The presentational flow chart “unwell adult” of the Manchester Triage System—Curse or blessing?

Abstract

Background The presentational flow chart “unwell adult” of the Manchester Triage System (MTS) occupies a special role in this triage system, defined as the nonspecific presentation of an emergency patient. Current scientific studies show that a considerable proportion of emergency room patients present with so-called "nonspecific complaints". The aim of the present study is to investigate in detail the initial assessment of emergency patients triaged according to the presentational flow chart "unwell adult". Methods Monocentric, retrospective observational study. Results Data on 14,636 emergency department visits between March 12th and August 12th, 2019 were included. During the observation period, the presentational flow chart "unwell adult" was used 1,143 times and it was the third most frequently used presentational flow chart. Patients triaged with this flow chart often had unspecific complaints upon admission to the emergency department. Patients triaged with the “unwell adult” chart were often classified with a lower triage level. Notably, patients who died in hospital during the observation period frequently received low triage levels. The AUC for the MTS flow chart “unwell adult” and hospitalization in general for older patients (age ≥ 65 years) was 0.639 (95% CI 0.578–0.701), and 0.730 (95% CI 0.714–0.746) in patients triaged with more specific charts. The AUC for the MTS flow chart “unwell adult” and admission to ICU for older patients (age ≥65 years) was 0.631 (95% CI 0.547–0.715) and 0.807 (95% CI 0.790–0.824) for patients triaged with more specific flow charts. Comparison of the predictive ability of the MTS for in-hospital mortality in the group triaged with the presentational flow chart “unwell adult” revealed an AUC of 0.682 (95% CI 0.595–0.769) vs. 0.834 (95% CI 0.799–0.869) in the other presentational flow charts. Conclusion The presentational flow chart "unwell adult" is frequently used by triage nurses for initial assessment of patients. Patient characteristics assessed with the presentational flow chart "unwell adult" differ significantly from those assessed with MTS presentational flow charts for more specific symptoms. The quality of the initial assessment in terms of a well-functioning triage priority assessment tool is less accurate than the performance of the MTS described in the literature.

Mortality risk for different presenting complaints amongst older patients assessed with the Manchester triage system

“…One might speculate that patients assigned to this flowchart did not report specific complaints such as chest pain. Our finding that NSCs are common is in line with the literature [9,16,7]. High admission-and mortality rates were reported as well [11,10,17].…”

“…Recently, safety concerns have been raised with regard to undertriage and mortality prediction, especially in older patients, when using the MTS [3][4][5][6][7]. Undertriage occurred in 30% of patients with sepsis in one study [5].…”

Identification through the Manchester Triage System of the older population at risk of delirium: A case–control study

“…The aim of our study was to analyse which flow charts and discriminators of the but at the same time, shortcomings have been detected in some cases (Zachariasse et al, 2017), such as errors in application by inexperienced nursing staff; when screening more than one patient every 15 min; or in the triage of certain specific populations such as young patients or older individuals with comorbidities (Ausserhofer et al, 2021). In the older population, the atypical presentation of diseases makes the correct identification of the flow charts difficult, and there have even been reports of greater mortality among those identified as being of lowest priority (Brutschin et al, 2021;Lucke et al, 2021). Therefore, nursing knowledge of the specific characteristics of the older population is essential for proper triage (Grossmann et al, 2014).…”

Five Level Triage vs. Four Level Triage in a Quaternary Emergency Department: National Analysis on Waiting Time, Validity, and Crowding—The CREONTE (Crowding and RE-Organization National TriagE) Study Group

“…Although some real-life 5T studies have been performed, most of these have been performed on a single symptom or disease, often on a small number of patients. Some of these were wait time studies, and others were real-life 5LT validation studies [81][82][83][84][85].…”