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ARTICLE IN PRESS

International Emergency Nursing ■■ (2014) ■■–■■

Contents lists available at ScienceDirect

International Emergency Nursing


j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n

REVIEW

Efficacy of the Manchester Triage System: a systematic review


Thereza Raquel Machado Azeredo (Student in Nursing) a,
Helisamara Mota Guedes RN, MS, PhDst (Nurse, Doctorate’s Student in Nursing, Assistant
Professor) a,b,*, Ricardo Alexandre Rebelo de Almeida RN, MS (Nurse) c,
Tânia Couto Machado Chianca RN, MS, PhD (Nurse, PhD in Nursing, Titular Professor) b,
José Carlos Amado Martins RN, MS, PhD (Adjunct Professor, Coordinator, Post-doctoral
student (with scholarship of the FCT – Portugal)) d,e,f
a
Federal University of the Mucuri and Jequitinhonha Valley, Diamantina, Minas Gerais, Brazil
b
Federal University of Minas Gerais, Minas Gerais, Brazil
c Centro Hospitalar University of Coimbra, Coimbra, Portugal
d Scientific-Pedagogical Unit of Medical-Surgical Nursing, Nursing School of Coimbra, Coimbra, Portugal
e
Health Sciences Research Unit – Nursing, Coimbra, Portugal
f University of São Paulo at Ribeirão Preto College of Nursing/WHO Collaborating Centre for Nursing Research Development, Brazil

A R T I C L E I N F O A B S T R A C T

Article history: Introduction: The growing number of patients in emergency departments can lead to overcrowding, often
Received 25 January 2014 adding to organisational problems. Triage aims to predict the severity of disease, with the aim of organising
Received in revised form 19 May 2014 patient flow. The aim of this study was to analyse the efficacy of the Manchester Triage System (MTS)
Accepted 14 June 2014
for risk classification of patients.
Methods: A systematic review of the literature in Ebscohost, Pubmed and Scielo (2002–2013) was un-
Keywords:
dertaken. Articles were selected independently by two researchers using selection criteria. Twenty-two
Nursing
articles were selected for inclusion in this review.
Emergency medical services
Triage Results: The results support the applicability of the MTS, which has proven validity for use in children,
Risk assessment adults, patients with coronary syndrome and patients with acute pulmonary embolism. The MTS was
Manchester triage found to be inclusive, and to predict emergency department admission and death in the short term.
Manchester protocol Conclusion: The majority of studies found that the MTS was useful in triage of patients in emergency
departments, but sub-triage and super-triage (i.e. under and over classification of severity, respectively)
still occur.
© 2014 Elsevier Ltd. All rights reserved.

1. Introduction sification that allows patients to be allocated to the most suitable


service for faster treatment (Ganley and Gloster, 2011).
Globally, the number of patients presenting to emergency de- Triage scales predict disease severity, mortality rate and re-
partments with a wide variety of problems, ranging from high clin- quired resources, and should be easily understood, applicable and
ical severity to minor injuries, is increasing (Bittencourt and Hortale, have high interobserver agreement (Christ et al., 2010).
2009). This may lead to overcrowding in emergency deparments Worldwide, various triage scales are used in emergency depart-
which often have other organisational problems, such as assisting ments due to functional differences in services. There is a need for
patients based on order of arrival as opposed to the severity of their a uniform triage scale that is suitable for all services (Christ et al.,
medical conditional (Souza et al., 2011). 2010). There is no infallible measurement instrument, as measure-
Triage has emerged as a method to optimise attendance, and to ment errors can arise due to personal factors, environmental situ-
minimise the damage caused by overcrowding, by identifying pa- ations, changes in the method of data collection and cultural
tients who need immediate care. Patients are classified according adaptation processes (Souza et al., 2011).
to clinical severity, level of suffering and risk to their own health. The Manchester Triage System (MTS) is a classification system
In this way, triage is defined as a dynamic process of patient clas- of priority and risk prediction for patients seeking emergency care,
widely used in the European Union (Cooke and Jinks, 1999;
Storm-Versloot et al., 2011). It aims to standardise the service, pro-
* Corresponding author. Tel.: +55 3835326073. viding support and emplacement to decision-making when a patient
E-mail address: helisamaraguedes@gmail.com (H.M. Guedes). enters the health service, such that patients are seen in order of

http://dx.doi.org/10.1016/j.ienj.2014.06.001
1755-599X/© 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Thereza Raquel Machado Azeredo, Helisamara Mota Guedes, Ricardo Alexandre Rebelo de Almeida, Tânia Couto Machado Chianca,
José Carlos Amado Martins, Efficacy of the Manchester Triage System: a systematic review, International Emergency Nursing (2014), doi: 10.1016/j.ienj.2014.06.001
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Table 1
Inclusion and exclusion criteria of articles.

Inclusion Exclusion

1-studies published in Portuguese, Spanish or English; 1-congresses and conferences abstracts;


2-studies published in the last ten years; 2-unpublished studies and theses;
3-studies that consider at least a variable related to implementation, evaluation or 3-studies that do not address the STM as the main focus of the work and do not
characterization of the Manchester Triage System; respond to the research question.
4-studies who had as a research subject patients or records of risk classification or
STM own.

severity of their clinical condition rather than order of arrival at the CINAHL Plus with Full Text, Database of Abstracts of Reviews of
emergency department (Storm-Versloot et al., 2011). Effects, Cochrane Central Register of Controlled Trials, Cochrane Da-
The MTS has a list of 52 pre-defined conditions or presentation tabase of Systematic Reviews, Cochrane Methodology Register,
flowcharts that are combined with the main complaint reported by Library, Information Science Technology Abstracts, Nursing and Allied
the patient and recorded on a form by a nurse. Classification is Health Collection: Comprehensive, Health Technology Assess-
divided into five colours: red (immediate), orange (very urgent), ments, MedicLatina, Academic Search Complete, NHS Economic Eval-
yellow (urgent), green (standard) and blue (non-urgent) (Speake uation Database, Regional Business News, ERIC and Business Source
et al., 2003). Complete. This search was performed by two researchers who iden-
Although theoretical and systematised perspectives have ad- tified the same number of articles.
dressed the use of the MTS in emergency departments, it is ex- Scientific articles published between 1 January 2002 and the date
tremely relevant to identify and analyse the scientific publications of the survey (29 January 2013) were eligible for inclusion in this
on the topic, as the MTS has been introduced into practice rela- review. The researchers chose to review articles published only
tively recently. This will improve understanding of this triage system, within the last 10 years as part of the selection criteria because it
and demonstrate the scientific indications for its implementation limits the studies to a specific time period. In order to identify rel-
in different social contexts. evant studies for inclusion in the review, a set of synonyms and
As such, the aim of this study was to assess the efficacy of the related terms were used to restrict the search and meet the study
MTS for the risk classification of patients, and to describe and analyse objectives. The combinations of keywords used by both research-
its use in relevant articles identified. ers in each database and the search results are shown in Table 2.
Initially, articles were selected independently by two research-
2. Methods ers after reading the article titles. Disagreements between research-
ers were resolved by consensus. In total, 56 articles were selected
Systematic reviews involve synthesis of the research related to using Inclusion Criteria 1 and 2, and Exclusion Criteria 1 and 2.
a specific issue, and frequently involve the efficacy of an interven- The abstracts of these 56 articles were read, with 28 articles se-
tion (Sampaio and Mancini, 2007). This review aimed to reduce the lected by one investigator and 25 articles selected by the other in-
risk of bias by using a rigorous search methodology for study se- vestigator. Eleven of these studies were not selected by both
lection, and evaluating the relevance and validity of the research, reviewers, and following discussion, eight were withdrawn and three
collection, synthesis and interpretation of data from the surveys were retained. As such, 27 studies were selected using Inclusion Cri-
(Galvão et al., 2004). teria 3 and 4, and Exclusion Criterion 3.
This systematic review assessed the level of evidence of each Information that was not clearly described in the abstract was
study in accordance with Sampaio and Mancini (2007): I, system- obtained by reading the full article. Articles were retained or ex-
atic review of randomised controlled trials with or without cluded based on consensus between the two reviewers using In-
meta-analysis; II, randomized controlled trial; III, cohort study; IV, clusion Criterion 4. Ultimately, 22 articles related to the research
case–control study; V, quasi-experimental study; VI, descriptive question were included in this review.
study; VII, single case study or case series; and VIII, expert opinion For data analysis, articles were read repeatedly, and the most rel-
or case report. Starting from the analysis of theoretical assump- evant elements of each study were extracted, namely: author(s),
tions and defining efficacy as the ability of care, at its best, to improve country of publication, study design, sample characterisation, level
health (Donabedian, 1990), the following research question was of evidence and conclusion (Table 2).
asked: “What is the efficacy of the MTS for risk identification in pa-
tients seeking a hospital urgency/emergency service?” Table 1 shows 3. Results
the inclusion and exclusion criteria for articles in this review.
On 29 January 2013, Pubmed, Scielo and Ebscohost were searched Table 3 summarises the study details (author, year of publica-
for relevant articles. Ebscohost includes the following databases: tion and country) and levels of evidence of the articles in this review.

Table 2
Distribution of keywords for database.

Palavra-Chave Ebsco Pubmed Scielo

“Manchester Protocol” OR “Manchester system” OR “Manchester Triage” 98 70 3


“Manchester Protocol” OR “Manchester system” OR “Manchester Triage” AND “Triage” 98 55 02
“Manchester protocol” OR “Manchester System” OR “Manchester Triage” AND “risk assessment” 26 04 00
“Manchester protocol” OR “Manchester System” OR “Manchester Triage” AND “emergency service” 62 35 01
“Manchester Protocol” OR “Manchester system” OR “Manchester Triage” AND “triage” AND “risk assessment” 26 02 00
“Manchester Protocol” OR “Manchester system” OR “Manchester Triage” AND “triage” AND “emergency service” 62 34 01
“Manchester protocol” OR “Manchester System” OR “Manchester Triage” AND “risk assessment” AND “emergency service” 24 02 00
“Manchester Protocol” OR “Manchester system” OR “Manchester Triage” AND “triage” AND “risk assessment” AND “emergency service” 24 01 00

Please cite this article in press as: Thereza Raquel Machado Azeredo, Helisamara Mota Guedes, Ricardo Alexandre Rebelo de Almeida, Tânia Couto Machado Chianca,
José Carlos Amado Martins, Efficacy of the Manchester Triage System: a systematic review, International Emergency Nursing (2014), doi: 10.1016/j.ienj.2014.06.001
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Table 3
Articles’ characteristics found.

Author, Year and country Level of Evaluates Specific What is Affirms


Objective evidence the validity, condition the specific validity of
specificity, condition the MTS
sensitivity

Matias et al. (2008) – Portugal VI N Y ACS Y


To assess whether the MTS was used effectively in patients admitted to the hospital with a
diagnosis of acute coronary syndrome (ACS).
Pinto Júnior et al. (2010) – Portugal VI Y Y ACS Y
To assess the sensitivity of the MTS in assigning high priority to patients with acute coronary
syndrome, and the sensitivity and specificity of the combinations of flowcharts and
discriminators routinely used for triage in the Emergency Department of Hospital de S. João,
Porto.
Pinto Júnior et al. (2012) – Brazil III Y N Y
To assess the predictive validity of the Manchester Triage System implemented in a municipal
hospital in Belo Horizonte, MG, Brazil.
Souza et al. (2011) – Brazil VI Y N Y
To assess the level of agreement between an institutional protocol and the Manchester protocol for
the risk assessment of patients attended in an emergency room of a public hospital in Belo
Horizonte – MG – Brazil.
Soler et al. (2010) – Spain VI N N Y
Discuss the system of triage integrated in the computerised clinical history and used in the hospital
network of Navarre.
Martins et al. (2009) – Portugal III Y N Y
To determine whether the subgroups created by the application of MTS have different propensities
for indirect triage outcomes such as death in the A&E department or being admitted to hospital.
Seiger et al. (2011) – The Netherlands III N Y Pediatric Y
To assess the clinical severity of undertriaged patients in the MTS and to define the determinants of
undertriage.
Roukema et al. (2006) – The Netherlands III Y Y Pediatric Y
To assess the validity of the Manchester Triage System in paediatric emergency care, using
information on vital signs, resource utilisation and hospitalization.
Dann et al. (2005) – England VI Y Y Discriminator Y
To determine the efficacy of the MTS discriminator ‘pain’ at identifying ‘standard’ and ‘non-urgent’ ‘pain’
attenders in emergency departments, and to estabiish a method of assessing pain duration that
allows patients with chronic, mild pain to be more appropriately triaged.
Storm-Versloot et al. (2011) – The Netherlands III Y N Y
To compare the validity of an existing informally structured triage system with the Emergency
Severity Index (ESI) and the Manchester Triage System (MTS).
van der Wulp et al. (2009) – The Netherlands III Y N Y
To compare the degree to which the Emergency Severity Index (ESI) and the Manchester Triage
System (MTS) predict admission and mortality.
Santos et al. (2014) – Portugal III Y N Y
To determine whether the MTS second version is a useful instrument for determining the risk of
hospital admission, intrahospital death and resource utilisation in ED and to compare it with the
MTS first version.
van Veen et al. (2008) – The Netherlands III Y Y Pediatric Y
To validate use of the Manchester triage system in paediatric emergency care.
Christ et al. (2010) – Germany VI Y N Y
To identify modern triage instruments and assess their validity and reliability.
Speake et al. (2003) – England III Y Y Chest pain Y
To assess the ability of nurses using the MTS to identify those patients with chest pain requiring
immediate electrocardiogram (ECG) and physician assessment within ten minutes.
van Ierland et al. (2013) – The Netherlands III Y Y Pediatric Y
To assess whether the flowcharts and discriminators of the Manchester Triage System can be used
as indicators of alarming signs of serious febrile illness to predict the risk of hospitalization for
febrile children who present at the emergency department.
Providência et al. (2011) – Portugal III Y Y AMI Y
To evaluate the impact of MTS on short-term mortality in acute myocardial infarction and detect
potential improvements, and to analyse high-risk groups: diabetic patients, women and older
patients.
Paiva et al. (2012) – Portugal III Y Y PE Y
To assess the appropriateness of MT in this set of patients presenting acutely to the emergency
department, and to determine whether it assists in a rapid diagnosis, acts as a protective triage
tool and affects short-term mortality.
van der Wulp et al. (2008) – The Netherlands III Y N Y
To assess the reliability and validity of the Manchester Triage System in a general emergency
department patient population.
Trigo et al. (2008) – Portugal III Y Y ACS N
To evaluate the effectiveness of the MTS in classifying STEMI patients and its effect on IHD.
Nijman et al. (2011) – The Netherlands III Y Y Pediatric N
To evaluate the discriminative ability of the MTS to identify serious bacterial infections in children
with fever in the emergency department and to study the association between predictors of SBI
and discriminators of MTS urgency of care.
van der Straten et al. (2012) – The Netherlands III Y Y Triaging low Y
To assess the safety and efficiency of triaging low urgent self-referred patients at the emergency urgent self-
department to a general practitioner based on MTS. referred patients

Y-Yes; N-No; ACS-Acute Coronary Syndrome; PE-Acute Pulmonary Embolism; AMI-Acute Myocardial Infarction.

Please cite this article in press as: Thereza Raquel Machado Azeredo, Helisamara Mota Guedes, Ricardo Alexandre Rebelo de Almeida, Tânia Couto Machado Chianca,
José Carlos Amado Martins, Efficacy of the Manchester Triage System: a systematic review, International Emergency Nursing (2014), doi: 10.1016/j.ienj.2014.06.001
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Evaluation of validity/specificity/sensitivity of the MTS, evalua- Storm-Versloot et al. (2011) reported similar validity in both the ESI
tion of use of the MTS for a specific condition, and affirmation of and the MTS, but the ESI had a higher rate of sub-triage (i.e. clas-
efficacy of the MTS are also shown (Table 3). sification of more-severe cases as less urgent) than the MTS.
Of the 22 studies in this review, nine (40.9%) were from the Neth- van der Wulp et al. (2008) reported that sub-triage into orange
erlands, seven (31.9%) were from Portugal, two (9.1%) were from and yellow categories was a serious problem with the MTS, espe-
Brazil, two (9.1%) were from the UK, one (4.5%) was from Germany cially in elderly patients, because symptoms often presented in an
and one (4.5%) was from Spain. atypical way; sensitivity was greater in children. The MTS was also
Only three (13.6%) articles did not use validity, specificity and/ found to have moderate sensitivity for the identification of pa-
or sensitivity to evaluate the efficacy of the MTS. Twenty (90.9%) tients requiring immediate and very urgent care.
studies reported that the MTS had good efficacy, and two (9.1%) Four studies in Portugal evaluated the efficacy of the MTS in
studies reported that the MTS was not efficacious. patients with Acute Coronary Syndrome (Matias et al., 2008; Paiva
Thirteen articles (59%) evaluated the efficacy of the MTS in a spe- et al., 2012; Pinto Júnior et al., 2010; Providência et al., 2011). Pinto
cific group of patients, and studies regarding use of the MTS in chil- Júnior et al. (2010) reported that the MTS had high sensitivity for
dren were the most common (Nijman et al., 2011; Seiger et al., 2011). assigning “immediate” and “very urgent” priority levels in these
Use of the MTS in patients with clinical conditions such as chest patients, and use of a flowchart/discriminator suggestive of
pain, acute coronary syndrome and acute pulmonary embolism was Acute Coronary Syndrome had very high specificity and moderate
also investigated (Dann et al., 2005; van der Straten et al., 2012). sensitivity. Therefore, possible evolution towards a more sensitive
Regarding the evidence levels of studies, 72.7% of studies rep- instrument without loss of specificity or vice versa is dependent
resented Level III evidence and 27.3% represented Level VI evi- on the analysis of cases of acute coronary syndrome who
dence (Table 2). present with atypical symptoms. This was confirmed by Matias
et al. (2008), who found that most in-patients with Acute Coro-
4. Discussion nary Syndrome were categorised as orange and yellow, indicating
the need for “very urgent” and “urgent” care, respectively. The
The MTS is used in many countries around the world, and its number of patients who should have been classified as “very urgent”
efficacy has been shown in scientific studies focusing on a specific or “urgent”, but were not classified as such, was high (28%). It is
disease, age group or the general population. probable that the situation and condition of the patient worsened
The studies in this review were conducted in different contexts due to the improper classification. This may not have been due to
and using different methods to assess the efficacy of the MTS. Most incorrect screening, but the fact that the complaints of the patient
studies used a methodological tool to measure the validity, speci- and clinical presentation at the time of screening led to screening
ficity and/or sensitivity of the MTS. results indicating a lower level of priority, in addition to clinical
Use of structured triage, such as the MTS, by nurses in the emer- deterioration after admission.
gency department helps to identify patients who are identified as Providência et al. (2011) reported that the MTS was highly ef-
having life-threatening presentations receive the fastest service. It fective for the triage of most patients with acute myocardial in-
has been suggested that the ideal triage system should allow re- farction, particularly those presenting with typical symptoms,
source planning, in addition to the identification of patients who resulting in rapid diagnosis and initiation of therapy. Younger pa-
need urgent medical care (Christ et al., 2010). Soler et al. (2010) tients seemed to be better protected, as atypical manifestations were
claimed that triage systems should be structured and based on scales more common in elderly patients. Providência et al. (2011) sug-
with five levels, such as the MTS. The MTS has a standard nomen- gested that the disease may not have developed completely at the
clature, uses common definitions, has a robust methodology for time of emergency department presentation, and the patient’s con-
screening, implements a model of integral formation, and allows dition may deteriorate after screening, as found by Matias et al.
the screening method developed to be audited. (2008).
Studies that evaluated the MTS without focusing on patients with Trigo et al. (2008) reported that the MTS led to the
a specific condition (40.9%) found that, in addition to prioritising misclassification of patients with Acute Coronary Syndrome with
the care of patients, the MTS was able to predict the evolution of ST segment elevation; these patients were classified as less urgent,
patients during their stay in the institution, as different rating cat- resulting in a longer delay before the onset of treatment. Matias et al.
egories had different developments in severity (Pinto Júnior et al., (2008) and Providência et al. (2011), found that this failure in the
2012). In addition, the MTS was considered to be more inclusive classification of patients with acute myocardial infarction with ST
compared with an institutional protocol, which increased the level segment elevation by the MTS was not due to the clinical and de-
of priority when there were disagreements between classifica- mographic characteristics of patients in the study. This proves a
tions (Souza et al., 2011). failure in the classification of MTS.
Martins et al. (2009) reported that the MTS was an extremely The MTS has been shown to be a sensitive instrument for the
important tool to distinguish between patients at low and high risk classification of patients with chest pain who present at an emer-
of death in the short term, and to identify patients who would require gency department. The stratification of chest pain allowed ade-
hospitalisation for at least 24 h before discharge. quate allocation of resources for these patients, but further studies
Santos et al. (2014) reported that the risk for hospital admis- are needed to assess if the training of professionals responsible for
sion was five times greater in high-priority patients (classified as screening can be improved (Matias et al., 2008).
red or orange using the MTS) compared with low-priority pa- Paiva et al. (2012) assessed the adequacy of the MTS for use in
tients (classified as yellow, green or blue), and death during patients with acute pulmonary embolism. The MTS was found to
hospitalisation was 5.5 times higher in high-priority patients. In ad- have high sensitivity for assigning “urgent” priority in patients who
dition, the MTS was considered to be a good discriminator for the presented at an emergency department.
use of diagnostic tools in the emergency department. Five studies investigated the use of the MTS for paediatric
Comparison of the Emergency Severity Index (ESI) with the MTS patients. Seiger et al. (2011) found that the MTS was a moderately
revealed that both tools were predictive of admission to the emer- sensitive and specific instrument in paediatric patients, but super-
gency department. However, the ESI was a better predictor of ad- triage (i.e. classification of less-severe cases as more urgent) was a
mission than the MTS. Mortality was associated with urgency problem, and was much more common than sub-triage (Roukema
category for both triage systems (van der Wulp et al., 2009). et al., 2006; Seiger et al., 2011).

Please cite this article in press as: Thereza Raquel Machado Azeredo, Helisamara Mota Guedes, Ricardo Alexandre Rebelo de Almeida, Tânia Couto Machado Chianca,
José Carlos Amado Martins, Efficacy of the Manchester Triage System: a systematic review, International Emergency Nursing (2014), doi: 10.1016/j.ienj.2014.06.001
ARTICLE IN PRESS
T.R.M. Azeredo et al./International Emergency Nursing ■■ (2014) ■■–■■ 5

In addition, the MTS demonstrated moderate validity com- Acknowledgements


pared with a referenced standard independent paediatric emer-
gency care, and had sensitivity for “very urgent” classification of 63%, The authors wish to thank FAPEMIG (Ref. No. APQ-01153-12) and
meaning that 37% of patients who should have been seen within CAPES, Science Without Borders (Ref. No. 0458-13-9) for financial
10 min were not categorised as “urgent” (Roukema et al., 2006). The support.
study looked at multiple MTS categories, ranging from emergent
to non-urgent. Thus, specific modifications in the MTS should be
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This study had a few limitations. Unpublished manuscripts, books
and resource utilisation in emergency department. Emergency Medicine Journal.
and abstracts were not included, so items with negative results or 31, 148–152.
without positive results may not have been included (Sousa and Seiger, N., van Veen, M., Steyerberg, E.W., Ruige, M., van Meurs, A.H., Moll, H.A., 2011.
Ribeiro, 2008). In addition, articles published outside the desig- Under triage in the Manchester Triage System: an assessment of severity and
options improvement. Archives of Disease in Childhood. 96, 653–657.
nated study period were excluded. One of the other limitations of Soler, W., Muñoz, M.G., Bragulat, E., Álvaez, A., 2010. El triaje: herramienta
the study was the selection of the study time period that ex- fundamental en urgencias y emergencias [Triage: a key tool in emergency care].
cluded articles published prior to 2002, even though articles were Anales del Sistema Sanitario de Navarra. 33 (Suppl. 1), 55–68.
Sousa, M.R., Ribeiro, A.L.P., 2008. Systematic review and meta-analysis of diagnostic
published in the 1990s. and prognostic studies: a tutorial. Arquivos Brasileiros de Cardiologia. 92,
229–238.
6. Conclusion Souza, C.C., Toledo, A.D., Tadeu, L.F.R., Chianca, T.C.M., 2011. Risk classification
in an emergency room: agreement level between a Brazilian institutional
and the Manchester Protocol. Revista Latino-Americana de Enfermagem. 19,
This review examined the efficacy of the MTS for risk classifi- 26–33.
cation of patients. Only two of 22 studies reported unfavourable Speake, D., Teece, S., Mackway-Jones, K., 2003. Detecting high-risk patients with chest
pain. Emergency Nurse. 11, 19–21.
results for the MTS. The remaining articles generally considered the
Storm-Versloot, M.N., Ubbink, D.T., Kappelhof, J., Luitse, J.S.K., 2011. Comparison of
MTS to be effective for use in children, adults, and people with acute informally structured triage system, the Emergency Severity Index, and the
coronary syndrome and acute pulmonary embolism. The MTS was Manchester Triage System to distinguish patient priority in the emergency
department. Academic Emergency Medicine. 18, 822–829.
considered to be predictive of admission to the emergency depart-
Trigo, J., Gago, P., Mimoso, J., Santos, W., Marques, N., Gomes, V., 2008. In-hospital
ment and short-term death. delay ST-segment-elevation myocardial infarction after Manchester triage. Revista
The articles in this review were performed in different geo- Portuguesa de Cardiologia. 27, 1251–1259.
graphical areas of the world, showing high suitability and validity van der Straten, L.M., van Stel, H.F., Spee, F.J., Vreeburg, M.E., Schrijvers, A.J., Sturms,
L.M., 2012. Safety and efficiency of triaging low urgent self-referred patients to
of the MTS. It is suggested that the two studies with unfavourable general practitioner at an acute care post: an observational study. Emergency
results should be replicated in other locations. Medicine Journal. 29, 877–881.

Please cite this article in press as: Thereza Raquel Machado Azeredo, Helisamara Mota Guedes, Ricardo Alexandre Rebelo de Almeida, Tânia Couto Machado Chianca,
José Carlos Amado Martins, Efficacy of the Manchester Triage System: a systematic review, International Emergency Nursing (2014), doi: 10.1016/j.ienj.2014.06.001
ARTICLE IN PRESS
6 T.R.M. Azeredo et al./International Emergency Nursing ■■ (2014) ■■–■■

van der Wulp, I., van Baar, M.E., Schrijvers, A.J., 2008. Reliability and validity of the van Ierland, Y., Seiger, N., van Veen, M., Moll, H.A., Oostenbrink, R., 2013. Alarming
Manchester Triage System in a general emergency department patient population signs in the Manchester Triage System: a tool to identify febrile children at risk
in the Netherlands: results of a simulation study. Emergency Medicine Journal. of hospitalization. The Journal of Pediatrics. 162, 862–866.
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van der Wulp, I., Schrijvers, A.J., van Stel, H.F., 2009. Predicting admission and mortality J., et al., 2008. Manchester triage system in paediatric emergency care: prospective
with the Emergency Severity Index and the Manchester Triage System: a observational study. BMJ. 337, a1501.
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Please cite this article in press as: Thereza Raquel Machado Azeredo, Helisamara Mota Guedes, Ricardo Alexandre Rebelo de Almeida, Tânia Couto Machado Chianca,
José Carlos Amado Martins, Efficacy of the Manchester Triage System: a systematic review, International Emergency Nursing (2014), doi: 10.1016/j.ienj.2014.06.001