Nishi Fernanda Ayache, de Oliveira Motta Maia Flávia, de Souza Santos Itamar, de Almeida Lopes Monteiro da Cruz Dina
1University Hospital, University of São Paulo, São Paulo, Brazil 2The Brazilian Centre for Evidence-Informed Healthcare: a Joanna Briggs Institute Centre of Excellence, São Paulo, Brazil 3School of Medicine, University of São Paulo, São Paulo, Brazil 4School of Nursing, University of São Paulo, São Paulo, Brazil.
JBI Database System Rev Implement Rep. 2017 Jun;15(6):1747-1761. doi: 10.11124/JBISRIR-2016-003139.
Triage is the first assessment and sorting process used to prioritize patients arriving in the emergency department (ED). As a triage tool, the Manchester Triage System (MTS) must have a high sensitivity to minimize the occurrence of under-triage, but must not compromise specificity to avoid the occurrence of overtriage. Sensitivity and specificity of the MTS can be calculated using the frequency of appropriately assigned clinical priority levels for patients presenting to the ED. However, although there are well established criteria for the prioritization of patients with suspected acute coronary syndrome (ACS), several studies have reported difficulties when evaluating patients with this condition.
The objective of this review was to synthesize the best available evidence on assessing the sensitivity and specificity of the MTS for screening high-level priority adult patients presenting to the ED with ACS.
The current review considered studies that evaluated the use of the MTS in the risk classification of adult patients in the ED. In this review, studies that investigated the priority level, as established by the MTS to screen patients under suspicion of ACS or the sensitivity and specificity of the MTS, for screening patients before the medical diagnosis of ACS were included. This review included both experimental and epidemiological study designs.
The results were presented in a narrative synthesis. Six studies were appraised by the independent reviewers. All appraised studies enrolled a consecutive or random sample of patients and presented an overall moderate methodological quality, and all of them were included in this review. A total of 54,176 participants were included in the six studies. All studies were retrospective. Studies included in this review varied in content and data reporting. Only two studies reported sensitivity and specificity values or all the necessary data to calculate sensitivity and specificity. The remaining four studies presented either a sensitivity analysis or the number of true positives and false negatives. However, these four studies were conducted considering only data from patients diagnosed with ACS. Sensitivity values were relatively uniform among the studies: 0.70-0.80. A specificity of 0.59 was reported in the study including only patients with non-traumatic chest pain. On the other hand, in the study that included patients with any complaint, the specificity of MTS to screen patients with ACS was 0.97.
The current review demonstrates that the MTS has a moderate sensitivity to evaluate patients with ACS. This may compromise time to treatment in the ED, an important variable in the prognosis of ACS. Atypical presentation of ACS, or high specificity, may also explain the moderate sensitivity demonstrated in this review. However, because of minimal data, it is not possible to confirm this hypothesis. It is difficult to determine the acceptable level of sensitivity or specificity to ensure that a certain triage system is safe.
分诊是用于对抵达急诊科（ED）的患者进行优先排序的首个评估和分类过程。作为一种分诊工具，曼彻斯特分诊系统（MTS）必须具有高敏感性以尽量减少分诊不足的发生，但不能以牺牲特异性为代价来避免过度分诊。MTS的敏感性和特异性可以通过为前往ED就诊的患者适当分配临床优先等级的频率来计算。然而，尽管对于疑似急性冠状动脉综合征（ACS）患者的优先排序有既定标准，但多项研究报告在评估此类患者时存在困难。
本综述的目的是综合现有最佳证据，以评估MTS对筛查前往ED就诊的ACS成年高优先级患者的敏感性和特异性。
本综述纳入了评估MTS在ED成年患者风险分类中应用的研究。在本综述中，纳入了调查MTS确定的用于筛查疑似ACS患者的优先等级，或MTS在ACS医学诊断前筛查患者的敏感性和特异性的研究。本综述包括实验性和流行病学研究设计。
结果以叙述性综述形式呈现。独立评审员评估了六项研究。所有评估的研究均纳入了连续或随机抽样的患者，且总体方法学质量中等，所有这些研究均纳入本综述。六项研究共纳入54176名参与者。所有研究均为回顾性研究。本综述纳入的研究在内容和数据报告方面各不相同。只有两项研究报告了敏感性和特异性值或计算敏感性和特异性所需的所有必要数据。其余四项研究要么进行了敏感性分析，要么给出了真阳性和假阴性的数量。然而，这四项研究仅考虑了诊断为ACS患者的数据。各研究中的敏感性值相对一致：0.70 - 0.80。仅纳入非创伤性胸痛患者的研究报告的特异性为0.59。另一方面，在纳入有任何主诉患者的研究中，MTS筛查ACS患者的特异性为0.97。
本综述表明，MTS在评估ACS患者时具有中等敏感性。这可能会影响在ED的治疗时间，而治疗时间是ACS预后的一个重要变量。ACS的非典型表现或高特异性也可能解释了本综述中显示的中等敏感性。然而，由于数据极少，无法证实这一假设。难以确定可接受的敏感性或特异性水平以确保某个分诊系统是安全的。
