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

Globally, the number of patients presenting to emergency de-
partments with a wide variety of problems, ranging from high clin-
ical severity to minor injuries, is increasing (Bittencourt and Hortale,
2009). This may lead to overcrowding in emergency deparments
which often have other organisational problems, such as assisting
patients based on order of arrival as opposed to the severity of their
medical conditional (Souza et al., 2011).
Triage has emerged as a method to optimise attendance, and to
minimise the damage caused by overcrowding, by identifying pa-
tients who need immediate care. Patients are classified according
to clinical severity, level of suffering and risk to their own health.
In this way, triage is defined as a dynamic process of patient clas-
* Corresponding author. Tel.: +55 3835326073.
E-mail address: helisamaraguedes@gmail.com (H.M. Guedes).
service for faster treatment (Ganley and Gloster, 2011).
Triage scales predict disease severity, mortality rate and re-
quired resources, and should be easily understood, applicable and
have high interobserver agreement (Christ et al., 2010).
Worldwide, various triage scales are used in emergency depart-
ments due to functional differences in services. There is a need for
a uniform triage scale that is suitable for all services (Christ et al.,
2010). There is no infallible measurement instrument, as measure-
ment errors can arise due to personal factors, environmental situ-
ations, changes in the method of data collection and cultural
adaptation processes (Souza et al., 2011).
The Manchester Triage System (MTS) is a classification system
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-
viding support and emplacement to decision-making when a patient
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
 ARTICLE IN PRESS
2 T.R.M. Azeredo et al./International Emergency Nursing ■■ (2014) ■■–■■

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
emergency department (Storm-Versloot et al., 2011).
The MTS has a list of 52 pre-defined conditions or presentation
flowcharts that are combined with the main complaint reported by
the patient and recorded on a form by a nurse. Classification is
divided into five colours: red (immediate), orange (very urgent),
yellow (urgent), green (standard) and blue (non-urgent) (Speake
et al., 2003).
Although theoretical and systematised perspectives have ad-
dressed the use of the MTS in emergency departments, it is ex-
tremely relevant to identify and analyse the scientific publications
on the topic, as the MTS has been introduced into practice rela-
tively recently. This will improve understanding of this triage system,
and demonstrate the scientific indications for its implementation
in different social contexts.
As such, the aim of this study was to assess the efficacy of the
MTS for the risk classification of patients, and to describe and analyse
its use in relevant articles identified.
2. Methods
Systematic reviews involve synthesis of the research related to
a specific issue, and frequently involve the efficacy of an interven-
tion (Sampaio and Mancini, 2007). This review aimed to reduce the
risk of bias by using a rigorous search methodology for study se-
lection, and evaluating the relevance and validity of the research,
collection, synthesis and interpretation of data from the surveys
(Galvão et al., 2004).
This systematic review assessed the level of evidence of each
study in accordance with Sampaio and Mancini (2007): I, system-
atic review of randomised controlled trials with or without
meta-analysis; II, randomized controlled trial; III, cohort study; IV,
case–control study; V, quasi-experimental study; VI, descriptive
study; VII, single case study or case series; and VIII, expert opinion
or case report. Starting from the analysis of theoretical assump-
tions and defining efficacy as the ability of care, at its best, to improve
health (Donabedian, 1990), the following research question was
asked: “What is the efficacy of the MTS for risk identification in pa-
tients seeking a hospital urgency/emergency service?” Table 1 shows
the inclusion and exclusion criteria for articles in this review.
On 29 January 2013, Pubmed, Scielo and Ebscohost were searched
for relevant articles. Ebscohost includes the following databases:
CINAHL Plus with Full Text, Database of Abstracts of Reviews of
Effects, Cochrane Central Register of Controlled Trials, Cochrane Da-
tabase of Systematic Reviews, Cochrane Methodology Register,
Library, Information Science Technology Abstracts, Nursing and Allied
Health Collection: Comprehensive, Health Technology Assess-
ments, MedicLatina, Academic Search Complete, NHS Economic Eval-
uation Database, Regional Business News, ERIC and Business Source
Complete. This search was performed by two researchers who iden-
tified the same number of articles.
Scientific articles published between 1 January 2002 and the date
of the survey (29 January 2013) were eligible for inclusion in this
review. The researchers chose to review articles published only
within the last 10 years as part of the selection criteria because it
limits the studies to a specific time period. In order to identify rel-
evant studies for inclusion in the review, a set of synonyms and
related terms were used to restrict the search and meet the study
objectives. The combinations of keywords used by both research-
ers in each database and the search results are shown in Table 2.
Initially, articles were selected independently by two research-
ers after reading the article titles. Disagreements between research-
ers were resolved by consensus. In total, 56 articles were selected
using Inclusion Criteria 1 and 2, and Exclusion Criteria 1 and 2.
The abstracts of these 56 articles were read, with 28 articles se-
lected by one investigator and 25 articles selected by the other in-
vestigator. Eleven of these studies were not selected by both
reviewers, and following discussion, eight were withdrawn and three
were retained. As such, 27 studies were selected using Inclusion Cri-
teria 3 and 4, and Exclusion Criterion 3.
Information that was not clearly described in the abstract was
obtained by reading the full article. Articles were retained or ex-
cluded based on consensus between the two reviewers using In-
clusion Criterion 4. Ultimately, 22 articles related to the research
question were included in this review.
For data analysis, articles were read repeatedly, and the most rel-
evant elements of each study were extracted, namely: author(s),
country of publication, study design, sample characterisation, level
of evidence and conclusion (Table 2).
3. Results
Table 3 summarises the study details (author, year of publica-
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
 ARTICLE IN PRESS
T.R.M. Azeredo et al./International Emergency Nursing ■■ (2014) ■■–■■ 3

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
 ARTICLE IN PRESS
4 T.R.M. Azeredo et al./International Emergency Nursing ■■ (2014) ■■–■■
Evaluation of validity/specificity/sensitivity of the MTS, evalua-
tion of use of the MTS for a specific condition, and affirmation of
efficacy of the MTS are also shown (Table 3).
Of the 22 studies in this review, nine (40.9%) were from the Neth-
erlands, seven (31.9%) were from Portugal, two (9.1%) were from
Brazil, two (9.1%) were from the UK, one (4.5%) was from Germany
and one (4.5%) was from Spain.
Only three (13.6%) articles did not use validity, specificity and/
or sensitivity to evaluate the efficacy of the MTS. Twenty (90.9%)
studies reported that the MTS had good efficacy, and two (9.1%)
studies reported that the MTS was not efficacious.
Thirteen articles (59%) evaluated the efficacy of the MTS in a spe-
cific group of patients, and studies regarding use of the MTS in chil-
dren were the most common (Nijman et al., 2011; Seiger et al., 2011).
Use of the MTS in patients with clinical conditions such as chest
pain, acute coronary syndrome and acute pulmonary embolism was
also investigated (Dann et al., 2005; van der Straten et al., 2012).
Regarding the evidence levels of studies, 72.7% of studies rep-
resented Level III evidence and 27.3% represented Level VI evi-
dence (Table 2).
4. Discussion
The MTS is used in many countries around the world, and its
efficacy has been shown in scientific studies focusing on a specific
disease, age group or the general population.
The studies in this review were conducted in different contexts
and using different methods to assess the efficacy of the MTS. Most
studies used a methodological tool to measure the validity, speci-
ficity and/or sensitivity of the MTS.
Use of structured triage, such as the MTS, by nurses in the emer-
gency department helps to identify patients who are identified as
having life-threatening presentations receive the fastest service. It
has been suggested that the ideal triage system should allow re-
source planning, in addition to the identification of patients who
need urgent medical care (Christ et al., 2010). Soler et al. (2010)
claimed that triage systems should be structured and based on scales
with five levels, such as the MTS. The MTS has a standard nomen-
clature, uses common definitions, has a robust methodology for
screening, implements a model of integral formation, and allows
the screening method developed to be audited.
Studies that evaluated the MTS without focusing on patients with
a specific condition (40.9%) found that, in addition to prioritising
the care of patients, the MTS was able to predict the evolution of
patients during their stay in the institution, as different rating cat-
egories had different developments in severity (Pinto Júnior et al.,
2012). In addition, the MTS was considered to be more inclusive
compared with an institutional protocol, which increased the level
of priority when there were disagreements between classifica-
tions (Souza et al., 2011).
Martins et al. (2009) reported that the MTS was an extremely
important tool to distinguish between patients at low and high risk
of death in the short term, and to identify patients who would require
hospitalisation for at least 24 h before discharge.
Santos et al. (2014) reported that the risk for hospital admis-
sion was five times greater in high-priority patients (classified as
red or orange using the MTS) compared with low-priority pa-
tients (classified as yellow, green or blue), and death during
hospitalisation was 5.5 times higher in high-priority patients. In ad-
dition, the MTS was considered to be a good discriminator for the
use of diagnostic tools in the emergency department.
Comparison of the Emergency Severity Index (ESI) with the MTS
revealed that both tools were predictive of admission to the emer-
gency department. However, the ESI was a better predictor of ad-
mission than the MTS. Mortality was associated with urgency
category for both triage systems (van der Wulp et al., 2009).
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
Storm-Versloot et al. (2011) reported similar validity in both the ESI
and the MTS, but the ESI had a higher rate of sub-triage (i.e. clas-
sification of more-severe cases as less urgent) than the MTS.
van der Wulp et al. (2008) reported that sub-triage into orange
and yellow categories was a serious problem with the MTS, espe-
cially in elderly patients, because symptoms often presented in an
atypical way; sensitivity was greater in children. The MTS was also
found to have moderate sensitivity for the identification of pa-
tients requiring immediate and very urgent care.
Four studies in Portugal evaluated the efficacy of the MTS in
patients with Acute Coronary Syndrome (Matias et al., 2008; Paiva
et al., 2012; Pinto Júnior et al., 2010; Providência et al., 2011). Pinto
Júnior et al. (2010) reported that the MTS had high sensitivity for
assigning “immediate” and “very urgent” priority levels in these
patients, and use of a flowchart/discriminator suggestive of
Acute Coronary Syndrome had very high specificity and moderate
sensitivity. Therefore, possible evolution towards a more sensitive
instrument without loss of specificity or vice versa is dependent
on the analysis of cases of acute coronary syndrome who
present with atypical symptoms. This was confirmed by Matias
et al. (2008), who found that most in-patients with Acute Coro-
nary Syndrome were categorised as orange and yellow, indicating
the need for “very urgent” and “urgent” care, respectively. The
number of patients who should have been classified as “very urgent”
or “urgent”, but were not classified as such, was high (28%). It is
probable that the situation and condition of the patient worsened
due to the improper classification. This may not have been due to
incorrect screening, but the fact that the complaints of the patient
and clinical presentation at the time of screening led to screening
results indicating a lower level of priority, in addition to clinical
deterioration after admission.
Providência et al. (2011) reported that the MTS was highly ef-
fective for the triage of most patients with acute myocardial in-
farction, particularly those presenting with typical symptoms,
resulting in rapid diagnosis and initiation of therapy. Younger pa-
tients seemed to be better protected, as atypical manifestations were
more common in elderly patients. Providência et al. (2011) sug-
gested that the disease may not have developed completely at the
time of emergency department presentation, and the patient’s con-
dition may deteriorate after screening, as found by Matias et al.
(2008).
Trigo et al. (2008) reported that the MTS led to the
misclassification of patients with Acute Coronary Syndrome with
ST segment elevation; these patients were classified as less urgent,
resulting in a longer delay before the onset of treatment. Matias et al.
(2008) and Providência et al. (2011), found that this failure in the
classification of patients with acute myocardial infarction with ST
segment elevation by the MTS was not due to the clinical and de-
mographic characteristics of patients in the study. This proves a
failure in the classification of MTS.
The MTS has been shown to be a sensitive instrument for the
classification of patients with chest pain who present at an emer-
gency department. The stratification of chest pain allowed ade-
quate allocation of resources for these patients, but further studies
are needed to assess if the training of professionals responsible for
screening can be improved (Matias et al., 2008).
Paiva et al. (2012) assessed the adequacy of the MTS for use in
patients with acute pulmonary embolism. The MTS was found to
have high sensitivity for assigning “urgent” priority in patients who
presented at an emergency department.
Five studies investigated the use of the MTS for paediatric
patients. Seiger et al. (2011) found that the MTS was a moderately
sensitive and specific instrument in paediatric patients, but super-
triage (i.e. classification of less-severe cases as more urgent) was a
problem, and was much more common than sub-triage (Roukema
et al., 2006; Seiger et al., 2011).
 ARTICLE IN PRESS
T.R.M. Azeredo et al./International Emergency Nursing ■■ (2014) ■■–■■
In addition, the MTS demonstrated moderate validity com-
pared with a referenced standard independent paediatric emer-
gency care, and had sensitivity for “very urgent” classification of 63%,
meaning that 37% of patients who should have been seen within
10 min were not categorised as “urgent” (Roukema et al., 2006). The
study looked at multiple MTS categories, ranging from emergent
to non-urgent. Thus, specific modifications in the MTS should be
considered for paediatric patients in order to reduce super-triage,
while maintaining sensitivity in more urgent categories (Seiger et al.,
2011).
Seiger et al. (2011) evaluated sub-triage of the MTS in paediat-
ric patients, and concluded that the number of cases of severe
sub-triage was very small (approximately 1%). However, severe sub-
triage could have serious consequences. A systematic assessment
of vital signs in all children was recommended in order to reduce
sub-triage.
Another paediatric study reported that the MTS had little dis-
criminative ability to predict the presence of serious bacterial in-
fections in children with fever in the emergency department (Nijman
et al., 2011). Although important predictors of severe bacterial in-
fection are represented within the MTS, a different role is as-
signed to them in the classification of urgency.
van Ierland et al. (2013) assessed whether the flowcharts and
discriminators of the MTS were able to predict the risk of
hospitalisation in children with fever, and found that the MTS has
the potential to identify children at risk of hospitalisation at the be-
ginning of the care process in the emergency department. However,
they recognised that the MTS may not be the ideal tool to recog-
nise the risk of hospitalisation in children. More sophisticated tools,
such as decision support systems, are rare for general clinical com-
plaints because their development and implementation are diffi-
cult and time consuming, and they require additional clinical features
that are not available from triage assessment.
Two of the 22 studies in this review did not report good effica-
cy for the MTS. These studies found that the MTS classified a high
percentage of patients with acute coronary syndrome with ST
segment elevation as less urgent (Trigo et al., 2008), and the MTS
did not predict the presence of severe bacterial infection in chil-
dren in the emergency department (Nijman et al., 2011). The study
selected people with ECG changes as part of the inclusion criteria
of the study.
5. Limitations
This study had a few limitations. Unpublished manuscripts, books
and abstracts were not included, so items with negative results or
without positive results may not have been included (Sousa and
Ribeiro, 2008). In addition, articles published outside the desig-
nated study period were excluded. One of the other limitations of
the study was the selection of the study time period that ex-
cluded articles published prior to 2002, even though articles were
published in the 1990s.
6. Conclusion
This review examined the efficacy of the MTS for risk classifi-
cation of patients. Only two of 22 studies reported unfavourable
results for the MTS. The remaining articles generally considered the
MTS to be effective for use in children, adults, and people with acute
coronary syndrome and acute pulmonary embolism. The MTS was
considered to be predictive of admission to the emergency depart-
ment and short-term death.
The articles in this review were performed in different geo-
graphical areas of the world, showing high suitability and validity
of the MTS. It is suggested that the two studies with unfavourable
results should be replicated in other locations.
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
5
Acknowledgements
The authors wish to thank FAPEMIG (Ref. No. APQ-01153-12) and
CAPES, Science Without Borders (Ref. No. 0458-13-9) for financial
support.
References
Bittencourt, R.J., Hortale, V.A., 2009. Interventions to solve overcrowding in hospital
emergency services: a systematic review. Cadernos de Saúde Pública. 25,
1439–1454.
Christ, M., Grossmann, F., Winter, D., Bingisser, R., Platz, E., 2010. Modern triage
in the emergency department. Deutsches Ärzteblatt International. 107,
892–898.
Cooke, M.W., Jinks, S., 1999. Does the Manchester triage system detect the critically
ill? Journal of Accident & Emergency Medicine. 16, 179–181.
Dann, E., Jackson, R., Mackway-Jones, K., 2005. Appropriate categorisation of mild
pain at triage: a diagnostic study. Emergency Nurse. 13, 28–32.
Donabedian, A., 1990. The seven pillars of quality. Archives of Pathology and
Laboratory Medicine. 114, 1115–1118.
Galvão, C.M., Saw, N.O., Trevizan, M.A., 2004. Systematic review: a resource that allows
for the incorporation of evidence into nursing practice. Revista Latino-Americana
de Enfermagem. 12, 549–556.
Ganley, L., Gloster, A., 2011. An overview of triage in the emergency department.
Nursing Standard. 26, 49–57.
Martins, H.M.G., Cuña, L.M.D.C.D., Freitas, P., 2009. Is Manchester (MTS) more than
a triage system? A study of its association with mortality and admission to a
large Portuguese hospital. Emergency Medicine Journal. 26, 183–186.
Matias, C., Oliveira, R., Duarte, R., Bico, P., Mendonça, C., Nuno, L., et al., 2008. The
Manchester Triage System in acute coronary syndromes. Revista Portuguesa de
Cardiologia. 27, 205–216.
Nijman, R.G., Zwinkels, R.L., van Veen, M., Steyerberg, E.W., van der Lei, J., Moll, H.A.,
et al., 2011. Can urgency classification of the Manchester triage system predict
serious bacterial infections in febrile children? Archives of Disease in Childhood.
96, 715–722.
Paiva, L., Providência, R., Faustino, A., Barra, S., Botelho, A., Leitao-Marques, A.M., 2012.
Manchester triage in acute pulmonary embolism: can it unmask the grand
impersonator? Emergency Medicine Journal. 29, e6.
Pinto Júnior, D., Lunet, N., Azevedo, A., 2010. Sensitivity and specificity of Manchester
Triage System for patients with acute coronary syndrome. Revista Portuguesa
de Cardiologia. 29, 961–987.
Pinto Júnior, D., Salgado, P.O., Chianca, T.C.M., 2012. Predictive validity of
the Manchester Triage System: evaluation of outcomes of patients admitted
to an emergency department. Revista Latino-Americana de Enfermagem. 20,
1–8.
Providência, R., Gomes, P.L., Barra, S., Silva, J., Seca, L., Antunes, A., et al., 2011.
Importance of Manchester triage in acute myocardial infarction: impact on
prognosis. Emergency Medicine Journal. 28, 212–216.
Roukema, J., Steyerberg, E.W., van Meurs, A., Ruige, M., van der Lei, J., Moll, H.A., 2006.
Validity of the Manchester Triage System in paediatric emergency care.
Emergency Medicine Journal. 23, 906–910.
Sampaio, R.F., Mancini, M.C., 2007. Systematic review studies: a guide for careful
synthesis of the scientific evidence. Revista Brasileira De Fisioterapia. 11,
83–89.
Santos, A.P., Freitas, P., Martins, H.M.G., 2014. Manchester triage system version II
and resource utilisation in emergency department. Emergency Medicine Journal.
31, 148–152.
Seiger, N., van Veen, M., Steyerberg, E.W., Ruige, M., van Meurs, A.H., Moll, H.A., 2011.
Under triage in the Manchester Triage System: an assessment of severity and
options improvement. Archives of Disease in Childhood. 96, 653–657.
Soler, W., Muñoz, M.G., Bragulat, E., Álvaez, A., 2010. El triaje: herramienta
fundamental en urgencias y emergencias [Triage: a key tool in emergency care].
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
and prognostic studies: a tutorial. Arquivos Brasileiros de Cardiologia. 92,
229–238.
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,
26–33.
Speake, D., Teece, S., Mackway-Jones, K., 2003. Detecting high-risk patients with chest
pain. Emergency Nurse. 11, 19–21.
Storm-Versloot, M.N., Ubbink, D.T., Kappelhof, J., Luitse, J.S.K., 2011. Comparison of
informally structured triage system, the Emergency Severity Index, and the
Manchester Triage System to distinguish patient priority in the emergency
department. Academic Emergency Medicine. 18, 822–829.
Trigo, J., Gago, P., Mimoso, J., Santos, W., Marques, N., Gomes, V., 2008. In-hospital
delay ST-segment-elevation myocardial infarction after Manchester triage. Revista
Portuguesa de Cardiologia. 27, 1251–1259.
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
general practitioner at an acute care post: an observational study. Emergency
Medicine Journal. 29, 877–881.
 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
Manchester Triage System in a general emergency department patient population
in the Netherlands: results of a simulation study. Emergency Medicine Journal.
25, 431–434.
van der Wulp, I., Schrijvers, A.J., van Stel, H.F., 2009. Predicting admission and mortality
with the Emergency Severity Index and the Manchester Triage System: a
retrospective observational study. Emergency Medicine Journal. 26, 506–509.
van Ierland, Y., Seiger, N., van Veen, M., Moll, H.A., Oostenbrink, R., 2013. Alarming
signs in the Manchester Triage System: a tool to identify febrile children at risk
of hospitalization. The Journal of Pediatrics. 162, 862–866.
van Veen, M., Steyerberg, E.W., Ruige, M., van Meurs, A.H., Roukema, J., van der Lei,
J., et al., 2008. Manchester triage system in paediatric emergency care: prospective
observational study. BMJ. 337, a1501.

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