Transcript THE MANCHESTER TRIAGE SYSTEM

THE MANCHESTER TRIAGE
SYSTEM
Telephone triage workshop
Copyright belongs to The
Manchester Triage Group
All rights reserved. No part of this publication may be
reproduced, stored in a retrieval system, or
transmitted, in any form or by any other means,
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otherwise, except as permitted by the UK Copyright,
Designs and Patents Act 1988, without prior
permission of the publisher Blackwell Publishing Ltd.
History

1994

a local problem
History

1995

a local group
History

1996

a local solution
Triage Group: Nomenclature
Number
Colour
Name
First
Red
Immediate
Second
Orange
Very urgent
Third
Yellow
Urgent
Fourth
Green
Standard
Fifth
Blue
Non-urgent
Triage Group: Target Times





First
Second
Third
Fourth
Fifth
10 min
0 min
60 min
120 min
240 min
Triage Group: Methodology
Y
Discriminators
RED
PRESENTATIONAL
Flow Chart
N
Y
ORANGE
Discriminators
N
Y
YELLOW
Y
N
Discriminators
Discriminators
N
BLUE
GREEN
History

1997

a publication
History

1998

a national
solution
History

1999

an international
solution
Key Features

Designed by practitioners

Based on presentation (not diagnosis)

50 presentational charts

Reductive

Pain at the centre of assessment

Easy documentation
Key Features


FIT FOR PURPOSE
CLINICAL RISK MANAGEMENT
TOOL
History

2005

2nd edition
Chart format

For example…
Allergy
Allergy

Discriminators


Defined in discriminator dictionary
Vital part of system - the discriminator is used in a consistant way
Standard ABCD
Airway Compromise
Inadequate breathing
Stridor
Shock
Unresponsive child
RED
Allergy
Facial oedema
Oedema of the tongue
Significant history of allergy
Unable to talk in sentences
Abnormal pulse
Severe pain or itch
Altered conscious level
Very low SaO2

ORANGE
Discriminators appear at the same point on
every relevant chart
Allergy
Low SaO 2
Widespread rash or blistering
Moderate pain or itch
RISK
LIMIT
YELLOW
Allergy
Local inflammation
Recent mild pain or itch
Recent problem

GREEN
Current or recent
(occurring within the past 7 days)
Another one…
Palpitations
Palpitations
Airway compromise
Inadequate breathing
Shock

Usual ABC
RED
Palpitations



Chest pain
History of overdose or poisoning
Abnormal pulse
Cardiac pain
Acutely short of breath
History of overdose or poisoning
Abnormal pulse
Altered conscious level
Hot child
Very hot adult
RISK
LIMIT
ORANGE
Palpitations
Current palpitation
History of unconsciousness
Significant cardiac history
Hot adult



Current palpitation
History of unconsciousness
Significant cardiac history
YELLOW
Palpitations
Recent problem
GREEN
Discriminator definitions…

Example - “Inappropriate History”:

“When the history (story) does not explain the
physical findings then the history is termed
inappropriate. This is important as it is a marker of
non-accidental injury in vulnerable children and
adults and may be the sentinel for abuse”
Discriminator definitions…

“Significant respiratory history”

“A history of previous life-threatening
episodes of a respiratory condition (eg
COPD) is significant as is brittle asthma”
Discriminator definitions…

“Acute neurological deficit”

“Any loss of neurological function that has
come on within the previous 24 hours. This
might include altered loss of sensation,
weakness of the limbs (either transiently or
permanently) and alterations of bladder
and bowel function”
Translating Manchester Triage
- into…..Telephone Triage and Advice
History

1998

Local use over telephone
Triage Group: TTA principles

Now
Now
Soon

Soon

Later

Advice
Later
Advice
Bites and Stings
ADVICE
Telephone charts
MTS TTA
12/03/2013
V 2.1
Airway compromise, inadequate
breathing or shock: If
unconscious place in the recovery
position, if conscious try to
reassure
Acutely short of breath, new
wheeze: If possible sit down and
lean slightly forward
Airway Compromise
Inadequate breathing
Facial Oedema
Oedema of the tongue
Unable to talk in sentences
Uncontrollable major haemorrhage
Envenomation
Uncontrollable major
haemorrhage: Continue to press
over the bleeding part. Do not
release the pressure
FtF NOW
ADVICE

Matching format
Uncontrollable minor
haemorrhage: Continue to press
over the bleeding part. Do not
release the pressure
Widespread rash or blistering:
Try not to scratch the affected
area. If you have an antihistamine
tablet take one now (not to drive if
sedating)
Uncontrollable minor haemorrhage
Widespread rash or blistering
Hot
Significant history of allergy
FtF SOON
Unresolved inflammation
Unresolved swelling
Unresolved pain or itch
FtF LATER
Call back if symptoms worsen,
concerned or new symptoms
develop
ADVICE

Same principles
If locally red and hot apply a cool
cloth or ice wrapped in a cloth for
5 min at a time.
Keep the affected part raised.
If you have an antihistamine tablet
take one now (not to drive if
sedating)
Advice
Only
ADVICE
If locally red and hot apply a cool cloth or ice
wrapped in a cloth for 5 min at a time.
Keep the affected part raised.
See your local chemist about taking
antihistamines.
Your symptoms should settle within 48 hrs
If things are getting worse or the area appears
infected (red lines tracking up from the bite)
then make an appointment to see you GP
Check you are covered for tetanus
Now
ED
Soon
Later
Advice
Home
The Triage Event
How to perform an effective triage
assessment
The purpose


MTS is designed to guide the triage
practitioner’s decision making and
assign a clinical priority rapidly to each
patient.
To make the most effective use of this
patient interaction the practitioner must
be competent to perform a triage
consultation.



The triage assessment must be systematic
All elements of the assessment are pieced
together to give a complete picture of the
patient’s presenting problem
For effective triage practitioners should have
sufficient experience of emergency care and
the inter-personal skills to communicate
effectively with patients and their families.
Triage is a Pit Stop not an MOT!




Triage is a rapid, focused assessment and
allocation of priority
Slowing of the process occurs when tasks
other than prioritisation are carried out
A rapid face to face triage intervention can
take as little as 30-60 seconds
Telephone triage should be expected to take
longer as you do not have a patient in front
of you
A framework for the triage
consultation
Assessment component

Greeting the patient
Triage activity


Listen to voice
Ascertain whether
patient or other
The patient history


Ask the patient what the problem is
This is a short, concise, subjective
history and tells you about the patients
injury / illness / health related problem
The presenting complaint


A patients presenting complaint can be
established from the subjective history
they provide.
This leads the triage practitioner to
choose the most appropriate
presentation flowchart.
Focused questions




This is where the triage practitioners knowledge and
skills are most evident.
Application of anatomical knowledge, pattern
recognition of presenting complaints and the ability
to react effectively to life threatening situations are
all the domain of the triage practitioner.
Focused questions can be used to obtain more detail
if required e.g. duration of the problem, mechanism
of injury, current medications, etc.
The format of these questions will be directed by the
discriminators in the chosen presentation flow chart
Physical examination & assessment
of physical parameters




Possible at face to face, less so on the end of
a phone but…some questions can be asked
such as…..
What things sound like – do they make a
gurgling sound when they breathe?
What things look like –does the limb look a
different colour when you compare it to the
other side?
What effect the problem is having – is your
vision blurred or strange?
Pain assessment


An integral part of the MTS
Pain assessment in telephone triage is
difficult so pain has been revised to be


Severe pain (face to face now)
Unresolved pain – (pain which has not
resolved despite the use of appropriate
analgesia)in the absence of any other
discriminator (face to face later)
Priority / plan of care


Priority assigned using the highest
discriminator applicable to the patient
Relevant advice given.
Documentation

Record information to
an agreed format; clear,
concise and relevant to
presenting complaint.
Include a record (subject
to local requirements)
of:
 Allergies
 Current medications
 Relevant past medical
history
 Advice given

Legible Signature
An effective triage event
Bites and Stings

By following this
systematic process,
facilitated by the triage
methodology, to guide
decision-making the
patient assessment can
be performed rapidly
and confidently to reach
an appropriate clinical
priority.
ADVICE
MTS TTA
12/03/2013
V 2.1
Airway compromise, inadequate
breathing or shock: If
unconscious place in the recovery
position, if conscious try to
reassure
Acutely short of breath, new
wheeze: If possible sit down and
lean slightly forward
Airway Compromise
Inadequate breathing
Facial Oedema
Oedema of the tongue
Unable to talk in sentences
Uncontrollable major haemorrhage
Envenomation
Uncontrollable major
haemorrhage: Continue to press
over the bleeding part. Do not
release the pressure
FtF NOW
ADVICE
Uncontrollable minor
haemorrhage: Continue to press
over the bleeding part. Do not
release the pressure
Widespread rash or blistering:
Try not to scratch the affected
area. If you have an antihistamine
tablet take one now (not to drive if
sedating)
Uncontrollable minor haemorrhage
Widespread rash or blistering
Hot
Significant history of allergy
FtF SOON
Unresolved inflammation
Unresolved swelling
Unresolved pain or itch
FtF LATER
Call back if symptoms worsen,
concerned or new symptoms
develop
ADVICE
If locally red and hot apply a cool
cloth or ice wrapped in a cloth for
5 min at a time.
Keep the affected part raised.
If you have an antihistamine tablet
take one now (not to drive if
sedating)
Advice
Only
ADVICE
If locally red and hot apply a cool cloth or ice
wrapped in a cloth for 5 min at a time.
Keep the affected part raised.
See your local chemist about taking
antihistamines.
Your symptoms should settle within 48 hrs
If things are getting worse or the area appears
infected (red lines tracking up from the bite)
then make an appointment to see you GP
Check you are covered for tetanus
Now
ED
Soon
Later
Advice
Home
General Discriminators
Appropriate advice
Airway compromise
Inadequate breathing
Currently fitting
Uncontrollable major Haemorrhage
Altered conscious level
Unresponsive child
Hot baby
Very hot
Severe pain
Uncontrollable minor haemorrhage
History of unconsciousness
Hot
Unresolved pain
Recent problem
Advice only
Face to Face NOW
Face to Face SOON
Face to Face Later
General Discriminators




95 year old lady found lying
unresponsive on the bedroom floor by
her daughter
Cyanosed
RR fast
Responding only to pain
General Discriminators
General Discriminators





24 month old boy, mum tells you he
has been unwell for the past 5 days
Seen GP on 2 occasions advised
analgesia and antipyretics
Today crying and listless
Refusing food and fluids
Temp 40oc
General Discriminators
General Discriminators





A 22-year-old man had a tooth removed
yesterday.
He is registered with a dentist, but it is
sunday
Increasing pain today & facial swelling and
bleeding
He has been biting onto a cotton wool ball as
instructed, but it won’t stop bleeding
Painful
General Discriminators
General Discriminators






53 year old man complains of being hit
on the leg with a metal bar
Felt faint 5 minutes after the event
No LOC
No bruising, contusions or wounds
Painful
Fully mobilising
General Discriminators
Workshops
Making safe, reproducible
triage decisions
Illness workshop 1
Case 1



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 heavy PV blood loss
She complains of nausea
Illness workshop 1
Case 2



A 22-year-old woman who has 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. She has a
large lump on the back of her head
lllness workshop 1
Case 4



A 22-year-old known migraine sufferer
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.
Illness workshop 1
Case 5




A 53-year-old woman 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
She still has pain
Injury workshop 1
Case 1



A 3-year-old child was playing in the kitchen
and accidentally pulled on the handle of a
saucepan which was being used to boil an
egg. The saucepan fell and the hot water
splashed over her left shoulder and back.
You can hear her screaming in the
background.
Her grandmother says that there are no
burns to her face.
Injury workshop 1
Case 2



It is 2.00 am on Saturday morning and the clubs
have just shut. A 21 year old man has been
assaulted. They state that he had not "been looking
for trouble" when he had been set upon by
three men.
The patient can talk to his friends.There is no obvious
external bleeding. His friends say that he
was punched and kicked.
They say that he was not unconscious. Patient
complains that his "head hurts a bit".
Injury workshop 1
Case 3



A 33-year-old woman has 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 says that her "head throbs". She was
apparently unconscious at the scene for two to
three minutes. She does not seem to be bleeding
Injury workshop 1
Case 4




A 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
severely damaged.
He is conscious but unable to remember the car
hitting him.
He appears to be in severe pain, particularly in his
hip and thigh
Injury workshop 1
Case 5
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

A 96-year-old man lives with his son who reports that his
father fell this morning and hit his chest on the side of the
bath. There is no obvious bruising.
Normally district nurses bathe the elderly gentleman, but
he had been incontinent of faeces and his son says he
could not stand the smell any longer.
There is no sign of external bleeding and he is not short
of breath.
Illness workshop 2
Case 1


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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 her breathing ‘sounds ok’.
She thinks her tongue is slightly swollen her
face feels puffy.
Illness workshop 2
Case 2





It is 10 o'clock in the morning. A 69-year-old man
phones 999 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.
He complains he has now had the symptoms for six
weeks.
Illness workshop 2
Case 3



A 76-year-old man says that he
has 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 while you are talking
to him – he can’t see any blood this
time.
He complains of severe spasms of pain
in his upper abdomen.
Illness workshop 2
Case 4




It is September and the first week of the university
term in the local town. A new first-year student
phones and says 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. He states that he had a
splenectomy at the age of 16 following trauma.
Illness workshop 2
Case 5




A 74-year-old man’s GP phones 999.
The patient 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.
GP 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
the surgery
Injury workshop 2
Case 2



A 55-year-old man is has 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 the first
aider says that there is a great deal of swelling.
On closer questioning, the first aider says that there
is a piece of bone poking through the skin.
Injury workshop 2
Case 3



An 8-year-old child has apparently suffered an insect
bite. His mum says that he is intermittently sobbing.
The mother states that the child has "never been
stung by an insect before". She is very worried
because her other son is allergic to wasp stings and
his grandad was allergic to penicillin.
She says that he is breathing normally and she
cannot see any swelling around his face. There is a 2
cm raised area on the left thigh with what appears to
be a sting visible centrally.
Injury workshop 2
Case 4




A 50-year-old man who has slipped and fallen down
three stairs this morning at. His speech is slightly
slurred and he says that he was out drinking last
night
During the fall he banged the back of his neck but
does not know if he has been unconscious.
He says that he has pain in his neck which radiates
down his right arm.
He has an unpleasant sensation like ‘ice cold water
being poured down his back and legs’.
Injury workshop 2
Case 5




A 17 year-old young man suffers a head-to-head
collision with another player during a game of
football. No LOC witnessed.
He is bleeding a lot from his nose and his mouth and
he has lost a tooth which is embedded in his upper
lip
He is distressed but can communicate and clear his
mouth of blood by spitting
His mouth and nose are swollen and he says his
vision is OK
Illness workshop 3
Case 1





An 19-year-old female university student’s
friend reports that she is 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 mmol
A glucose stick test shows ++++ of ketones
in her urine.
Temp 39.4 0c
Illness workshop 3
Case 2




A 55 year woman is having a palpitation
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 feels very fast
She feels panicky and frightened and
complains that her mouth feels very dry
lllness workshop 3
Case 3



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
An 48 year-old lady phones 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.
She complains of severe pain
Illness workshop 3
Case 4



A 42-year-old man complains of blurred
vision.
His left eye is red. He states that his eye is
not exactly painful - it is more of a
"discomfort".
He says that the vision in that eye is very
blurred
Illness workshop 3
Case 5
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


A 16-year-old girl who has been sent home from school
unwell. Her mother phones 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 says that she has been increasingly breathless for two
days.
She has never been in hospital before with her asthma.
She says that she has increased her salbutamol inhaler
to two puffs every two hours but the shortness of breath
does not improve.
Children workshop
Case 1



A 5-year-old child is was well until the day before
yesterday when she developed a slight fever. Today
she is complaining of pain in her left knee and
is unable to walk properly.
Mum has noticed no rash. The child feels slightly
warm
The child has told her mum that her left leg is "pretty
sore". She says that the pain gets worse when she
moves her hip. Her left knee is hot to touch
compared with the other knee.
Children workshop
Case 2



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
An eleven month old girl was seen by her GP two
days ago after presenting with a blanching rash. The
GP diagnosed Chicken Pox.
She is crying and restless, temperature 37.9oc
Today the child has a widespread rash and blistering
which includes the inside of her mouth.
Her mum says her face is not swollen but..
She is unable to take food or drink due to the
discomfort in her mouth
Children workshop
Case 3
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
A 6-year-old child is is unwell at school. Apparently
he had not been particularly well first thing in the
morning and by mid morning break his class teacher
had been concerned about him. He appeared to be
unable to do anything other than walk without
panting badly. He was not known to be on
medication.
The boy can speak to the teacher in short sentences
and is alert. There is no history of injury. The school
have no record of medicines or puffers He is
coughing intermittently.
Children workshop
Case 4
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

It is 3 o'clock in the morning when the parents of a 6
month old baby phone. They say the child has been
crying since midday the day before and they just do
not know what to do.
He feels very warm to touch but his dad says that his
temperature is OK using a tempadot. The parents
have looked carefully all over the child and there is
no sign of a rash.
Apparently the baby cried intermittently to start with,
but has been crying non-stop since 10 o'clock that
night. The child does not stop crying at all during the
phone call The child has not had any paracetamol
elixir, since it will not take anything by mouth.
Children workshop
Case 5
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

A 5-year-old boy complains of pain in his
tummy.
He is not vomiting and has had no episodes
of diarrhoea.
He says his pain is not there all the time but
it makes him want to curl up as it comes and
goes and but he describes the pain as ‘OK
really’
Behaviour workshop
Case 1
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



A 51-year-old man is waiting for an ambulance
having been found lying by the roadside
apparently intoxicated.
No obvious signs of injury.
The police say that he is slurring his words and
smells of alcohol.
He responds to their voice.
He has a confirmed history of alcohol abuse.
Behaviour workshop
Case 2




A 32 year-old woman’s 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. 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 in the background
Behaviour workshop
Case 3




A 15-year-old girl is at a a residential
children's home has drunk two mouthfuls of
bleach.
She has vomited three times in the past 20
minutes and has a burning sensation in the
back of her throat.
She has taken an overdose of paracetamol on
two previous occasions
She says drank the bleach because she
wanted to die.
Behaviour workshop
Case 5
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The husband of a 27-year-old woman phones He 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 orientated and denies taking any tablets or
medicines. She has told her husband that 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.