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Pain assessments at triage with the Manchester triage system: a prospective observational study
  1. Ineke van der Wulp1,
  2. Leontien M Sturms1,
  3. Annemarie de Jong2,
  4. Marian Schot-Balfoort2,
  5. Augustinus J P Schrijvers1,
  6. Henk F van Stel1
  1. 1Public Health, Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
  2. 2Sint Antonius Hospital Nieuwegein/Utrecht Oudenrijn, Nieuwegein and Utrecht, The Netherlands
  1. Correspondence to Dr I van der Wulp, Julius Center for Health Sciences and Primary Care, UMC Utrecht, PO Box 85500, Utrecht 3508 GA, The Netherlands; i.vanderwulp{at}umcutrecht.nl

Abstract

Objective Pain is one of the six general discriminators of the Manchester triage system (MTS). The frequency of pain assessments conducted at triage with the MTS, and patient, nurse and triage characteristics associated with pain assessments were studied. Also, nurses' reasons for not assessing pain at triage were studied.

Methods The study consisted of two parts. In part 1, nurses from two emergency departments (ED) registered patient characteristics and the process of triage for every presenting patient during 1 week in May 2009. The characteristics of triage nurses were registered on a second form. In part 2 of the study, 13 nurses were interviewed about reasons for not assessing pain at triage.

Results According to the MTS guidelines, pain assessments should have been conducted in 86.1% of the patient presentations. It was only assessed in 32.2% of these patients. Characteristics associated with conducting pain assessments were children under 12 years of age, patients referred by others than a general practitioner or ambulance service, intake of medication before an ED visit, experience of the nurse with the MTS and the duration of triage. Reasons for not assessing pain according to the guidelines included the thought of triage nurses that pain assessments result in overtriage.

Conclusions Pain assessments at triage are conducted infrequently because of insufficient education, conducting activities at triage that are not necessary for estimating urgency and a lack of clarity in the MTS guidelines. Changes in these areas are necessary to improve the reliability and validity of pain assessments and the MTS.

  • Emergency care systems
  • emergency departments
  • management

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The Manchester triage system (MTS) has been implemented in emergency departments (ED) since 1996.1 It is predominantly used in ED in the UK, Portugal and The Netherlands.1–3 The urgency of presenting patients is assessed by a triage nurse who selects a flowchart that represents the patient's complaint. In total, the system consists of 52 flowcharts with which patients are allocated on the basis of discriminators into one out of five triage categories. Each category represents a maximum waiting time for a patient to see a doctor: red (immediately); orange (10 min); yellow (60 min); green (2 h) and blue (4 h). Pain is one of the six general discriminators of the system. It occurs in 43 flowcharts but should be taken into account irrespective of the presenting complaint.1 The MTS prescribes to assess pain with the pain ruler (figure 1). Pain should be interpreted by taking into account the patient's judgement of the pain combined with the nurse's perception of the patient's pain. Both judgements are necessary because patients can have reasons for reporting their pain to be severe to justify their attendance, or to claim faster treatment.1 On the other hand, a single interpretation of pain from the triage nurse can lead to an underestimation of pain, especially in children.4

Figure 1

Pain ruler Manchester triage system.

Most studies conducted on pain assessments at triage were focused on the provision of analgesia.5–9 However, before providing analgesia a nurse should obtain information about the severity of the patient's pain. Only one study was found that measured the frequency of pain assessments at triage.10 It appeared that no pain scores were registered. Furthermore, after developing and implementing a pain scale only 12 out of 25 patients had pain scores recorded. From this study, it is unknown whether pain assessments were not conducted or not registered. Because pain is a predominant MTS discriminator it affects the systems' reliability and validity when it is not assessed. Besides, pain assessments are an important aspect of the quality of ED patient care and patient satisfaction.11

The objective of this study was to measure the frequency of pain assessments conducted in accordance with the MTS guidelines. Furthermore, we studied patient, nurse and triage characteristics associated with pain assessments and examined nurses' reasons for not assessing pain at triage.

Methods

Study design

A prospective observational study was conducted in two ED in The Netherlands. The protocol has been approved by the medical ethical committee of the participating hospitals.

Study setting and population

Two ED in the province of Utrecht participated in the study. These ED receive between 23 000 and 25 000 patients annually. The MTS was implemented in 2005 and 2007. Before implementation, the nurses of both departments attended an MTS course. ED trainee nurses received a course in their educational programme and received practical training by an experienced triage nurse. ED trainee nurses in one ED were allowed to triage under supervision of a certified ED nurse. This ED triaged patients 24 h a day while in the other ED patients were triaged between 11:00 and 19:00 hours (peak hours).

In this study, all patients were included who presented to the participating ED during triage hours between 11 May 2009 and 18 May 2009. In addition, nurses who triaged patients during this study period were eligible for inclusion in the study.

Data collection

The study consisted of two parts. In part 1 of the study, a data collection form was completed by the triage nurse for every presenting patient. This form registered patient characteristics and information about the process of triage: gender, date of birth, ethnicity, referrer to ED, medication intake before ED visit, flowchart used, discriminator used, measurements (temperature, pain assessment, peak expiratory flow rate, pulse rate, oxygen saturation, blood pressure, other), urgency category, medication provided, destination after triage and the duration of triage. The characteristics of triage nurses were registered on a second form, which was completed once by every triage nurse on duty. This form registered their date of birth, gender, whether they worked as an ED trainee nurse, the number of years of experience as ED nurse and their experience with the MTS. To minimise information bias, nurses were informed that the focus of this study was on the quality of triage rather than on pain assessments.

After part 1 of the study, the results were presented in a plenary session and the objective of part 2 of the study was introduced to the nurses. This was done to give them the opportunity to think about these results and to think about reasons for not assessing pain according to the MTS guidelines. During the next 6 weeks, nurses on duty were interviewed by a trained nurse. These semistructured interviews were recorded on a digital voice recorder.

Data analysis

The frequency of pain assessments was reported with descriptive statistics. The degree to which patient, nurse, and triage characteristics could predict pain assessments was analysed with binary logistic regression analyses. Assessing pain (yes or no) was the dependent variable. Independent variables were: patient gender, age and ethnicity, referral to the ED, medications taken before ED presentation, flowchart, triage category, duration of triage conversation, nurses' age and gender, ED trainee nurse, experience as ED nurse, experience with the MTS and hospital. These variables were tested in univariate logistic regression analyses. Furthermore, because ED trainee nurses have no experience as an ED nurse and are less experienced with the MTS, it was tested whether these interactions were associated with conducting pain assessments. All variables and interactions which significantly (p<0.05) predicted pain assessments were selected for multivariate analysis. In these analyses, patient presentations triaged with one out of nine flowcharts without the discriminator pain were excluded.

Missing data were analysed with SPSS missing value analysis and Little's test for data missing completely at random. The null hypothesis that the missing data were a random subset of the population was rejected because the test score was statistically significant (p<0.01). This indicates that the missing data are either missing at random (MAR) or missing not at random (MNAR).12 Whether missing data is MAR or MNAR can only be concluded on the basis of reasoning.13 Further analysis showed that it occurred more frequently within categories of the variables referral type (ambulance patients), triage category (urgent categories) and hospital. It was assumed that the missing data occurred randomly conditional on referrer type, urgency category and hospital. Therefore, the missing data were considered MAR and imputed with multivariate linear regression analysis (single imputation). Category prevalences, means and SE were checked for differences compared with the data before imputation. Because no substantial differences occurred, it was decided not to conduct a multiple imputation procedure. All analyses were performed with SPSS for Windows (version 15).

The semistructured interviews were transcribed for further analysis with Weft QDA (a qualitative data analysis tool).14 With this program text parts of the interviews were labelled and ordered.

Results

In total, 734 patients presented to both ED. In 38.9% of these presentations the data were registered incompletely, that is one or more variables on the registration form were not registered. Table 1 presents the characteristics of the patients by which the nurse conducted pain assessments or not. In both groups, the majority of the patients presenting to the ED were male, self-referred, or general practitioner referred, and triaged in MTS category green. Table 2 presents the characteristics of the triage nurses. The majority of the triage nurses was female and had more than 2.0 years of experience with the MTS.

Table 1

Characteristics of patients (n=734)

Table 2

Characteristics of triage nurses (n=22)

Pain assessments

From the allocated flowcharts and selected urgency categories, it was determined in how many patient presentations pain should have been assessed according to the MTS guidelines. This appeared to be necessary in 632 patient presentations (86.1%), while in 203 (32.1%) of these presentations pain assessments were conducted.

Remarkably, 188 patients were triaged on the basis of the discriminator pain while in only 71 of these patients (37.8%) the triage nurse registered that a pain assessment was conducted.

Associations with pain assessments

In univariate logistic regression analyses the variables hospital, patient age and ethnicity, type of referrer, medication intake before ED visit, duration of triage conversation, nurse gender, ED trainee nurse, experience with the MTS and the interaction ED trainee nurse by experience with the MTS, were significantly associated with conducting pain assessments. The results of the multivariate logistic regression analysis are presented in table 3. In this analysis, the variables hospital, ethnicity and nurse gender were no longer significantly (p>0.05) associated with conducting pain assessments. Children below 12 years of age, medication intake before ED visit and nurses' experience with the MTS showed the strongest association with conducting pain assessments. Also the interaction ED trainee nurse by experience with the MTS showed a strong association; ED trainee nurses were more likely to conduct pain assessments compared with certified ED nurses.

Table 3

Variables associated with conducting pain assessments

Reasons for not conducting pain assessments

Thirteen nurses were interviewed. Of these, eight nurses triaged 4 years with the MTS, four triaged between 1 and 1.5 years and one triaged for a few months. Eight nurses felt the results of the first part of the study represented daily practice while four disagreed. We asked what reasons nurses could have for not conducting pain assessments according to the MTS guidelines. Seven reasons were mentioned. Nurses estimate the patient's pain themselves without taking into account the patient's judgement because they think the patient's judgement often results in overtriage (n=8). Furthermore, they interpret the patient's pain by observing visual symptoms of pain such as paleness, perspiration, patient behaviour, facial expressions or movements, by asking patients whether they need or have already taken painkillers, by interpreting vital signs and by interpreting the complaint of the patient as painful or not. Another reason mentioned was that nurses experienced time constraints at triage because other activities are conducted, for example taking blood samples for laboratory testing (n=4). Some nurses mentioned that in certain cases it is not necessary to assess pain, for example if patients have taken pain killers before their ED visit, if they present themselves calmly, or when their complaint existed for at least 5 days (n=3). Two nurses mentioned that pain assessments are often forgotten either because the guidelines are not applied or because they are applied after the triage conversation. Another reason mentioned was unfamiliarity with the pain ruler and the guidelines (n=1). In several interviews this reason was confirmed as according to some nurses the guidelines state that only the patient's judgement of pain should be used. Moreover, some nurses thought pain assessments were not conducted because the pain ruler is difficult to use or to interpret. Finally, one nurse mentioned that a lack of education probably resulted in a lack of pain assessments.

Discussion

This study examined the frequency with which pain assessments at triage were conducted according to the MTS guidelines. It appeared that pain was assessed in approximately one third of the patient presentations who required pain assessments. Children, medication intake before ED visit, duration of triage and the interaction ED trainee nurses by experience with the MTS were associated with conducting pain assessments. The latter finding could possibly be explained by the tendency of ED trainee nurses to apply the guidelines more strictly compared with certified ED nurses, for example because of the fear of undertriage. This should be studied further.

Furthermore, it was found that a substantial number of patients were triaged with the discriminator pain while pain was not assessed at triage. This indicates that nurses do take pain into account at triage. However, it also indicates that they interpret the patient's pain solely. In the interviews this finding was confirmed as nurses explained that the patient's judgement often results in overtriage. This raises the question of whether this is a problem, as nurses can relieve the pain and retriage a patient into a less urgent triage category. However, in category orange the time to retriage is limited, which could influence patient flow in the ED negatively. Other reasons for not assessing pain were: time constraints; forgetting to assess pain; unfamiliarity with the pain ruler; difficulties with interpreting pain; a lack of education on pain assessments and the thought it is unnecessary to assess pain. The reported reasons indicate several problems, which may cause the small number of pain assessments. First, nurses are unfamiliar with the pain ruler or the MTS guidelines. MTS (refresher) courses should therefore focus on pain assessments more extensively. The results of audits of the process of triage as suggested by the guidelines1 as well as the results of the first part of the present study can be helpful. These results suggest to focus on elderly patients. The second problem relates to the organisation of triage. It is recommended to implement a computer program so that nurses can triage in front of the patient and are less likely to forget pain assessments or other measures. Also activities not necessary for assessing the urgency of the patient's complaint should be planned after triage. This will limit time pressures on triage nurses. The third and final problem seems a lack of clarity in the MTS guidelines. These guidelines do not prescribe how nurses should interpret pain with the pain ruler and how their interpretation of the patient's pain influences the triage decision. To increase nurses' confidence in assessing and interpreting pain, and to improve the reliability of pain assessments, we suggest to add characteristics of pain, which can be recognised by nurses, to the MTS guidelines, for example behaviour, paleness, or vital signs. However, caution is needed as some characteristics may not be strongly associated with pain intensity.15 Furthermore, the guidelines should describe the importance of both nurses' and patients' pain judgements for making a triage decision, for example by adding weights to both judgements. These suggestions will create more uniformity in pain assessments between nurses and therefore increase the reliability and validity of pain assessments and the MTS in total. Uniformity among patients is impossible to achieve because of differences in pain experiences.

As mentioned in the introduction, only one study was found that studied pain assessments at triage. In both studies pain assessments were not observed in practice and therefore assumptions were made. Evans et al10 were forced to assume that each assessment was registered due to the retrospective nature of the study. Although the data in the present study were collected prospectively, the same assumption was made; however, with less bias because the data were collected at triage. It was also assumed that if pain was registered, the nurse assessed it in accordance with the MTS guidelines. These assumptions could partly explain the differences between the reported frequencies, 48% versus 32%.

Pain assessments are important for making triage decisions with the MTS. The failure to assess pain can affect the quality of triage in the ED. It can result in different triage decisions because nurses then use other discriminators to triage patients compared with nurses who do conduct pain assessments. However, the exact effects of skipping pain assessments at triage with the MTS on triage decisions and patient outcomes are unknown. Besides the quality of triage, pain assessments are important for relieving the patient's pain sufficiently. Pain management in the ED has been reported to be inadequate in several studies,16–20 which can be related to poor pain assessments. These studies and the present study therefore emphasise the importance of educating nurses in assessing pain, uniform assessments and registrations of pain and the use of a reliable and valid pain tool.

Limitations

This study has some limitations. First, the occurrence of missing data, which was probably caused by the fact that nurses had to fill in a form for every triaged patient next to their normal activities. Furthermore, several missing data patterns were found. During the study it appeared that several nurses did not triage patients who arrived by ambulance because these were already triaged by the ambulance professional. Also information about patients triaged in the more urgent categories was more often missing, possibly because nurses had less time to complete a form. The differences between the amount of missing data in the hospitals may have occurred because the main researcher had attended one ED more frequently during data collection. By imputation of the missing data the influences on the precision of the estimates were decreased.

A second limitation is that information bias may have occurred because nurses were aware of the study. Although the study objective was unknown to them, this could have caused an overestimation of the exact number of pain assessments. A more precise estimate of the frequency of pain assessments could be obtained by observing triage conversations by camera. In addition, no assumptions have to be made that will increase the precision of the estimated frequency. However, the interviews showed that most nurses recognised the study results to what they experience in practice and that reasons exist for not assessing pain.

Finally, we interviewed a non-random sample of 13 nurses from two ED about reasons for not assessing pain, which limits the generalisability of the results of this study. In addition, the majority of these nurses had substantial MTS experience, which could have resulted in a more negative tendency about pain assessments. However, they were possibly better able to provide reasons for not assessing pain because of their practical experience.

Conclusions

Pain assessments according to the MTS guidelines were conducted in nearly one third of the patient presentations. Reasons for not conducting pain assessments indicate insufficient education, organisational difficulties and a lack of clarity in the MTS guidelines. It is important for the quality of triage that nurses assess pain according to these guidelines. Pain assessments are likely to increase when paying more attention to pain assessments in MTS (refresher) courses, by implementing a computer program, by skipping activities at triage that are not necessary for urgency estimation and by revising the MTS guidelines. Further study is needed to assess the influence of these suggestions on the reliability and validity of the pain ruler and the MTS in general.

Acknowledgments

The authors would like to thank the nurses and staff of the Sint Antonius Hospitals Nieuwegein and Utrecht Oudenrijn for participating in this study.

References

Footnotes

  • Competing interests None declared.

  • Ethics approval This study was conducted with the approval of the Medical Ethical Committee of the Sint Antonius Hospitals Nieuwegein/Utrecht Oudenrijn.

  • Provenance and peer review Not commissioned; externally peer reviewed.