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Australasian Emergency Nursing Journal (2014) xxx, xxxxxx

Available online at www.sciencedirect.com

ScienceDirect
journal homepage: www.elsevier.com/locate/aenj

RESEARCH PAPER

A comparison of emergency triage scales in

triaging poisoned patients
Dushan Jayaweera, MBBS, FACEM a,b,c,f,
Satish Mitter, MBBS, FACEM a,b,c,f
Andrew Grouse, MBBS, FACEM d
Luke Strachan, BN, GradCertCCN, MNurs(NursPrac) b
Margaret Murphy, BN, MHlthSc a
David Douglass, BN, GradCertCCN b
Liesel Gerlach, BN, MEmergNurs d
Naren Gunja, MBBS, MSc, FACEM, FACMT a,b,c,e,f
a

Emergency Department, Westmead Hospital, Sydney, Australia

Emergency Department, Blacktown-Mt.Druitt Hospital, Sydney, Australia
c
Department of Clinical Pharmacology & Toxicology, Western Sydney LHD, Sydney, Australia
d
Emergency Department, Nepean Hospital, Sydney, Australia
e
Discipline of Emergency Medicine, Sydney Medical School, NSW, Australia
f
School of Medicine, University of Western Sydney, NSW, Australia
b

Received 12 December 2013; received in revised form 14 May 2014; accepted 14 May 2014

KEYWORDS
Emergency nursing;
Poison control
centres;
Toxicology;
Triage;
Risk assessment

Summary
Background: Triage of toxicology patients presents a challenge due to their complexity,
underlying psychosocial issues, and additional pharmacological considerations. Two emergency
department triage systems used in Australia, the Australasian Triage Scale (ATS) and the Manchester Triage System (MTS), were compared in triaging patients presenting with poisoning and
envenoming.
Methods: In this simulation-based study, 30 triage nurses from three hospitals were given 8
tabletop scenarios and asked to provide a triage category. 20 nurses from two hospitals using
the ATS, and 10 nurses from a third hospital using the MTS, triaged 8 scenarios, grouped into

Corresponding author at: Emergency Department, Westmead Hospital, Westmead, NSW 2145, Australia. Tel.: +61 2 9845 7607;
fax: +61 2 9633 4296.
E-mail address: dushan.jayaweera@health.nsw.gov.au (D. Jayaweera).

http://dx.doi.org/10.1016/j.aenj.2014.05.004
1574-6267/ 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Jayaweera D, et al. A comparison of emergency triage scales in triaging poisoned
patients. Australas Emerg Nurs J (2014), http://dx.doi.org/10.1016/j.aenj.2014.05.004

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D. Jayaweera et al.
commonly encountered (n = 4) and rarely encountered (n = 4). Triage systems and scenario
groups were compared for median triage category and variance in scoring. Triage nurses also
noted if they would seek help from toxicology services or the poisons information centre (PIC)
for advice.
Results: Overall, MTS nurses triaged all 8 scenarios with a lower acuity triage category, though
statistically signicant for only 3 scenarios. ATS nurses scored higher acuity triage category in
all 4 rare highly toxic presentations, whereas MTS nurses scored higher acuity when vital
signs were abnormal. MTS showed wider variance in triage scores in both scenario groups when
compared to the ATS. Triage nurses without access to local toxicology services chose to contact
PIC in most cases.
Conclusions: When compared to the ATS, MTS gave a lower acuity triage score for all common and
rarely encountered poisoning scenario groups, which included highly toxic ingestions that appear
well at triage but may progress to severe poisoning. Triage nurses should refer to information on
highly toxic exposures and envenomation guidelines during their triage risk assessment.
2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights
reserved.

What is known
There is little published data on triage of the poisoned patient and no published studies comparing
the Australian Triage Scale and the Manchester Triage
Scale, in their risk assessment.

What this paper adds

This study compares the Australasian Triage Scale
(ATS) and the Manchester triage system (MTS) in the
assessment of patients presenting with toxicological
scenarios. Triage nurses using ATS provided higher
acuity triage scores compared with MTS nurses across
all study scenarios. Emergency departments should
carry additional information on highly toxic exposures and local envenomation guidelines for triage
nurses.

Introduction
Triage is an important tool for clinical decision making in the
Emergency Department (ED). A triage system is the process
by which a clinician assesses a patients clinical urgency.
Urgency is determined according to the patients clinical
condition and is used to determine the speed of intervention
that is necessary to achieve an optimal outcome.1 Urgency
is independent of the severity or complexity of an illness
or injury. ED nursing staff require specic training to perform this vital role at the front end of the hospital and take
years to perfect the art of triaging. Australian triage nurses
complete a national standardised triage-training programme
based on the Emergency Triage Education Kit in order to
perform this role.1
Triage of ED patients has evolved considerably over the
last two decades. Since their inception, triage systems
have continued to develop and be modied into ever more
useful tools in early recognition of the acutely ill. Two
common systems for triaging emergency patients are the

Australasian Triage Scale (ATS), utilised in the majority of

Australian EDs, and the Manchester Triage System (MTS),
utilised in the United Kingdom and some Australian EDs.25
The National Triage Scale (NTS) was implemented in 1993,
becoming the rst triage system to be used in all publicly
funded EDs throughout Australia. In the late 1990s, the NTS
underwent renement and was subsequently renamed the
ATS.1 At a similar time period, the MTS was jointly developed
by the Royal College of Nursing Accident and Emergency
Association and the British Association for Accident and
Emergency Medicine. The MTS consists of 52 algorithms or
ow charts that lead the triage nurse to a logical triage
choice for almost any presenting complaint, and results in a
ve-point scale similar to that described by the ATS. From
the very earliest use of these triage scales, a time limit
for clinical assessment has been associated with each triage
categorythese time limits are shown in Table 1 comparing
the two systems. The MTS has been modied for regionspecic envenoming presentations in the Australian context.
Applying these systems to the poisoned patient, triage aims
to rapidly assign treatment priority for a given overdose or
envenomation.
The existence of poisons information centres (PICs)
within a healthcare system has signicant implications on
emergency triage presentations.68 The ability to lter
the majority of trivial and minor exposures with out-ofhospital management selects higher acuity patients for ED

Table 1
Triage
category

1
2
3
4
5

Comparison of ATS and MTS.3,4

Treatment acuity (maximum waiting time
for medical assessment and treatment)
ATS

MTSa

Immediate
10 min
30 min
60 min
120 min

Immediate
10 min
60 min
120 min
240 min

The MTS has been modied by the hospital in our study to

match ATS waiting times.

Please cite this article in press as: Jayaweera D, et al. A comparison of emergency triage scales in triaging poisoned
patients. Australas Emerg Nurs J (2014), http://dx.doi.org/10.1016/j.aenj.2014.05.004

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Toxicology triage study

presentation.9 PICs also play a key role in ambulance triage

at the scene as well as in ambulance control systems that
decide on transportation of potentially poisoned patients.
ED triage nurses may also choose to contact a PIC during or

Table 2

at the completion of triage in order to modify risk stratication.

Poisoned and envenomed patients are a challenging
cohort when it comes to triage. Specic pharmacological

Study scenarios.

Group

Scenario

Details

Common
presentations

A: Supratherapeutic
paracetamol

A 48-year-old man with knee pain presents with vomiting. He has been
taking 2 tablets of Panadeine every 2 h for the last 12 h. He has vomited
twice clear uid in vomitus. His last Panadeine tablet was 2.5 h ago. He is
currently pain free, sitting on a chair and no longer nauseated. He has
arthritis in his knee after a previous work injury; he denies other medical
problems. His vital signs are HR 84, RR 14, BP 118/66, Sats 96% on room air
A 63-year-old woman with a history of trigeminal neuralgia self-presents
with an accidental overdose of her regular medication. She has inadvertently
mixed her regular prednisone with amitriptyline. This morning she took 4
tablets of amitriptyline 25 mg each and 1 tablet of prednisone 5 mg, instead
of the other way around. She appears well and coherent, but anxious. Her
observations are HR 112, RR 18, BP 136/78, Sats 98% on room air
A 4-year old girl is brought in by her mother after being bitten by a bug in
the garden. Mum heard her screaming while playing in the backyard an hour
ago. They have noticed more red-back spiders in their backyard over the last
few months. The child is now comfortable in her mums lap and does not
appear to be in pain. There is a small red welt on the R leg above the ankle;
there is no obvious swelling. Her obs are HR 100, RR 18, Sats 99% on room air
A 22-year-old male is brought in by ambulance with palpitations that he
noticed after waking up this morning. He was at a party last night and
bought some eccies from a friend he had 2 tablets last night along with
some alcohol. He appears anxious but co-operative. The Ambulance rhythm
strip shows sinus tachycardia at 110 beats per minute. His vital signs at
triage are HR 116, RR 14, BP 126/84
A 45-year-old man with a background of depression is brought in by
ambulance after ingesting a pesticide in his home. He admitted to
ambulance ofcers on scene that he drank half a bottle of Nufarm termite
killer about 1 h ago. He vomited several times and on route to the hospital,
he had a generalised seizure in the ambulance. The Ambulance ofcer gave
5 mg IM midazolam after which he has not had any seizures. On exam, he is
diaphoretic and incontinent of urine. His vital signs as per the Ambulance
ofcers are HR 56, BP 92/60, RR 10, Sats 100% (on NRB oxygen), blood
glucose level 6.2 mmol/L, GCS E2V3M5 = 10.
A 6-year-old autistic child is brought in by her grandmother after nding her
with an empty bottle of Ferrogradumet. The bottle was purchased yesterday
and contained about 30 tablets. The child had been playing in the bedroom
unsupervised for around 15 min. The grandmother noted that there were
some tablets on the oor, but did not count them as she panicked. The girl is
alert and behaving normally as per her grandmother. Her vital signs are HR
94, RR 18, Sats 99% on room air, weight 25 kg.
A 25-year-old male presents an hour after accidentally ingesting a mouthful
of blue-coloured weed killer. He picked up an unlabeled bottle thinking it
was a sports drink. He has mild epigastric discomfort and has vomited once.
He appears well and his vital signs are HR 86, RR 16, Sats 98% on room air,
GCS 15
A 58-year-old male presents after deliberate ingestion of 30 tablets of
Cardizem CD 240 mg, 2 h ago after an argument with his wife. He is brought
in by his brother and is regretful of his actions; he is co-operative and agrees
to stay for treatment. He has a background of hypertension. His vital signs
are HR 76, RR 14, BP 128/68, Sats 99% on room air, GCS 15

D: TCA medication
error

F: Red-back spider
bite

H: Ecstasy

Rare presentations

B: Organophosphate

C: Iron

E: Paraquat

G: Calcium channel
blocker

Please cite this article in press as: Jayaweera D, et al. A comparison of emergency triage scales in triaging poisoned
patients. Australas Emerg Nurs J (2014), http://dx.doi.org/10.1016/j.aenj.2014.05.004

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and/or toxicological knowledge may be required to triage

this group of patients. To date, we have not identied any
studies looking into the triage of this particular cohort of
patients and the unique challenge posed by their multifaceted presentations. Our objective was to compare the
two triaging systems, ATS and the MTS used by three Western Sydney hospitals, in scoring scenarios of poisoned and
envenomed patients. The existence of two triage systems
within our local health services allowed for an assessment
of the varying practices and whether front end streaming of
poisoned patients was dependent on the triage system used.
This study attempted to answer the question does using
different triaging systems affect the urgency assigned to toxicology patients? The study was not designed or aimed at
ascertaining which system was superior, but rather whether
there were differences in assigned urgency based on triaging
method.

Table 3

Results.

Scenario

ATS score
Median (IQR)

MTS score
Median (IQR)

MW test
P value

A (Common)
D (Common)
F (Common)
H (Common)
B (Rare)
C (Rare)
E (Rare)
G (Rare)

3.0
2.5
3.0
3.0
1.0
2.0
2.0
2.0

3.0
3.0
4.0
3.0
2.0
3.0
2.5
2.0

0.082
0.001
<0.001
0.328
0.131
0.010
0.214
0.100

(2.03.0)
(2.03.0)
(3.03.5)
(3.03.0)
(1.02.0)
(2.02.0)
(2.03.0)
(2.02.0)

(3.04.0)
(3.04.0)
(4.04.0)
(3.04.0)
(2.02.0)
(2.04.0)
(2.03.0)
(2.03.0)

ATS, Australasian triage scale; MTS, Manchester triage system;

IQR, interquartile range; MW, MannWhitney.

2 scenario groups and the variance in scoring between the

triage systems.

Methods

Results

This was a multi-centre study involving 3 emergency departments in Western Sydney. Two hospitals routinely used the
ATS and also had specialist toxicology units based at their
hospitals. The MTS was routinely used by a third hospital that
did not have a toxicology unit, but had access to specialist
toxicology services by telephone from the PIC. The study
was approved by the Human Research Ethics Committee at
each of the respective hospitals.
The study consisted of tabletop scenarios with ED triage
nurses applying the ATS or MTS scoring system in a simulated triage environment. A power calculation was done to
detect a difference in median triage scores, that a sample
of 10 nurses in each group would have 79% power to reject
the null hypothesis using a MannWhitney test with a signicance of 0.05. Triage nurses with a minimum 1 years
triage experience were invited to participate. Participation
was entirely voluntary and informed consent was obtained
from the nurses. There were 10 nurses form each of the
three sites that scored 8 scenarios. Participants had up to
5 min to enter a triage category for each scenario.10 The
participants had access to similar resources as they would
in a real triage environment including hospital intranet and
Internet facilities. Although participants were not allowed
to call for help, they were asked to write down sources of
help that they would seek for each scenario. Study investigators supervised triage scoring by participants, and noted any
requested resources but did not provide additional information or advice to participants.
In order to capture a variety of toxicological presentations, both high and lower acuity as well as common
and rare presentations, the study scenarios were broadly
grouped as commonly encountered (n = 4) and rarely
encountered (n = 4) by the investigators. The scenarios
are outlined in Table 2. Scenarios were designed by study
authors with a focus on triaging under toxicological principles, rather than for psychosocial factors, and attempted
to broadly cover the spectrum of toxicological presentations to Australian EDs. The primary comparator was the
median triage score between ATS and MTS for each scenario.
We also compared the median triage score assigned for the

An initial test for heterogeneity between hospitals, using the

KruskalWallis non-parametric analysis of variance, showed
that the hospitals were not all similar. However, the two
hospitals that utilised the ATS showed good agreement
in the median triage categories given across all scenarios
(MannWhitney test p-value 0.1230.739). Table 3 shows
the median triage scores (with interquartile range in brackets) for each scenario and their respective MannWhitney
test p-value. Statistical signicance was only shown between
the two triage systems for scenarios C, D and F. Overall,
MTS triage nurses scored all scenarios with a higher triage
category (lower acuity) compared with ATS nurses, statistically signicant for both scenario groups see Table 4. The
variance of the triage category assigned by MTS nurses was
signicantly wider for rare presentations than ATS nurses
(p < 0.001); this was trending similarly for common presentations also, but not statistically signicant (p = 0.065) see
Table 4. MTS nurses called for senior help on 52 out of the
80 triage occasions; 49 of these calls were to the PIC and
3 calls were to an ED senior doctor. ATS nurses at two hospitals called for help on 12 out of 160 scenarios these
were to either an ED senior doctor or a member of the local
toxicology team; none of these calls were to the PIC.

Discussion
There is little published research on triage of the toxicology patient. This is the rst study to directly compare the
ATS and MTS in triaging the poisoned patient. In our study,
the two hospitals that used the ATS had narrow agreement
in median triage scores for all scenarios. This allowed us to
compare the median triage score allocated by the two triaging methods, ATS and MTS. The MTS had a higher frequency
of lower acuity triage categories across all 8 scenarios compared to the ATS. In two of the common scenarios (D and F)
and one rare scenario (C) the allocated median triage category was of signicantly lower acuity by the MTS nurses.
This suggests that, overall, MTS under-triaged, or that ATS
over-triaged, these types of patients. Overall, triage scores

Please cite this article in press as: Jayaweera D, et al. A comparison of emergency triage scales in triaging poisoned
patients. Australas Emerg Nurs J (2014), http://dx.doi.org/10.1016/j.aenj.2014.05.004

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Table 4

Median triage scores and variance between triage systems.

Scenario group

Common
Rare

Median triage scores (IQR)

Variance

ATS

MTS

MW
P value

ATS

MTS

Levenes
P value

3.0 (2.03.0)
2.0 (2.02.0)

3.5 (3.04.0)
2.0 (2.03.0)

<0.001
<0.001

0.32
0.30

0.36
0.67

0.065
<0.001

ATS, Australasian triage scale; MTS, Manchester triage system; IQR, interquartile range; MW, MannWhitney.

using ATS had a smaller variance when compared to the MTS

across both common and rare scenario groups.
In all 4 rarely encountered scenarios, ATS nurses assigned
a higher median triage category. These scenarios were not
only rare but also potentially lethal. It is likely that accurate
risk assessment required additional toxicological knowledge
and the awareness of the time critical nature of intervention. The vital signs in 3 rare scenarios were within
the normal range. In serious poisoning, some patients may
present early, asymptomatic and with normal vital signs.
Although toxicity manifests late, instituting early treatment
and preparing resources needed to manage these patients
provides the best chance for a favourable outcome. Although
MTS uses a more algorithmic approach and may perform better at symptomatic poisoning with abnormal vital signs, it
may allow for triage decisions based on the ingested substance. In this study, if the MTS triage nurses contacting
the PIC were aware of the high lethality of a toxin, they
could have used the MTS discriminator for triage category 2
overdose high lethality dened as high potential of the
substance taken to cause harm, to assign a lower triage
category, even if the patient was asymptomatic and had
normal vital signs. This supports the utility of PIC in providing toxicological risk assessment and aiding triage nurse
decision-making. ATS nurses, when taking serious potential toxicity into consideration were able to provide lower
triage scores outside an algorithmic approach, more suited
for rare highly toxic scenarios. Equally, ATS nurses may be
over-triaging less serious poisoning. Vital signs at triage are
an important objective measure of clinical urgency and are
associated with prediction of mortality from poisoning.11,12
Hence, patients with overt signs of poisoning are likely to
be agged as higher acuity triage categories. However, ATS
guidelines and MTS discriminators suggest that physiological
markers should not be the only consideration in assigning a
triage category.
Although this was an adequately powered simulation
study, it cannot replicate subtle cues and signs of triaging a real patient. The inclusion of higher delity scenarios,
with photographs and videos, could be considered in future
studies to improve performance.13 As nurses volunteered to
participate in this study, this may have lead to a sampling
bias. The nurses in the two hospitals that used the ATS,
as noted on their responses did not contact the PIC but
elected to consult the local toxicology service on a few
occasions. The hospital that used the MTS did not have a
local toxicology service, and all triage nurses at this site
elected to contact the PIC in most scenarios (49/80). This
would indicate high use of PICs in those hospitals without
a local toxicology service and may improve risk assessment

of poisoned patients at triage. The presence of toxicology

units at the ATS hospitals may confound our results with
higher acuity from increased awareness in nurses working
in these EDs. Increasing awareness of toxicological presentations, red ags for severe toxicity and envenomation through
education is a priority in all EDs. PICs can contribute to
the education programme for ED nurses as well as improve
algorithms for detecting these red ags. Some EDs choose
to have a list of highly toxic pharmaceuticals and chemicals available for triage nurses to prompt early referral to
medical staff.14,15 These lists are most useful in rare but
highly toxic exposures. Though this study was not designed
to establish whether one triage system was better able to
predict the clinical needs of toxicology patients, such a
study would be worthy of future research.

Conclusions
There was good agreement and narrow variance of triage
categories assigned for poisoned patients in two hospitals
that used the Australian Triage Scale (ATS). When compared
to the ATS, the Manchester Triage Scale (MTS) gave a lower
acuity triage score for all common and rarely encountered
poisoning scenario groups, which included highly toxic ingestions that appear well at triage, but may progress to severe
poisoning. Our study suggests that further poisons education
and awareness is warranted in hospitals without dedicated
toxicology expertise. Emergency departments should carry
additional information on highly toxic exposures and local
envenomation guidelines for triage nurses.

Contributors
DJ, SM and NG conceived and designed the study. All authors
performed data collection under supervision by NG. DJ,
SM and NG analysed the data. DJ and NG drafted the
manuscript. All authors edited and nalised the manuscript.

Provenance and conicts of interest

We conrm that the study originated from our own ideas and
conception. This paper was not commissioned. We conrm
that there are no conicts of interest by any of the authors
with regards to the conduct or content of this study.

Please cite this article in press as: Jayaweera D, et al. A comparison of emergency triage scales in triaging poisoned
patients. Australas Emerg Nurs J (2014), http://dx.doi.org/10.1016/j.aenj.2014.05.004

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Funding
We conrm that there was no internal or external funding
for this study.

Acknowledgements
The authors would like to thank the triage nurses from 3 EDs
who participated in this study, Dr. Moinul Islam (Emergency
Medicine Registrar) and Dr. Karen Byth (Clinical Epidemiologist).

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Please cite this article in press as: Jayaweera D, et al. A comparison of emergency triage scales in triaging poisoned
patients. Australas Emerg Nurs J (2014), http://dx.doi.org/10.1016/j.aenj.2014.05.004