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THE MANCHESTER TRIAGE SYSTEM Telephone triage workshop.

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1 THE MANCHESTER TRIAGE SYSTEM Telephone triage workshop

2 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, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without prior permission of the publisher Blackwell Publishing Ltd.

3 History 1994 a local problem

4 History 1995 a local group

5 History 1996 a local solution

6 Triage Group: Nomenclature NumberColourName FirstRedImmediate SecondOrangeVery urgent ThirdYellowUrgent FourthGreenStandard FifthBlueNon-urgent

7 Triage Group: Target Times First Second Third Fourth Fifth 0 min10 min 60 min 120 min 240 min

8 Discriminators Y RED ORANGE YELLOWGREEN BLUE Y Y Y N N N N PRESENTATIONAL Flow Chart Triage Group: Methodology

9 History 1997 a publication

10 History 1998 a national solution

11 History 1999 an international solution

12 Key Features Designed by practitioners Based on presentation (not diagnosis) 50 presentational charts Reductive Pain at the centre of assessment Easy documentation


14 History 2005 2 nd edition

15 Chart format For example… Allergy

16 Discriminators Defined in discriminator dictionary Vital part of system - the discriminator is used in a consistant way Standard ABCD

17 Allergy Discriminators appear at the same point on every relevant chart

18 Allergy

19 Current or recent (occurring within the past 7 days)

20 Another one… Palpitations

21 Usual ABC

22 Palpitations Chest pain History of overdose or poisoning Abnormal pulse

23 Palpitations Current palpitation History of unconsciousness Significant cardiac history

24 Palpitations

25 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

26 Discriminator definitions… Significant respiratory history A history of previous life-threatening episodes of a respiratory condition (eg COPD) is significant as is brittle asthma

27 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

28 Translating Manchester Triage - into…..Telephone Triage and Advice

29 History 1998 Local use over telephone

30 Triage Group: TTA principles Now Soon Later Advice Now Soon Later Advice

31 Telephone charts Matching format Same principles





36 The Triage Event How to perform an effective triage assessment

37 The purpose MTS is designed to guide the triage practitioners 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.

38 The triage assessment must be systematic All elements of the assessment are pieced together to give a complete picture of the patients 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.

39 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

40 A framework for the triage consultation Assessment component Greeting the patient Triage activity Listen to voice Ascertain whether patient or other

41 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

42 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.

43 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

44 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?

45 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)

46 Priority / plan of care Priority assigned using the highest discriminator applicable to the patient Relevant advice given.

47 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

48 An effective triage event 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.

49 General Discriminators

50 95 year old lady found lying unresponsive on the bedroom floor by her daughter Cyanosed RR fast Responding only to pain

51 General Discriminators

52 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 40 o c

53 General Discriminators

54 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 wont stop bleeding Painful

55 General Discriminators

56 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

57 General Discriminators

58 Workshops Making safe, reproducible triage decisions

59 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

60 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

61 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.

62 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

63 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.

64 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".

65 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

66 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

67 Injury workshop 1 Case 5 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.

68 Illness workshop 2 Case 1 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.

69 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.

70 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 cant see any blood this time. He complains of severe spasms of pain in his upper abdomen.

71 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 0 c. 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.

72 Illness workshop 2 Case 5 A 74-year-old mans 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

73 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.

74 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.

75 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.

76 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

77 Illness workshop 3 Case 1 An 19-year-old female university students 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 0 c

78 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

79 lllness workshop 3 Case 3 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

80 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

81 Illness workshop 3 Case 5 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.

82 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.

83 Children workshop Case 2 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

84 Children workshop Case 3 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.

85 Children workshop Case 4 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.

86 Children workshop Case 5 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

87 Behaviour workshop Case 1 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.

88 Behaviour workshop Case 2 A 32 year-old womans 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 wont hurt herself again. She is sobbing in the background

89 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.

90 Behaviour workshop Case 5 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.

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