demonstrate its reliability or validity in Ireland.
The method of assessing the reliability of the MTS was to use the level of agreement
amongst nurses who use the scale on a regular basis. It was deemed the most
appropriate method to use and was supported by its use in the reliability testing of
other international scales. The use of paper scenarios, although having disadvantages,
52
was deemed appropriate in their ease of development and administration as well as
ensuring that identical information was given to each participant without
compromising patient confidentiality.
The overall findings of the study indicate a moderate level of agreement amongst the
nurses who participated in the study (k=0.45, p<0.001). This level of agreement
although the first to be carried out on the MTS is an increase on studies carried out on
other triage systems. There were a few discrepancies noted, namely the percentage of
patients who were ‘under’ (17% n=155) and ‘over’ (15% n=141) triaged, these figures
are a cause for concern as both may lead to adverse patient outcomes. The patients
who were ‘under’ triaged may have to wait for longer periods of time in order to
receive treatment and as a result may deteriorate, and the patients who were ‘over’
triaged who may receive treatment earlier, but it may be to the detriment of other
patients who were appropriately assigned to a higher category.
In order to increase the interrater agreement and the consistency of the MTS in Ireland
a number of implications for practice have been identified including the use of
educational strategies to increase nurses’ knowledge in the area of triage practice and
the use of the MTS, as well as increased exposure of nurses to specific disease
processes and injuries which they are not familiar with.
It is hoped that when these strategies are implemented it will lead to an increase in the
agreement amongst nurses and therefore supporting the MTS as a reliable and valid
triage scale for the Irish healthcare system.
53
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APPENDIX 1
QUESTIONNAIRE
62
Manchester Triage Reliability and Validity Questionnaire
Please place completed questionnaire in box provided in staff room
Kenneth Folliard Clinical Support Nurse Emergency Directorate
St James Hospital James St Dublin 8.
63
Guidelines for completing the questionnaire
In order to protect your anonymity please do not write your name anywhere on the questionnaire
Section 1 – Patient scenarios
Please read each scenario carefully and assign a triage category to each one using the principles of the Manchester Triage System indicate your choice by placing a circle around the corresponding triage category.
Section 2 - Demographic Characteristics
Please fill in this section by placing a tick in the appropriate box At the end of the questionnaire there is a blank section, please fill in any comments you have either about the Manchester Triage System or this study. Please remember that this study is NOT a test of individual nurses ability to correctly assign a triage category but rather how well the Manchester Triage System stands up to use by a number of different nurses. A copy of the Manchester Triage Nomenclature is included overleaf for your convenience
64
Manchester Triage Nomenclature
Triage Category Name Colour Max time
(in minutes)
Category 1 Immediate Red 0
Category 2 Very urgent Orange 10
Category 3 Urgent Yellow 60
Category 4 Standard Green 120
Category 5 Non-urgent Blue 240
(Manchester Triage Group 2006 p2) Reproduced with permission from the Manchester triage group
65
Section A: Patient Scenarios
1
A 37-year-old man, with a two-year history of back problems, is brought in by ambulance with
lumbar pain. He states that he is in constant pain day and night and has not worked for over a year.
The pain on this occasion it is not the worst he has ever had but is "quite bad". He cannot stand up because of the pain. He has tingling down the back of his left calf.
He has suffered no direct trauma to the back.
Please circle your triage decision: 1. 2. 3. 4. 5.
2
A 54 year-old-man attends having wrenched his right shoulder pushing a truck with colleagues at
work He felt a sudden sharp pain in his shoulder and upper arm
C/o Reduced range of movement in shoulder Unable to abduct right arm due to pain
He assesses his pain score at 6
Please circle your triage decision: 1. 2. 3. 4. 5.
3
A 56-year-old who is a heavy smoker collapses while running for a bus. He appears to be unconscious for about 30 seconds, and when he comes round he complains to his wife that he
has a crushing feeling in the centre of his chest. When he reaches hospital he says that the pain is not too bad. He says he has never had pain like
this in the past. The pain is not worse with coughing or deep breathing and does not radiate to his left arm.
His pulse is 40 beats per minute and regular and he is not on medication.
Please circle your triage decision: 1. 2. 3. 4. 5.
4
A 27-year-old woman is brought to the department from home. Her partner who 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 and orientated and denies taking any tablets or medicines. She says 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.
Please circle your triage decision: 1. 2. 3. 4. 5.
5
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 you observe heavy PV blood loss B/P 90/50, Pulse 120, 02 sats 92% on air
She complains of nausea
Please circle your triage decision: 1. 2. 3. 4. 5
66
6
A paramedic ambulance crew brings in A 22-year-old woman who had 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. There is a right occipital haematoma
Please circle your triage decision: 1. 2. 3. 4. 5.
7
An 81 year-old man is brought in by ambulance complaining of chest pain.
The patient describes the pain as radiating to his neck and jaw He feels nauseous and has vomited twice in the ambulance
The paramedics have already administered morphine and aspirin with some effect. Pain score assessed as 7
The patient has known IHD, pernicious anaemia and leg ulcers.
Please circle your triage decision: 1. 2. 3. 4. 5.
8
A 22-year-old known migraine sufferer attends the department 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.
Please circle your triage decision: 1. 2. 3. 4. 5.
9
A 53-year-old woman attends the department 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
Her pain score is 4 Temp 36oc, pulse 68 beats p.m. O2 sats 98% on air
Please circle your triage decision: 1. 2. 3. 4. 5.
10
It is 2.00 am on Saturday morning and the clubs have just shut. A 21-year-old man is brought to
the department by his friends. They state that he had not "been looking for trouble" when he had been set upon by three men. There is no further history.
The patient can talk but makes very little sense. He smells of alcohol. There is no obvious external haemorrhage. His friends say that he was punched and kicked.
The patient says that he was not knocked unconscious and his friends confirm this. He says that his "head hurts a bit".
Please circle your triage decision: 1. 2. 3. 4. 5
67
11
A 33-year-old woman is brought to the emergency department having 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 has a large left frontal haematoma.
She says that her "head throbs". She was apparently unconscious at the scene for two to three minutes. There are no signs of external haemorrhage.
Please circle your triage decision: 1. 2. 3. 4. 5.
12
The department is put on standby for 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
reported to be severely damaged. On arrival he is conscious but unable to remember the car hitting him. GCS 13
He complains of severe pain in right groin area, hip and thigh. He has loin pain with haematuria ++ on urine testing
O2 sats 95% on air
Please circle your triage decision: 1. 2. 3. 4. 5.
13
The local police bring a 24-year-old known schizophrenic patient into the emergency department.
He has been acting strangely. He is expressing paranoid ideas; in particular, he thinks there is a plot to poison him. He says that
he knows who they are and if he sees them he will kill them. He has apparently tried to kill himself in the past.
The patient becomes uncommunicative but sits quietly with the accompanying policeman.
Please circle your triage decision: 1. 2. 3. 4. 5.
14
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 has no wheeze or stridor.
Her tongue is slightly swollen and she has some swelling around her face. Her saturation on air is 98%.
Please circle your triage decision: 1. 2. 3. 4. 5.
15
It is 10 o'clock in the morning. A 69-year-old man comes into the unit 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. 02 sats 98% on air
He complains he has now had the symptoms for six weeks.
Please circle your triage decision: 1. 2. 3. 4. 5
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16
A 76-year-old man attends the Emergency department having apparently 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 in triage. He complains of severe spasms of pain in his
upper abdomen
Please circle your triage decision: 1. 2. 3. 4. 5.
17
It is September and the first week of the university term in the local town. A new first-year student
returns to the department saying 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. Just as he is about to leave the room he hands in a card, which states that he had a splenectomy at the age of 16 following
trauma.
Please circle your triage decision: 1. 2. 3. 4. 5.
18
A 74-year-old man is sent to the department by his GP. He 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.
BP 110/68, pulse 68/min GP letter 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 triage
Please circle your triage decision: 1. 2. 3. 4. 5.
19
A 72-year-old woman attends the emergency department having been brought in by taxi from her
local supermarket. Apparently she was just about to be served at the cheese counter when a small child pushed a supermarket trolley into her left leg, which has bled a considerable
amount. One of the supermarket staff has applied a bandage and she was able to walk to the taxi unaided.
She says she feels no pain but is worried her leg looks a mess. On removing the dressing from the wound you find a large flap of skin and some generalised
bruising but the bleeding has stopped completely.
Please circle your triage decision: 1. 2. 3. 4. 5.
20
A 55-year-old man is brought to the emergency department by ambulance following 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 there is a great deal of swelling.
On closer examination, there is an area of considerable pallor over the lateral aspect of the ankle where a piece of bone lies immediately under the skin.
Please circle your triage decision: 1. 2. 3. 4. 5
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21
A 50-year-old man who had slipped and fallen down three stairs this morning at home is brought
into the emergency department. He smells of stale alcohol. During the fall he banged the back of his head but does not know if he has been unconscious.
The patient continually complains of pain in his neck, which radiates down his right arm. He has an unpleasant sensation like ‘ice cold water is being poured down his back and legs’.
The patient is alert and there are no signs of haemorrhage.
Please circle your triage decision: 1. 2. 3. 4. 5.
22
A 17 year-old young man arrives at the department following a head-to-head collision with
another player during a game of football. No LOC witnessed. He holds a blood soaked, gauze dressing to his face
On closer inspection his nose is bleeding ++ and he has avulsed his front tooth which is embedded in a deep laceration to the interior of his upper lip
He is distressed but can communicate and clear his mouth of blood by spitting His mouth and nose are swollen, sensation normal, VA normal.
Please circle your triage decision: 1. 2. 3. 4. 5.
23
A 19-year-old female university student is brought into the department 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 mmols
A glucose stick test shows ++++ of ketones in her urine. Temp 39.4 0c
Please circle your triage decision: 1. 2. 3. 4. 5.
24
A 55-year woman walks into the department complaining of palpitations
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 is 140 beats per/min, regular She feels panicky and frightened and complains that her mouth feels very dry
Please circle your triage decision: 1. 2. 3. 4. 5.
25
A 48 year-old lady attends the emergency department 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.
Pain score 7 Temp 37.6oc
Please circle your triage decision: 1. 2. 3. 4. 5
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26
A 42-year-old man attended the emergency department complaining of blurred vision.
His left eye appears red. He states that his eye is not exactly painful - it is more of a "discomfort". Visual acuity in the left eye is 6/24 and in the right eye is 6/6. This patient did not previously wear
corrective spectacles.
Please circle your triage decision: 1. 2. 3. 4. 5.
27
A 16-year-old girl who has been sent home from school unwell attends the department with her
mother. 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 is fully alert and orientated and says that she has been increasingly breathless for two days. Pulse rate is 100.
She has never been in hospital before with her asthma. Oxygen saturation is 92% on air.
Please circle your triage decision: 1. 2. 3. 4. 5.
28
A 51-year-old man is brought to the emergency department, by ambulance, having been found
lying by the roadside apparently intoxicated. No obvious signs of injury.
He is slurring his words and smells of alcohol. A glucose stick test shows a blood glucose level of 4.3 mmols per litre. He responds to voice.
He has a confirmed history of alcohol abuse
Please circle your triage decision: 1. 2. 3. 4. 5.
29
A 32 year-old woman is brought into the emergency department by a friend. She is
uncommunicative. Her 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. The patient is not
shocked. 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 and wants you to
contact her husband.
Please circle your triage decision: 1. 2. 3. 4. 5.
30
A 15-year-old girl is brought in from a residential children's home after drinking two mouthfuls of
bleach. She has vomited three times in the past 20 minutes and complains of a burning sensation in the
back of her throat. She has taken an overdose of paracetamol on two previous occasions
She says she is bored with life and bored with school and drank the bleach because she wanted to die.
Please circle your triage decision: 1. 2. 3. 4. 5
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Section 2
Demographic Characteristics
Please indicate your Gender: Female Male
Please indicate your age: < 20 21-30
31-40 41-50 > 50
Please tick, which indicates your current position:
Staff Nurse C N M 1
C N M 2 Advanced Nurse Practitioner
Please indicate your experience in emergency nursing (in years)
How long have you been qualified? (In years)
What professional qualifications do you hold? (Tick all that apply) RGN RSCN RM
RPN RNMH PHN
Please indicate which academic qualifications you hold:
Certificate Diploma Post Graduate/Higher Diploma
Bachelors Degree Masters Degree
Other (Please specify) _________________________________________
When did you receive training in Manchester Triage (e.g. 2001)?
Thank you for completing this questionnaire. If you have any other comments or
suggestions regarding the Manchester Triage System or this questionnaire please feel free to include them in the space provided below.
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APPENDIX 2
LETTER TO PARTICIPANTS
73
RE: Masters Research to determine the validity and reliability of the Manchester Triage System in the Irish healthcare setting
Dear:
As you may be aware I am undertaking a Masters Degree from University College
Dublin, as part of this degree I must complete a research project. I have decided to
examine the reliability and validity of the Manchester triage system in an Irish healthcare
setting. The Manchester Triage System has been in operation within the Emergency
Department since 1998 and as of yet there are no studies evaluating its effectiveness
either within the Irish system or internationally. I aim to complete this project by the use
of a statistical method called inter rater agreement; which examines how well two or
more raters (nurses) agree on a triage code given the same patient information.
I am writing to ask for your assistance in conducting this study. The method which I
have decided on is in a questionnaire format, which I will ask you to fill it out and place
completed in a box in the staff room. The questionnaire will be divided into two
sections; the first section will contain approx thirty adult scenarios which using the
Manchester Triage system you will be asked to assign a triage category to, the results of
this section will be analyzed and presented in statistical format. The second section will
ask you for some information about you such as your educational qualifications, length
of experience in emergency nursing, this section is to allow me to build up a
demographic profile of the nurses who complete the questionnaire, if you do not wish to
divulge some of these details then you may leave them blank.
Emergency Department, St James Hospital, Dublin 8
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The inclusion criteria are that the participants must have a minimum of six months
experience in emergency nursing and have attended a Manchester Triage study day. By
completing the questionnaire you are consenting to take part in the study so a separate
consent form will not be included. Your anonymity will be completely protected should
you decide to take part in this study. The questionnaires do not contain any identification
code system so there will be no way of tracing the questionnaire back to you once you
have submitted it.
If you do not wish to take part in the study then you simply do not return the
questionnaire, you are not obligated to take part if you do not wish to.
If you decide to take part in this study you will be greatly enhancing the knowledge
surrounding the Manchester Triage System. This study is not a test of individual nurses’
ability to correctly triage a patient but a test of how well the Manchester Triage system
performs when used by a number of different nurses.
I wish to thank you for taking the time to read this letter and thank you in advance
should you decide to take part in this study.
If you have any queries please do not hesitate to contact me
Yours Sincerely
_______________________________________________
Kenneth Folliard RGN HDip Emergency Nursing Msc Candidate
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APPENDIX 3
LETTER TO CLINICAL DIRECTOR
76
February 17, 2013
RE: Masters Research to determine the validity and reliability of the Manchester Triage System in the Irish healthcare setting
Ms Una Geary Clinical Director Emergency Directorate, St James Hospital, James St. Dublin 8
Dear Ms Geary
I am undertaking a Masters Degree in Nursing Studies in University College Dublin. As part of this education programme I must complete a research dissertation. I am seeking your approval to carry out this research within the Emergency Department of St James Hospital. Ethical approval is being sought from the St. James’s hospital and Federated Dublin Voluntary Hospitals Joint Research Ethics Committee. Mr P Plunkett has agreed to act as Clinical Supervisor for this project.
Please find attached a brief outline of the research proposal. A full research proposal is available which I can supply to you should you wish to view it
Sincerely,
Kenneth Folliard Clinical Support Nurse
Emergency Department, St James Hospital, Dublin 8
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APPENDIX 4
LETTER TO DIRECTOR OF NURSING
78
February 17, 2013
RE: Masters Research to determine the validity and reliability of the Manchester Triage System in the Irish healthcare setting
Ms Catherine Carey Acting Director of Nursing, St James Hospital, James St. Dublin 8
Dear Ms Carey,
I am undertaking a Masters Degree in Nursing Studies in University College Dublin. As part of this education programme I must complete a research dissertation. I am seeking your approval to carry out this research within the Emergency Department of St James Hospital. Ethical approval is being sought from the St. James’s hospital and Federated Dublin Voluntary Hospitals Joint Research Ethics Committee. Mr P Plunkett has agreed to act as Clinical Supervisor for this project.
Please find attached a brief outline of the research proposal. A full research proposal is available which I can supply to you should you wish to view it
Sincerely,
Kenneth Folliard Clinical Support Nurse
Emergency Department, St James Hospital, Dublin 8
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APPENDIX 5
ETHICAL APPROVAL APPLICATION
80
St. James’s hospital AND federated Dublin voluntary hospitals
Joint research ethics committee
ADMINISTRATIVE APPLICATION 1. Title of research project: A measurement into the level of reliability and validity of the Manchester Triage System in an Irish healthcare setting 2. Name of local project supervisor(s) – who should ordinarily be a hospital
consultant: Mr. Patrick Plunkett. Consultant in Emergency Medicine Mr Jonathon Drennan, Lecturer/Research Supervisor, University College Dublin. 3. Name and address of the person to whom the Committee’s decision is to be
communicated: Kenneth Folliard RGN, HDNS (Emergency), Clinical Support Nurse Emergency Department, St. James’s Hospital, Dublin 8. 4. For each funded research project a review fee of €634.87 is payable. Payment to the “Research Ethics Committee” should accompany the study documentation submitted to the Joint Research Ethics Committee. If you believe the review fee should not be charged for the project now being proposed please give the reason(s) here: The research study will be self-funded as part of the MSc in Nursing, University College Dublin. Please note that, for funded projects, after the initial ethical review is complete, (i.e. after all conditions attached to the approval of the original submission have been responded to and after that response has been approved), any amendment arising attracts a review fee as follows: Major Amendment: €126.97 Minor Amendment: €63.49 Payment should accompany the amendment documentation. “Funded research project” generally means a clinical trial sponsored by a Pharmaceutical Company. However, the Committee also expects payment to review other types of research project if the project is financially supported to a degree which makes it reasonable to expect such a payment. Signed ______________________Date ______________________ Project Supervisor.
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St. James’s hospital AND federated Dublin voluntary hospitals
Joint research ethics committee Confidential Research Protocol, 2003 Edition.
Please place an “X” or after the appropriate response in the boxed areas. NA is an abbreviation for Not Applicable. 1. Title of research project: A measurement into the level of reliability and validity of the Manchester Triage System in an Irish healthcare setting 2. Name of local project supervisor(s) – Mr. Patrick Plunkett, Consultant in Emergency Medicine. Senior Lecturer in Emergency Medicine. Mr Jonathon Drennan, Lecturer/Research Supervisor, University College Dublin. DECLARATION BY SUPERVISOR I confirm that the information provided in this protocol is correct. I also undertake to provide an annual report on the anniversary of Research Ethics Committee approval with details of the number of subjects who have been recruited, the number who have completed the study and details of any adverse effects. Signed: Date: _____________________________________________________________________ Research Ethics Committee comments: Approved subject to: Approval by Irish Medicines Board Approved without conditions. Signed: (Chair)
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3. What are the objectives of the research project? Aim: The aim of this study is to measure the inter rater reliability of the Manchester Triage System in an Irish Healthcare setting Objectives: 4a. Does the design of the study allow a statistically significant conclusion to be reached? YES √ NO 4b. has statistical advice been sought? YES √ NO 5. Will the conduct of the project conform to the principles of the Declaration of Helsinki? (Recommendations guiding Medical Doctors in Biomedical Research involving Human Subjects; the text of this Declaration is included on pages 3 to 8). YES √ NO If not, elucidate:
6. Please itemise here any ethical problems which you perceive to be associated with the research project:
There are no major ethical issues or problems likely to arise. The participant’s autonomy will be maintained by respecting their decision to engage by responding to the questionnaire or not. The information sheet provided with the questionnaire will maximise the possible benefits the study hopes to achieve for future services and will ensure that the participants’ well being is secure with no risks involved, thereby maintaining the principles of beneficence and non-maleficence
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SECTION A Details of project 7. Background: What person or organisation devised this project? Kenneth Folliard RGN, HDNS (Emergency) Clinical Support Nurse I am currently undertaking a Masters Degree in Nursing at University College Dublin. As part of this programme I am conducting a research study to investigate the level of reliability and validity of the Manchester Triage System in an Irish healthcare setting B. Has a detailed research protocol been drawn up? (If so, such documentation must be submitted to the Committee.) YES √ NO C. Has the investigator who may be asked to present the project to the Committee studied all the documentation drawn up for the project, and will the documentation be studied by all the investigators before the project begins? YES √ NO D. Briefly describe the scientific rationale for the project: The Manchester Triage System has been introduced into numerous emergency departments (ED) in Ireland yet no published research has demonstrated the reliability of the MTS and there is no documented evidence of it effectiveness within the Irish healthcare setting. There is also contradictory evidence in relation to inter-rater agreement amongst nurses and doctors and some research to suggest that triage scales are not a good predictor of either department acuity or admission rates. (Brillman et al 1996) Relevance of the Project The Report of the National Task Force on Medical Staffing (2003) in its recommendations included that EDs utilise a uniform triage scale that produces comparable and comprehensive information on patient attendance and acuity and that patients should be directed to triage as the first point of contact with the Emergency Department. The Report on Nurse Staffing Levels in Emergency Departments (2003) use triage codes as a means of calculating the number of nurses required on a shift so the importance of triage and accurate triage has a direct impact on staffing levels within an ED. This is true at local level in St James Hospital which uses the triage codes of patients to imply to the acuity of the department (Annual Report St James Hospital 2003 p 45).
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8. Planning and organisational structure (briefly outline the study methods, the various treatment groups, what parameters will be studied, how often and for how long, and what outcome measures or end points will be used to assess the efficacy of the project, for each subject): A quantitative research design will be employed in this study using a self-administered questionnaire. Data will be collected by the use of a questionnaire as derived from the literature review. The questionnaire will be divided into two parts. The first part will contain sample patient scenarios which the respondents will be asked to assign a triage category to. The second will contain a demographic section which will enquire to the personal characteristics of the respondents such as educational level, years qualified etc. this information will allow the researcher to build a profile of the respondents and allow for correlation of these characteristics with the item being studied. There are limitations to the use of questionnaires namely poor response rates (Burns and Grove 2001) but in comparison to other methods of data collection which were considered: simultaneous triage by nurse and researcher or retrospective chart audit, it was deemed the most appropriate. The use of a questionnaire in this type of study is also supported by its use in similar studies in examining the reliability and validity of other triage systems (Dilley & Standen 1998, Bergeron et al 2002, Crellin 2003). The issue of poor response rates will be addressed by the implementation of strategies outlined by Edwards et al (2005) such as advance notice, follow-up contact and the assurance of confidentiality. The patient scenarios will be obtained from the Manchester Triage group and all have ‘expected’ answers and have been validated through a panel of experts in emergency care both for content validity and for the accuracy by which each scenario reflects the triage category they have been designed for (Manchester Triage Group 2006). Although paper scenarios have been described as having limitations as they do not provide the nurse with the visual, audible and verbal cues used to make triage decisions (Jelinek & Little 1996), the use of actual patients would have substantial ethical implications for patient confidentiality. The questionnaire variables will mainly be at ordinal and nominal level which will allow for descriptive and frequency statistics to be used i.e. means standard deviations and percentages for the demographic section and modes for the scenarios section. As a research design of this kind does not investigate a relationship between independent and dependant variables but is concerned with the reliability and validity of the MTS as seen through the inter rater agreement of the respondents, an element of psychometric analysis will be employed. The test of choice will be Cohen’s Kappa. A chance corrected measure introduced by Scott (1955) and extended by Cohen (1960) which has become known as Cohen’s Kappa. The project will commence as soon as the patient scenarios have been received from the Manchester Triage Group, permission got from the Clinical Director and ethical approval received from the JREC
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9. What is the nature and extent of the medical examination that participants and controls are to undergo before participating in this project? N/A A medical examination is not required. 10. How will the health of the participants and controls be monitored during and after the trial? (List clinical, laboratory and other examinations): N/A The health of the participants will not be monitored during or after this study. 11. Will participants or controls undergo independent medical examination, before, during or after the trial? YES NO √ NA 12. If a placebo group is to be used, will the group receive the best standard therapy? YES NO NA√ 13. If the project involves the use of radioactive substances or of laser therapy has the approval of the Head of Medical Physics been obtained? YES NO NA√ If not, elucidate:
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SECTION B Investigators and Facilities 14. Name, qualification and position of each person associated with this project: Name Qualification Position
a) Kenneth Folliard
RGN. Higher Diploma Nursing Studies (Emergency Nursing).
Clinical Support Nurse / CNM II.
b) Patrick K Plunkett FRCSEd, FRCSGlas, FFAEM Consultant in Emergency Medicine
c) Jonathan Drennan
MEd, BSc, FFNRCSI, Postgraduate Diploma in Statistics, RGN, RMHN, RPN, RNT
Lecturer University College Dublin
15. is each investigator a registered medical practitioner? YES NO √ If not, elucidate: Principal investigator is a registered nurse. Clinical supervisor is a registered medical practitioner. Research supervisor is a registered nurse. 16. Is each investigator a member of a major medical defence body? YES NO √ If not, elucidate: Clinical supervisor is member of Medical Protection Society. This study has no clinical component. 17. What payments, monetary or otherwise, if any, are to be made to any of the investigators (include payments to any institution or research facility)? There will be no payments, monetary or otherwise, made to any of the investigators. 18. What payments, whether monetary or otherwise, if any, are to be made to any person or institution providing facilities to be used for the purpose of the clinical trial? There will be no payments made to any person or institution. 19. In which hospital or facility will the project take place? Emergency Department, St. James’s Hospital, Dublin 8.
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SECTION C Participants 20. How many subjects and controls from this centre are expected to participate in this project? Number Subjects: 40 Controls: None This is an approximate number of subjects as it depends on the numbers of nurses who have training in the Manchester Triage System at the time of project implementation 21. If this is a multicentre trial please indicate: No a) The expected overall number of subjects: b) The number and geographical distribution of the centres involved in the study:
22. What criteria are to be used for the selection of participants? The inclusion criteria for participant selection are:
• Registered General Nurses working in the Emergency Department of St James Hospital who have had training in the use of the Manchester Triage System
The exclusion criteria for participant selection are:
• Nurses who have not had training in the use of the Manchester Triage system
23. Are women of childbearing potential included? YES √ NO NA If so, does the protocol/patient information sheet address the 8 points in the committee's checklist for studies involving women of childbearing potential (1–scientific justification, 2–negative teratogenic studies, 3–warning to subject that fetus may be damaged, 4–initial negative pregnancy test, 5–forms of contraception defined, 6–duration of use to exceed drug metabolism, 7–exclude those unlikely to follow contraceptive advice, 8–notify investigator if pregnancy suspected)? YES NO NA√
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Pregnant, or potentially pregnant, women are as entitled as any other member of society to provide their views on the service they receive, or wish to receive. There are no ethical issues likely to arise.
23. State the exclusion criteria (age, other illness, other medications etc.):
• Nurses who have not had training in the use of the Manchester Triage system
25. What are the proposed methods by which participants and controls are to be recruited? YES NO √ NA If no, elucidate: The participants will be recruited through the Nurse Manager of the Emergency Directorate who Written information explaining and describing the study will be given to the participants along with a questionnaire. This ensures that they are fully aware of the purpose of the research thus giving them the option to participate in the survey if they so wish. Implied consent will be assumed, if the patient completes the questionnaire they have consented to the study. 26. What inducements or rewards, whether monetary or otherwise, are to be offered to participants and controls? YES NO √ NA If no, elucidate: No inducements, rewards or payments will be made to research participants.
27. What arrangements exist to provide compensation to each participant who may suffer injury or loss as a result of this research project?
It is anticipated that participants will not suffer injury or loss as a result of being involved in this project. Is the Ethics Committee’s standard compensation statement (above) being adopted? YES NO √ NA
89
If “NO” please give alternative wording. The wording used in answer to question 27 must also appear in the Patient Information Sheet. 28. Have you submitted to the committee, with this form, a patient information leaflet and consent form prepared by a sponsor or other external group, or a patient information leaflet and consent form based on the committee's guidelines (attached to this form) to be given to each participant and control? YES NO √ If no, elucidate: 29. What criteria are to be used to ensure that the identity of each participant and control remains confidential? Only the investigator's group within the institution will know the identity of the subjects; YES NO √ If no, indicate the criteria used. The participants will be known to the researcher but the questionnaires will be completely anonymous and left in a box in the staff common room when filled by the participant As no identity codes are used, once the questionnaires have been filled, it will be impossible to link them to the original participant. As the returns will be completely anonymous, the essential point is that the primary researcher is not in a position to associate the data with an identifiable individual. The guarantee of anonymity and confidentiality is included in the information leaflet. All research data will be maintained in keeping with the Data Protection Act (1988) and the Data Protection (Amendment) Act (2003). All documents pertaining to the survey will be stored in a locked cabinet in the researcher’s home and will be retained securely and confidentially for a period of five years, as per good practice. Access to the locked cabinet containing the data will be strictly restricted to the researcher. All computerised data will be saved on the researcher’s lap-top in a locked cabinet in the researcher’s home and access is restricted only to the researcher by password. Hard copies will be kept in a locked cabinet in the researcher’s home, with access strictly restricted to the researcher. 30. Give details of any risks to subjects or to controls from investigative or therapeutic procedures or from withholding of therapy? NOTE: for the protection of both the investigator and the subject this list must be comprehensive and must also appear in full in the patient information leaflet.
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As this study will not involve any investigative or therapeutic procedures, or withholding of therapy, then it is expected that no such risks will arise. 31. Indicate how adverse events are to be notified and evaluated: Any adverse events will be reported to the St. James’s Hospital and Federated Dublin Voluntary Hospitals Joint Research Ethics Committee for further investigation and evaluation. SECTION D Drugs and other Therapeutic Substances 32. Is the object of this project to assess the effect of a drug or therapeutic substance? YES NO √ If NO, skip to the end of the form. 33. Name of the substance or preparation which is the subject of the proposed project: 34. Name of the company or organisation which produces this substance or preparation: 35. Code number used by the company or organisation for this trial: 36. Does the organisation and performance of this trial conform to the International Conference on Harmonisation guidelines on Good Clinical Practice? YES NO 37. Give details of the pharmacology, dosage, toxicity, and side effects of the substance or preparation: NOTE: for the protection of both the investigator and the subject the list of side effects must be comprehensive and must also appear in full in the patient information leaflet.
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APPENDIX 6
LETTER OF ETHICAL APPROVAL
92
93
APPENDIX 7
LETTER OF APPROVAL FROM CLINICAL DIRECTOR
94
95
APPENDIX 8
LETTER OF APPROVAL DIRECTOR OF NURSING
96
Folliard, Kenneth (Clinical Support Nurse) ([email protected]) From: Breen, Catherine (Nursing Admin) Sent: 25 April 2006 16:25 To: Folliard, Kenneth (Clinical Support Nurse) Subject: Masters Research to determine the validity and reliability of the Manchester Triage System in the Irish healthcare setting Hi Ken, We are in receipt of your letter to the Acting Director of Nursing requesting permission to undertake a research study in our Accident and Emergency Department. Catherine Carey (Acting DON) has given her permission pending Ethical approval from Ethics Committee. With best wishes and good luck with your study. Regards, Catherine (Breen), on behalf of Catherine Carey, Acting Director of Nursing. ********************************************************************** This email and any files transmitted with it are confidential and intended solely for the use of the individual or entity to whom they are addressed. If you have received this email in error please notify the system manager. www.stjames.ie *********************************************************************
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APPENDIX 9
APPROVAL TO REPRODUCE MTS TABLE
98
Windle Jill ([email protected]) To: "'Kenneth Folliard'" <[email protected]> Subject: RE: Triage Questionnaire Hi Kenny There is absolutely no reason why you should not recreate the table and under the UK copyright laws you are not prohibited from doing so but I appreciate your asking. Jill -----Original Message----- From: Kenneth Folliard [mailto:[email protected]] Sent: 17 May 2006 10:20 to: [email protected] Subject: Triage Questionnaire
HI Jill I was wondering if I could get permission to reproduce the table on page 2 of Emergency Triage 2nd edition which outlines the nomenclature, colours and maximum time each category may wait. I wish to include it in my questionnaire as a reminder of the Triage system, Regards
Kenny...
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APPENDIX 10
MANCHESTER TRIAGE SCENARIOS
100
Scenario Number Scenario details MTS ‘correct’ answer
1
A 37-year-old man, with a two-year history of back problems, is brought in by ambulance with lumbar pain. He states that he is in constant pain day and night and has not worked for over a year. The pain on this occasion it is not the worst he has ever had but is "quite bad". He cannot stand up because of the pain. He has tingling down the back of his left calf. He has suffered no direct trauma to the back.
Discuss which presentational chart to use – Back Pain Discuss this patients triage category - Yellow Discriminator – Unable to walk - ? New neurological deficit
2
A 54 year-old-man attends having wrenched his right shoulder pushing a truck with colleagues at work He felt a sudden sharp pain in his shoulder and upper arm C/o Reduced range of movement in shoulder Unable to abduct right arm due to pain He assesses his pain score at 6
Discuss which presentational chart to use – Limb Problems Discuss this patients triage category – Yellow Discriminators – Moderate Pain
3
A 56-year-old who is a heavy smoker collapses while running for a bus. He appears to be unconscious for about 30 seconds, and when he comes round he complains to his wife that he has a crushing feeling in the centre of his chest. When he reaches hospital he says that the pain is not too bad. He says he has never had pain like this in the past. The pain is not worse with coughing or deep breathing and does not radiate to his left arm. His pulse is 40 beats per minute and regular and he is not on medication.
Discuss which presentational chart to use – Chest Pain Discuss this patients triage category – Orange Discriminators – Cardiac Pain - Abnormal Pulse
101
Scenario Number Scenario details MTS ‘correct’ answer
4
A 27-year-old woman is brought to the department from home. Her partner who 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 and orientated and denies taking any tablets or medicines. She says 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.
Discuss which presentational chart to use – Behaving Strangely Discuss this patients triage category - Green Discriminators – there are no discriminators to allocate a higher category
5
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 you observe heavy PV blood loss B/P 90/50, Pulse 120, 02 sats 92% on air She complains of nausea
Discuss which presentational chart to use – Pregnancy (PV Bleed) Discuss this patients triage category - Orange Discriminators – Severe pain
6
A paramedic ambulance crew brings in A 22-year-old woman who had 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. There is a right occipital haematoma
Discuss which presentational chart to use – Fits Discuss this patients triage category - Yellow Discriminators – History of head injury
102
Scenario Number Scenario details MTS ‘correct’ answer
7
An 81 year-old man is brought in by ambulance complaining of chest pain. The patient describes the pain as radiating to his neck and jaw He feels nauseous and has vomited twice in the ambulance The paramedics have already administered morphine and aspirin with some effect. Pain score assessed as 7 The patient has known IHD, pernicious anaemia and leg ulcers.
Discuss which presentational chart to use – Chest Pain Discuss this patients triage category - Orange Discriminators – Cardiac Pain
8
A 22-year-old known migraine sufferer attends the department 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.
Discuss which presentational chart to use – Headache (Neck pain) Discuss this patients triage category - Orange Discriminators – Abrupt onset - Signs of meningism
9
A 53-year-old woman attends the department 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. Her pain score is 4 Temp 36oc, pulse 68 beats p.m. O2 sats 98% on air
Discuss which presentational chart to use – Diarrhoea and Vomiting Discuss this patients triage category – Green Discriminator – Vomited - Recent mild pain
103
Scenario Number Scenario details MTS ‘correct’ answer
10
It is 2.00 am on Saturday morning and the clubs have just shut. A 21-year-old man is brought to the department by his friends. They state that he had not "been looking for trouble" when he had been set upon by three men. There is no further history. The patient can talk but makes very little sense. He smells of alcohol. There is no obvious external haemorrhage. His friends say that he was punched and kicked. The patient says that he was not knocked unconscious and his friends confirm this. He says that his "head hurts a bit".
Discuss which presentational chart to use – Assault (Apparently Drunk) Discuss this patients triage category - Green Discriminator – Recent mild pain
11
A 33-year-old woman is brought to the emergency department having 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 has a large left frontal haematoma. She says that her "head throbs". She was apparently unconscious at the scene for two to three minutes. There are no signs of external haemorrhage
Discuss which presentational chart to use – Head Injury (Major Trauma) Discuss this patients triage category - Yellow Discriminators – History of Unconsciousness
12
The department is put on standby for 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 reported to be severely damaged. On arrival he is conscious but unable to remember the car hitting him. GCS 13 He complains of severe pain in right groin area, hip and thigh. He has loin pain with haematuria ++ on urine testing O2 sats 95% on air
Discuss which presentational chart to use – Major Trauma Discuss this patients triage category - Orange Discriminators – Significant mechanism of injury
104
Scenario Number Scenario details MTS ‘correct’ answer
13
The local police bring a 24-year-old known schizophrenic patient into the emergency department. He has been acting strangely. He is expressing paranoid ideas; in particular, he thinks there is a plot to poison him. He says that he knows who they are and if he sees them he will kill them. He has apparently tried to kill himself in the past. The patient becomes uncommunicative but sits quietly with the accompanying policeman.
Discuss which presentational chart to use – Mental Illness Discuss this patients triage category – Yellow Discriminators – Significant psychiatric history
14
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 has no wheeze or stridor. Her tongue is slightly swollen and she has some swelling around her face. Her saturation on air is 98%.
Discuss which presentational chart to use – Exposure to chemicals Discuss this patients triage category – Orange Discriminators – Facial oedema - Oedema to the tongue
15
It is 10 o'clock in the morning. A 69-year-old man comes into the unit 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. 02 sats 98% on air He complains he has now had the symptoms for six weeks.
Discuss which presentational chart to use – Shortness of breath in Adults Discuss this patients triage category – BLUE Discriminator – defaults as none of the above apply
105
Scenario Number Scenario details MTS ‘correct’ answer
16
A 76-year-old man attends the Emergency department having apparently 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 in triage. He complains of severe spasms of pain in his upper abdomen
Discuss which presentational chart to use – GI Bleed Discuss this patients triage category – Orange Discriminator – Severe pain
17
It is September and the first week of the university term in the local town. A new first-year student returns to the department saying 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. Just as he is about to leave the room he hands in a card, which states that he had a splenectomy at the age of 16 following trauma
Discuss which presentational chart to use – Sore Throat (Unwell Adult) Discuss this patients triage category – Yellow Discriminator - Hot Adult
18
A 74-year-old man is sent to the department by his GP. He 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. BP 110/68, pulse 68/min GP letter 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 triage
Discuss which presentational chart to use – Abdominal pain in adults Discuss this patients triage category – Orange Discriminator – Pain radiating to the back
106
Scenario Number Scenario details MTS ‘correct’ answer
19
A 72-year-old woman attends the emergency department having been brought in by taxi from her local supermarket. Apparently she was just about to be served at the cheese counter when a small child pushed a supermarket trolley into her left leg, which has bled a considerable amount. One of the supermarket staff has applied a bandage and she was able to walk to the taxi unaided. She says she feels no pain but is worried her leg looks a mess. On removing the dressing from the wound you find a large flap of skin and some generalised bruising but the bleeding has stopped completely.
Discuss which presentational chart to use – Wounds Discuss this patients triage category - Green Discriminator – Recent problem
20
A 55-year-old man is brought to the emergency department by ambulance following 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 there is a great deal of swelling. On closer examination, there is an area of considerable pallor over the lateral aspect of the ankle where a piece of bone lies immediately under the skin.
Discuss which presentational chart to use – Limb Problems Discuss this patients triage category - Orange Discriminator – Critical skin
21
A 50-year-old man who had slipped and fallen down three stairs this morning at home is brought into the emergency department. He smells of stale alcohol. During the fall he banged the back of his head but does not know if he has been unconscious. The patient continually complains of pain in his neck, which radiates down his right arm. He has an unpleasant sensation like ‘ice cold water is being poured down his back and legs’. The patient is alert and there are no signs of haemorrhage.
Discuss which presentational chart to use – Neck Pain (Falls) Discuss this patients triage category - Orange Discriminators – Acute neurological deficit
107
Scenario Number Scenario details MTS ‘correct’ answer
22
A 17 year-old young man arrives at the department following a head-to-head collision with another player during a game of football. No LOC witnessed. He holds a blood soaked, gauze dressing to his face On closer inspection his nose is bleeding ++ and he has avulsed his front tooth which is embedded in a deep laceration to the interior of his upper lip He is distressed but can communicate and clear his mouth of blood by spitting His mouth and nose are swollen, sensation normal, VA normal.
Discuss which presentational chart to use – Facial Problems Discuss this patients triage category – Yellow Discriminators – Uncontrollable minor haemorrhage - Acutely avulsed tooth
23
A 19-year-old female university student is brought into the department 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 mmols A glucose stick test shows ++++ of ketones in her urine. Temp 39.4 0c
Discuss which presentational chart to use – Diabetes Discuss this patients triage category – Orange Discriminators – Hyperglycaemia with ketosis
24
A 55-year woman walks into the department complaining of palpitations 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 is 140 beats per/min, regular She feels panicky and frightened and complains that her mouth feels very dry
Discuss which presentational chart to use – Palpitations Discuss this patients triage category – Orange Discriminators – Abnormal pulse
108
Scenario Number Scenario details MTS ‘correct’ answer
25
A 48 year-old lady attends the emergency department 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. Pain score 7 Temp 37.6oc
Discuss which presentational chart to use – Ear Problems Discuss this patients triage category - Yellow Discriminator – Moderate Pain
26
A 42-year-old man attended the emergency department complaining of blurred vision. His left eye appears red. He states that his eye is not exactly painful - it is more of a "discomfort". Visual acuity in the left eye is 6/24 and in the right eye is 6/6. This patient did not previously wear corrective spectacles
Discuss which presentational chart to use – Eye Problems Discuss this patients triage category – Yellow Discriminator – Recent reduced visual acuity
27
A 16-year-old girl who has been sent home from school unwell attends the department with her mother. 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 is fully alert and orientated and says that she has been increasingly breathless for two days. Pulse rate is 100. She has never been in hospital before with her asthma. Oxygen saturation is 92% on air.
Discuss which presentational chart to use – Asthma Discuss this patients triage category – Yellow Discriminator – Low Sa02 - No improvement with own asthma medications
109
Scenario Number Scenario details MTS ‘correct’ answer
28
A 51-year-old man is brought to the emergency department, by ambulance, having been found lying by the roadside apparently intoxicated. No obvious signs of injury. He is slurring his words and smells of alcohol. A glucose stick test shows a blood glucose level of 4.3 mmols per litre. He responds to voice. He has a confirmed history of alcohol abuse
Discuss which presentational chart to use – Apparently Drunk Discuss this patients triage category - Yellow Discriminators – Altered conscious level wholly attributable to alcohol
29
A 32 year-old woman is brought into the emergency department by a friend. She is uncommunicative. Her 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. The patient is not shocked. 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 and wants you to contact her husband.
Discuss which presentational chart to use – Self Harm Discuss this patients triage category - Yellow Discriminators – Marked distress
30
A 15-year-old girl is brought in from a residential children's home after drinking two mouthfuls of bleach. She has vomited three times in the past 20 minutes and complains of a burning sensation in the back of her throat. She has taken an overdose of paracetamol on two previous occasions She says she is bored with life and bored with school and drank the bleach because she wanted to die
Discuss which presentational chart to use -Self Harm Discuss this patients triage category - Orange Discriminators – High risk of further self-harm
