Powered by TCPDF (www.tcpdf.org) Emergency Triage ManchesterTriageGroup Emergency Triage Manchester Triage Group EDITED BY Kevin Mackway-Jones Janet Marsden Jill Windle THIRD EDITION Thiseditionfirstpublished2014(cid:2)C 2014byJohnWiley&Sons,Ltd. Secondedition2006(cid:2)C BlackwellPublishingLtd. Firstedition1997(cid:2)C BMJPublishingGroup Registeredoffice: JohnWiley&Sons,Ltd,TheAtrium,SouthernGate,Chichester, WestSussex,PO198SQ,UK Editorialoffices: 9600GarsingtonRoad,Oxford,OX42DQ,UK 111RiverStreet,Hoboken,NJ07030-5774,USA Fordetailsofourglobaleditorialoffices,forcustomerservicesandforinformationabouthowtoapplyfor permissiontoreusethecopyrightmaterialinthisbookpleaseseeourwebsiteat www.wiley.com/wiley-blackwell Therightoftheauthortobeidentifiedastheauthorofthisworkhasbeenassertedinaccordancewiththe UKCopyright,DesignsandPatentsAct1988. 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LibraryofCongressCataloging-in-PublicationData Emergencytriage/ManchesterTriageGroup;editedbyKevinMackway-Jones,JanetMarsden,JillWindle. Thirdedition. p.;cm. Includesbibliographicalreferencesandindex. ISBN978-1-118-29906-7(pbk.:alk.paper)–ISBN978-1-118-29902-9–ISBN978-1-118-29903-6 (emobi)–ISBN978-1-118-29904-3(epdf)–ISBN978-1-118-29905-0(epub) I.Mackway-Jones,Kevin,editor. II.Marsden,Janet,editor. III.Windle,Jill,editor. IV.Manchester TriageGroup,issuingbody. [DNLM:1.Triagemethods. 2.EmergencyService,Hospital. WX215] RA975.5.E5 362.18–dc23 2013024786 AcataloguerecordforthisbookisavailablefromtheBritishLibrary. Wileyalsopublishesitsbooksinavarietyofelectronicformats.Somecontentthatappearsinprintmaynot beavailableinelectronicbooks. Anyonewishingtolicenseallorpartofthisbookinelectronicformatforintegrationintoasoftware productorahospital’selectronicpatientrecords,oranyonewishingtolicensethistitlefortranslationplease [email protected] CoverdesignbyNathanHarris Setin9.5/13ptMeridienbyAptara®Inc.,NewDelhi,India 1 2014 Contents Editors,vi MembersoftheoriginalManchesterTriageGroup,vii InternationalReferenceGroup,viii Prefacetothethirdedition,ix Prefacetothefirstedition,xi 1 Introduction,1 2 Thedecision-makingprocessandtriage,6 3 Thetriagemethod,11 4 Painassessmentaspartofthetriageprocess,25 5 Patientmanagement,triageandthetriagepractitioner,35 6 Auditingthetriageprocess,42 7 Telephonetriage,47 8 Beyondprioritisation,54 Presentationalflowchartindex,62 Presentationalflowcharts,64 Discriminatordictionary,174 Index,185 Generaldiscriminators,190 v Editors Kevin Mackway-Jones, Consultant Emergency Physician, Manchester RoyalInfirmaryandRoyalManchesterChildren’sHospital;MedicalDirec- tor, North West Ambulance Service; Honorary Civilian Consultant Advi- sor in Emergency Medicine to the British Army; Professor of Emergency Medicine,CentreforEffectiveEmergencyCare,ManchesterMetropolitan University. Janet Marsden, Professor of Ophthalmology and Emergency Care and Director, Centre for Effective Emergency Care, Manchester Metropolitan University. Jill Windle, Lecturer Practitioner in Emergency Nursing, Salford Royal HospitalsNHSFoundationTrustandUniversityofSalford. vi Members of the original Manchester Triage Group KassimAli,ConsultantinEmergencyMedicine SimonBrown,SeniorEmergencyNurse HelenFiveash,SeniorEmergencyNurse JulieFlaherty,SeniorPaediatricEmergencyNurse StephanieGibson,SeniorEmergencyNurse ChrisLloyd,SeniorEmergencyNurse KevinMackway-Jones,ConsultantinEmergencyMedicine SueMcLaughlin,SeniorPaediatricEmergencyNurse JanetMarsden,SeniorOphthalmicEmergencyNurse RosemaryMorton,ConsultantinEmergencyMedicine KarenOrry,SeniorEmergencyNurse BarbaraPhillips,ConsultantinPaediatricEmergencyMedicine PhilRandall,ConsultantinEmergencyMedicine JoanneRoyle,SeniorEmergencyNurse BrendanRyan,ConsultantinEmergencyMedicine IanSammy,ConsultantinEmergencyMedicine SteveSouthworth,ConsultantinEmergencyMedicine DebbieStevenson,SeniorEmergencyNurse ClaireSummers,ConsultantinEmergencyMedicine JillWindle,LecturerPractitionerinEmergencyNursing vii International Reference Group Austria StefanKovacevic AndreasLueger WillibaldPateter Brazil WelfaneCordeiro MariadoCarmosRausch Ba´rbaraTorres Germany JoergKrey HeinzpeterMoecke PeterNiebuhr Mexico AlfredoTanakaChavez ElizabethHernandezDelgadillo NoeArellanoHernandez Norway GretheDoelbakken EndreSandvik GermarSchneider Portugal PauloFreitas AntonioMarques AngelaValenca Spain ConxaOliverMartinez GemaGarciaRiestra GabrielRedondoTorres viii Preface to the third edition Time continues to move on and it is now nearly 20 years since a group of senior emergency physicians and emergency nurses first met to con- sidersolutionstothemuddlethatwastriageinManchester,UK.Wehad no expectation that the solution to our local problems would be robust enough(andtimelyenough)tobecomethetriagesolutionforthewhole United Kingdom. Never in our wildest dreams did we imagine that the ManchesterTriageSystem(MTS)wouldbegenericenoughtobeadopted aroundtheworld.Muchtooursurprise,however,bothofthesefantastic ideascameabout,andtheMTScontinuestobeusedinmanylanguagesto triagetensofmillionsofEmergencyDepartmentattenderseachyear. The basic principles that drive the MTS (recognition of the presenta- tionandreductivediscriminatoridentification)areunchanging–butfrom time to time it has become necessary to make some adjustments to the detail. The third edition builds on the changes we made in the second; it takes into account the comments passed to us by users over the years (forwhichweareverygrateful)andalsothecontributionsoftheInterna- tionalReferenceGroup,whobringabroadperspectivefromotherclinical situations and cultures. It also seeks to include modifications that reflect newresearchandalterationsinthepracticeofemergencycare.Significant changes include new charts for unwell neonates and babies and a major, evidence-based change in the way in which fever in childhood is priori- tised. We have clarified discriminator terminology and definitions where thiswasprovingdifficult(forinstance‘abnormalpulse’isnowclarifiedas ‘new abnormal pulse’ and ‘known immunosupression’ has been restated as‘knownorlikelyimmunospression’).Wehavealsotakentheopportu- nitytostandardisetheorderinwhichdiscriminatorsappearonthecharts. Overallthough,asinthesecondedition,thechangesaresmallinnumber. Thisneweditionalsocontinuesourattempttoputtriageinthecontext of changes that are happening in many emergency care systems around the world. Emergency care continues to be the focus of political and management attention. The care of increasing numbers of patients with ix x Prefacetothethirdedition less urgent conditions (who make up the majority in most settings) con- tinue to be a source of concern, since under-resourced systems that focused (rightly) on patients with the highest clinical priority inevitably resultedindelayedcareforthoseattheotherendofthepriorityscale.In the consumer age, this delay (which delivers a poor patient experience) is unacceptable. It is often easier to blame the clinical prioritisation sys- tem (triage) for this delay than to deal with an under-resourced system. Another current vogue is to try to replace a dedicated emergency care triage system with a hospital-wide track and trigger score. The evidence is clear that, unsurprisingly, this cannot be done without a considerable additionalrisktophysiologicallynormalpatientsearlyintheevolutionof theirillness. Ourstandpointhasalwaysbeenthatproperemergencytriageisvitalin all systems or circumstances where the demand for emergency care out- strips the ability to deliver it. We continue to believe that these circum- stances occur occasionally in even the best managed and resourced sys- tems, and frequently in those with the usual demands and staffing. Thus clinicalprioritisation(whethercalledtriage,initialassessmentoranything else)remainsacornerstoneofclinicalriskmanagementinemergencycare, andabandoningitcompletelyisnotanoption. KevinMackway-Jones,JanetMarsden,JillWindle Manchester,2013