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Validity of the Manchester Triage System in patients with sepsis presenting at the ED: a first assessment
  1. Ingo Gräff1,
  2. Bernd Goldschmidt2,
  3. Procula Glien1,
  4. Ramona C Dolscheid-Pommerich3,
  5. Rolf Fimmers4,
  6. Daniel Grigutsch5
  1. 1Emergency Department, University Hospital Bonn, Bonn, Germany
  2. 2Department of Process Management, University Hospital Bonn, Bonn, Germany
  3. 3Department of Clinical Chemistry and Clinical Pharmacology, University Hospital Bonn, Bonn, Germany
  4. 4Institute for Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
  5. 5Department of Anesthesiology, University Hospital Bonn, Bonn, Germany
  1. Correspondence to Dr Ingo Gräff, Emergency Department, University Hospital Bonn, Sigmund-Freud-Str. 25, Bonn 53127, Germany; info{at}


Background The Manchester Triage System (MTS) does not have a specific presentational flow chart for sepsis. The goal of this investigation was to determine adequacy of acuity assignment for patients with sepsis presenting at the ED and triaged using the MTS.

Materials and methods This retrospective analysis included patients >16 presenting to an ED in Bonn, Germany, on the first 12 days of each month between June 2012 and March 2014. Patients were classified into one of three septic groups, or no sepsis. For those with sepsis, adequacy of acuity assignment was based on the criteria of the first consensus conference of the American College of Chest Physicians and Society of Critical Care Medicine, first published in 1992. Adequacy of prioritisation is expressed as sensitivity and likelihood ratio (LR–).

Results Among 20 836 patients evaluated, 801 (3.8%) were septic; of these, 581 (72.5%) had sepsis, 194 (24.2%) had severe sepsis and 26 (3.2%) had severe sepsis with circulation dysfunction. Patients who met the criteria for sepsis were correctly prioritised with a sensitivity of 70.4% (95% CI 66.5 to 74.0). The LR– was 0.628 (95% CI 0.564 to 0.698). Patients with severe sepsis were appropriately prioritised with a sensitivity of 84.5% (95% CI 78.1 to 89.4), and LR– was 0.330 (95% CI 0.243 to 0.450). In the group with severe sepsis and circulation dysfunction, sensitivity of MTS was 61.5% (95% CI 39.3 to 79.8), and LR– was 0.466 (95% CI 0.286 to 0.757).

Conclusions The MTS has some weaknesses regarding priority levels in emergency patients with septic illness. Overall, target key symptoms (discriminators) which aim at identifying systemic infection and ascertaining vital parameters are insufficiently considered.

  • emergency department
  • triage

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  • Contributors IG, BG, PG, RCD-P and DG: conceived the study, designed the trial and drafted the article. IG, BG, RF and DG: analysed the data. IG, BG, PG, RCD-P, RF and DG: Approved the final version.

  • Competing interests None declared.

  • Ethics approval Following consultation with the chairman of the local ethics committee (K. Racké, MD, PhD, Professor, University Clinics Bonn) permission was obtained to analyse the data evaluated in this study without approval by the ethics committee since the analysis was purely retrospective. The German General Medical Council explicitly excludes retrospective studies from approval by the ethics committee in their code of medical ethics (article 15/1) ( Furthermore, as stipulated in article six of the German Data Protection Act (, the physician may use existing patient data for retrospective analyses without explicitly asking for the consent of patients. All collected clinical data evaluated in this study were fully anonymised before analysis. Therefore, according to prior agreement with the local ethics committee and the data protection officer appointed by the University Clinics Bonn, verbal or written informed consent was not obtained. The study design is consistent with the Declaration of Helsinki.

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

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