Veen, M. van

Can urgency classification of the Manchester triage system predict serious bacterial infections in febrile children? (Article)

2011-08-01T00:00:00Z

Objective: To evaluate the discriminative ability of the Manchester triage system (MTS) to identify serious bacterial infections (SBIs) in children with fever in the emergency department (ED) and to study the association between predictors of SBI and discriminators of MTS urgency of care. Methods: This prospective observational study included 1255 children with fever (1 month-16 years) attending the ED of the Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands in 2008-9. Triage urgency was determined with the MTS (urgency (U) level 1-5). The relationship between triage urgency and SBI was assessed with multivariable logistic regression, including effects of age, sex and temperature. Discriminative ability was assessed by receiver operating characteristic curve analysis. Results: SBI prevalence was 11% (n = 131, 95% CI 9% to 12%). The discriminative value of the MTS for predicting SBI was 0.57 (95% CI 0.52 to 0.62), and the MTS did not contribute to a model including age, sex and temperature. The sensitivity of the MTS (U1-2 vs U3-5) to detect SBI was 0.42 (95% CI 0.33 to 0.51) and specificity was 0.69 (95% CI 0.66 to 0.72). MTS high urgency discriminators include several known predictors of SBI, such as fever, work of breathing, meningism and oxygen saturation, but apply to non-SBI children as well. Conclusion: The MTS has poor discriminative ability to predict the presence of SBIs in children presenting with fever to the paediatric ED. Important predictors of SBI are represented within the MTS, but are used in a different way to classify urgency.

Undertriage in the Manchester triage system: An assessment of severity and options for improvement (Article)

2011-07-01T00:00:00Z

Background: The Manchester Triage System (MTS) determines an inappropriately low level of urgency (undertriage) to a minority of children. The aim of the study was to assess the clinical severity of undertriaged patients in the MTS and to define the determinants of undertriage. Methods: Patients who had attended the emergency department (ED) were triaged according to the MTS. Undertriage was defined as a 'low urgent' classification (levels 3, 4 and 5) under the MTS; as a 'high urgent' classification (levels 1 and 2) under an independent reference standard based on abnormal vital signs (level 1), potentially life-threatening conditions (level 2), and a combination of resource use, hospitalisation, and follow-up for the three lowest urgency levels. In an expert meeting, three experienced paediatricians used a standardised format to determine the clinical severity. The clinical severity had been expressed by possible consequences of treatment delay caused by undertriage, such as the use of more interventions and diagnostics, longer hospitalisation, complications, morbidity, and mortality. In a prospective observational study we used logistic regression analysis to assess predictors for undertriage. Results: In total, 0.9% (119/13,408) of the patients were undertriaged. In 53% (63/119) of these patients, experts considered undertriage as clinically severe. In 89% (56/63) of these patients the high reference urgency was determined on the basis of abnormal vital signs. The prospective observational study showed undertriage was more likely in infants (especially those younger than three months), and in children assigned to the MTS 'unwell child' flowchart (adjusted OR<3 months4.2, 95% CI 2.3 to 7.7 and adjusted ORunwell child11.1, 95% CI 5.5 to 22.3). Conclusion: Undertriage is infrequent, but can have serious clinical consequences. To reduce significant undertriage, the authors recommend a systematic assessment of vital signs in all children.

Safety of the manchester triage system to identify less urgent patients in paediatric emergence care: A prospective observational study (Article)

2011-06-01T00:00:00Z

Objective: To assess hospitalisation rate as a proxy for the ability of the Manchester Triage System (MTS) to identify less urgent paediatric patients. We also evaluated general practitioner (GP) services to determine if they met patients' needs compared to emergency department care. Methods: Self-referred children triaged as less urgent by the MTS in two emergency departments in the Netherlands were included in a prospective observational study. Therapeutic interventions during emergency department consultation, hospitalisation after consultation and determinants for hospitalisation were assessed using logistic regression analysis. Results: During emergency department consultation, extensive therapeutic interventions were performed more often in patients with extremity problems (n=175, 19%) and dyspnoea (n=30, 15%). 191 (3.5%) of 5425 patients were hospitalised. Age and presenting problem remained statistically significant in multivariable logistic analysis, predicting hospitalisation with ORs of 3.0 (95% CI 2.2 to 4.1) for age <1 year, 2.5 (1.5 to 4.1) for dyspnoea, 3.5 (2.5 to 4.9) for gastrointestinal problems and 2.8 (1.1 to 7.2) for patients with fever without identified source compared to all other patients. 3975 (76%) of 5234 patients were contacted for follow-up after discharge. Six (0.15%) patients were hospitalised after emergency department discharge. Conclusion: In the MTS less urgent categories, overall hospitalisation is low, although children <1 year of age or with dyspnoea, gastrointestinal problems or fever without identified source have an increased risk for hospitalisation. Except for these patient groups, the MTS identifies less urgent patients safely. It may not be optimal for GP services to treat patients with extremity problems.

Validity of telephone and physical triage in emergency care: The Netherlands Triage System (Article)

2011-05-30T00:00:00Z

Background:Due to emergency care overcrowding, right care at the right place and time is necessary. Uniform triage of patients contacting different emergency care settings will improve quality of care and communication between health care providers. Objective:Validation of the computer-based Netherlands Triage System (NTS) developed for physical triage at emergency departments (EDs) and telephone triage at general practitioner cooperatives (GPCs). Methods: Prospective observational study with patients attending the ED of a university-affiliated hospital (September 2008 to November 2008) or contacting an urban GPC (December 2008 to February 2009). For validation of the NTS, we defined surrogate urgency markers as best proxies for true urgency. For physical triage (ED): resource use, hospitalization and follow-up. For telephone triage (GPC): referral to ED, self-care advice after telephone consultation or GP advice after physical consultation. Associations between NTS urgency levels and surrogate urgency markers were evaluated using chi-square tests for trend. Results:We included nearly 10 000 patients. For physical triage at ED, NTS urgency levels were associated with resource use, hospitalization and follow-up. For telephone triage at GPC, trends towards more ED referrals in high NTS urgency levels and more self-care advices after telephone consultation in lower NTS urgency levels were found. The association between NTS urgency classification and GP advice was less explicit. Similar results were found for children; however, we found no association between NTS urgency level and GP advice. Conclusions:Physically and telephone-assigned NTS urgency levels were associated with majority of surrogate urgency markers. The NTS as single triage system for physical and telephone triage seems feasible.

Repeatability of the Manchester triage system for children (Article)

2010-07-01T00:00:00Z

Objective: The authors aimed to assess the repeatability of the Manchester Triage System (MTS) in children. Methods: All emergency department nurses (n=43) from a general teaching hospital and a university children's hospital in The Netherlands triaged 20 written case scenarios using the Manchester Triage system. Second, at two emergency departments (EDs), real-life simultaneous triage of patients (<16 years) was performed by ED nurses and two research nurses. The written case scenarios and the patients included in the real-life simultaneous triage study were representative of children attending the ED, in age, problem and urgency level. The authors assessed inter-rater agreement using quadratic weighted kappa values. Results: The weighted kappa between the nurses, triaging the case scenarios, was 0.83 (95% CI 0.74 to 0.91). In total, 88% (N=198) of the eligible ED patients were triaged simultaneously, with a weighted κ of 0.65 (95% CI 0.56 to 0.72). Conclusions: The MTS showed good to very good repeatability in paediatric emergency care.

Imputation is beneficial for handling missing data in predictive models (Article)

2007-09-01T00:00:00Z