JBI Database of Systematic Reviews & Implementation Reports
2015;13(11):64-73
Assessing sensitivity and specificity of the Manchester Triage System in the evaluation of acute coronary syndrome in adult patients in emergency care: a systematic review protocol
Fernanda Ayache Nishi
1,3
Flávia de Oliveira Motta Maia
1,3
Dina de Almeida Lopes Monteiro da Cruz
2,3
1. University Hospital, University of São Paulo, Brazil 2. School of Nursing, University of São Paulo, Brazil 3. The Brazilian Center for Evidence-based Healthcare: a Collaborating Center of the Joanna Briggs Institute
Corresponding author: Fernanda Ayache Nishi [email protected]
Review question/objective The objective of this review is to assess the sensitivity and specificity of the Manchester Triage System in the evaluation of adult patients with acute coronary syndrome in emergency departments.
Background Acute coronary syndrome Acute coronary syndrome (ACS) is a group of clinical conditions that include myocardial infarction with 1
or without elevation of the ST segment and unstable angina. The term acute myocardial infarction (AMI) can be applied when there is evidence of myocardium necrosis with a clinical sign compatible with myocardial ischaemia. Acute myocardial infarction can be identified using clinical methods including electrocardiography (ECG), elevation in myocardium necrosis biomarkers, and imaging.
2
Acute myocardial infarction is one of the leading causes of death and disability worldwide, and may be 2
the first manifestation of coronary artery disease.
3
Estimating the prevalence of coronary diseases in the general population is quite a complex task. In 2010, the prevalence of coronary diseases was reported as 6.4% among the general population in the United States.
4
One of the main manifestations of ACS is chest pain. However, even in the presence of this typical symptom, early diagnosis of ACS is a challenge for health care professionals who initially attend to
doi: 10.11124/jbisrir-2015-2213
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these patients. Several authors have indicated the importance and difficulty of recognizing chest pain of cardiac origin, where immediate medical attention is required.
5,6
Manchester Triage System Triage, or risk classification, is a clinical management tool used in emergency services to guide patient 7
flow when the need for medical attention exceeds that available. The Manchester Triage Group was developed in 1994 in the United Kingdom. The aim was to establish a consensus among physicians and nurses in the emergency room by creating a triage pattern focused on the development of the following:
7
• Common nomenclature • Common definitions • A sound triage methodology • A professional training program. Thus, the Manchester Triage System (MTS) was created. The MTS simplifies the clinical management of each patient, and consequently, the whole service, by utilizing a system that defines the clinical priority for adults and children. The assessment of clinical priority needs to be fast; therefore, it is separated from the process of medical diagnosis. Restricting the time allocated for patient classification prevents an attempt to make a medical diagnosis at the time of classification.
7
The main goal of the MTS is to set a time limit for each patient to be attended to safely, that is, with no 7
risk to the patient’s health. One of the main principles of the system is the higher the perceived risk to 8
the patient’s health, the shorter the waiting time for medical attendance. The MTS comprises a scale of five priority levels (Table 1). Table 1: MTS scale of five priority levels and maximum response time limits for medical attendance
Maximum response time (minutes)
Evaluation
Color
Immediate
RED
0
Very urgent
ORANGE
10
Urgent
YELLOW
60
Standard
GREEN
120
Non-urgent
BLUE
240
Table adapted from Sistema Manchester de Classificação de Risco - Classificação de Risco na Urgência e Emergência, 2010, p .26.
The MTS is composed of 52 distinct flowcharts that “guide” the triage decision-making process. Based on the main presenting symptom of the patient seeking emergency care, the health care professional
doi: 10.11124/jbisrir-2015-2213
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2015;13(11):64-73
must choose one of the 52 flowcharts in order to proceed with evaluation. Classification into one of the 7,9
five clinical priority levels is set for each patient using the selected flowchart.
The lack of a risk classification system within an emergency room implies attendance on a first-come, first-served basis, which in many cases may jeopardize a patient’s safety, as patients whose health status is more unstable or severe are not prioritized. MTS sensitivity and specificity The MTS is a tool that aims to define the degree of severity and associated safe waiting time for patients in the emergency department, establishing an order of priority for medical care. It determines the clinical priority of every patient who comes to the emergency department. It is possible to evaluate the sensitivity and specificity of the MTS by calculating the frequency of appropriately assigned clinical priority levels to patients presenting at the emergency department. A “diagnostic test” can be understood as a laboratory or imaging test: however, the concepts related to “test” also apply to clinical information from other findings, such as physical examination and patient history.
11,12
The sensitivity of a test is understood as the capacity of the test to detect individuals who 10
present with a particular condition,
or the proportion of individuals with a particular condition who
have been tested positive for this condition (true positive). Highly sensitive tests can be used at the beginning of the diagnostic process, when a great number of possibilities are being considered, with the intention of excluding as many options as possible.
11
The specificity of a test is defined as the
capacity of the test to identify individuals who do not have a particular medical condition, or the proportion of individuals without the condition who have a negative test (true negative).
11
A triage
system that presents a good sensitivity can minimize the occurrence of undertriage, the same way, systems with suitable specificity can avoid the occurrence of overtriage. Acute Coronary Syndrome triage The assessment of patients with ACS suspected using the MTS, can occur through different flow charts, since the patient does not always have typical symptoms and concerns such as chest pain as the main complaint. For this reason, in addition to the flowchart “chest pain”, other flowcharts, including “shortness of breath in adults”, “unwell adult”, “collapsed adult”, and “palpitations”, enable distinguishing chest pain and other urgent conditions from non-urgent conditions, and can assist the appraiser to establish the highest priority level to treat patients with these urgent conditions. According to the algorithm from the American Heart Association, every patient who presents symptoms of chest discomfort suggestive of ischaemia must receive medical attention within 10 minutes.
13
Therefore, in order to recognize patients in those conditions, the health care professional
applying MTS must establish priority levels of “red” or “orange”, thereby setting a safe waiting time for these patients. Although there are well-established criteria for the prioritization of patients with suspected ACS, 6,14,15
several studies have reported the difficulties of evaluating patients with these conditions.
Various
factors can interfere with the outcome of this process, such as atypical presentation of symptoms, AMI classification, patient age, and professional skill. Primary studies have addressed the issue from different perspectives. Studies have been conducted to 6
evaluate the ability of nurses using MTS to detect high-risk patients with chest pain, the impact of
doi: 10.11124/jbisrir-2015-2213
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2015;13(11):64-73
8
MTS on short-term mortality in AMI, and the sensitivity and specificity of MTS for patients with ACS,
13
and to assess whether the MTS was used effectively in patients admitted to the hospital with a diagnosis of acute coronary syndrome.
15
These studies concluded that use of the MTS by nurses is a sensitive method for identifying high risk cardiac chest pain, but further studies are required to assess whether additional training can improve 6
the sensitivity of MTS. The MTS safeguards patients with typical AMI presentation and ST elevation 8
during myocardial infarction, and who are under 70 years of age. The MTS has a high sensitivity in prioritization (immediate/very urgent) of patients with ACS.
14
Additionally, most patients admitted for
ACS are initially triaged as “orange” or “yellow”, an indication for prompt assessment in the emergency department. This has a positive effect on time to first medical assessment, but has no effect on time to hospital admission.
15
A systematic review addressing a similar theme was published.
16
The review evaluated the efficacy of
MTS for all groups of patients and included studies that evaluated the MTS in relation to different outcomes. This proposed review is different as it will include primary studies with a specific sub-population (patients with ACS). Another important difference lies in the fact that the published review did not include critical appraisal of the primary studies included in review. A systematic review that synthesizes the available evidence on the sensitivity of MTS to evaluate patients with an ACS medical diagnosis is necessary to guide decisions related to the use or adoption of the instrument, as well as providing data that can contribute to improvements to the system.
Keywords acute coronary syndrome; myocardial infarction; emergency department; Manchester Triage System; sensitivity and specificity
Inclusion criteria Types of participants This review will consider studies that include adult patients (over 18 years) who have sought emergency care with any complaint, have been classified by MTS, and have received a medical diagnosis of ACS. Studies involving children (18 years or under) will be excluded, as although the instrument can be used for evaluating children, this is a population with very specific characteristics, and the inclusion of studies conducted on children could bias the results. Furthermore, ACS generally affects the adult population and incidences are highly related to risk factors such as age, sex, smoking, hypertension 2,3
and diabetes.
Types of intervention(s)/phenomena of interest This review will consider studies that evaluate the use of the MTS without modifications in risk classification of patients. No comparator will be used. Types of outcomes This review will consider studies that include the following outcome measures:
Priority level established by MTS in the evaluation of patients with medical diagnosis of ACS.
doi: 10.11124/jbisrir-2015-2213
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Analysis of the sensitivity or specificity of MTS in the evaluation of patients with ACS.
The MTS can be seen as a test; in the case of evaluation of patients with ACS, the test will be considered “positive” when the classification of these patients is “red” or “orange” (establishing medical attention within a safe time limit). The sensitivity of MTS will be determined by assessing the MTS classification in diagnosed cases of ACS (true positives and false negatives). The specificity of MTS will be determined by assessing the MTS classification in cases without ACS diagnosis (true negatives and false positives). Types of studies This review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies for inclusion. This review will also consider descriptive epidemiological study designs including case series, individual case reports and descriptive cross sectional studies for inclusion.
Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in all languages will be considered for inclusion in this review. Studies published after 1994 (the year when MTS was created) will be considered for inclusion in this review. The databases to be searched include: MEDLINE, CINAHL, Web of Science, EMBASE, Scopus, LILACS, Bandolier, Clinical Evidence, Science Direct, IBECS, ProQuest and Cochrane Central Register of Control Trials. The search for unpublished studies will include: Google scholar, Banco de Teses – CAPES and Digital Dissertations. Initial keywords to be used will be: Acute Coronary Syndrome, Myocardial Infarction, Triage System, Severity Index, Manchester Triage System, sensitivity, specificity
Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute, the JBI Critical Appraisal Checklist for Diagnostic Test Accuracy Studies (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
doi: 10.11124/jbisrir-2015-2213
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Data extraction Data will be extracted from papers included in the review using the JBI standardized data extraction tool for accuracy of diagnostic test studies
17
(Appendix II). The data extracted will include specific
details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
Data synthesis Sensitivity, specificity, true positives (TP), false positives (FP), true negatives (TN) and false negatives (FN) will be extracted directly from the papers. If this is not possible, values will be calculated from the data that was provided. Positive and negative likelihood ratios, diagnostic odds ratios, and 95% confidence intervals will be calculated. The data will be displayed on forest and ROC plots. Quantitative data will, where possible be pooled in statistical meta-analysis using Revman 5 (Cochrane Collaboration) The decision to conduct meta-analysis will consider the methodological and clinical basis of the primary studies.
10,17
All results will be subject to double data entry. Heterogeneity will be
assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.
Conflicts of interest No conflict of interest is declared from the researchers.
Acknowledgements The authors would like to acknowledge post graduate staff of School of Nursing of University of São Paulo for their assistance. The authors would also like to acknowledge the nursing staff of University Hospital for their encouragement in pursuing this project.
doi: 10.11124/jbisrir-2015-2213
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References 1. Kumar A, Cannon CP. Acute coronary syndromes: diagnosis and management, part I. Mayo Clin Proc. 2009;84(10):917-38. 2. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al. Third universal definition of myocardial infarction. Circulation. 2012;126(16):2020-35. 3. Ferreira-González I. The Epidemiology of Coronary Heart Disease. Rev Esp Cardiol. 2014;67(2):139-44. 4. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, et al. Executive summary: heart disease and stroke statistics--2014 update: a report from the American Heart Association. Circulation. 2014;129(3):399-410. 5. Rohacek M, Bertolotti A, Grützmüller N, Simmen U, Marty H, Zimmermann H, et al. The challenge of triaging chest pain patients: the bernese university hospital experience. Emerg Med Int. 2012;2012:975614. 6. Speake D, Teece S, Mackway-Jones K. Detecting high-risk patients with chest pain. Emerg Nurse. 2003;11(5):19-21. 7. Mackway-Jones K, Marsden J, Windle J. Sistema Manchester de Classificação de Risco Classificação de Risco na Urgência e Emergência. 2 ed. Belo Horizonte: Grupo Brasileiro de Classificação de Risco; 2010. 8. Providência R, Gomes PL, Barra S, Silva J, Seca L, Antunes A, et al. Importance of Manchester Triage in acute myocardial infarction: impact on prognosis. Emerg Med J. 2011;28(3):212-6. 9. Grouse AI, Bishop RO, Bannon AM. The Manchester Triage System provides good reliability in an Australian emergency department. Emerg Med J. 2009;26(7):484-6. 10. White S, Schultz T, Enuameh YAK. Synthesizing Evidence of Diagnostic Accuracy. Philadelphia: Lippincott Williams & Wilkins; 2011. 11. Benseñor IM, Lotufo PA. Epidemiologia: abordagem prática. São Paulo: Sarvier; 2005. 12. Fletcher RH. Epidemiologia clínica: elementos essenciais. Porto Alegre: Artmed; 2006. 288 p. 13. O'Connor RE, Brady W, Brooks SC, Diercks D, Egan J, Ghaemmaghami C, et al. Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S787-817. 14. Pinto D, Lunet N, Azevedo A. Sensitivity and specificity of the Manchester Triage System for patients with acute coronary syndrome. Rev Port Cardiol. 2010;29(6):961-87. 15. Matias C, Oliveira R, Duarte R, Bico P, Mendonça C, Nuno L, et al. The Manchester Triage System in acute coronary syndromes. Rev Port Cardiol. 2008;27(2):205-16. 16. Azeredo TR, Guedes HM, Rebelo de Almeida RA, Chianca TC, Martins JC. Efficacy of the Manchester Triage System: a systematic review. Int Emerg Nurs. 2015;23(2):47-52. 17. Campbell JM, Klugar M, Ding S, Carmody DP, Hakonsen SJ, Jadotte YT, et al. Diagnostic test accuracy: methods for systematic review and meta-analysis. Int J Evid Based Healthc. 2015;13(3):154-62.
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Appendix I: Appraisal instruments JBI critical appraisal checklist for diagnostic test accuracy studies
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Appendix II: Data extraction instrument Author/Date Inclusion/exclusion criteria: i.e. presenting
Inclusion:
symptoms, results from previous tests Exclusion:
Sample size Participant demographics (i.e. age, sex, spectrum
of
presenting
symptoms,
comorbidity, current treatments, recruitment centers) Study methodology ( consecutive or random; retrospective or prospective) Period that study was carried out (beginning and end date) Index test description (including criteria for positive test) Reference test description (including criteria for positive test) Geographical location of data collection Setting of data collection Persons executing and interpreting index tests (numbers, training, and expertise) Persons executing and interpreting reference test Index/reference time interval (and treatments carried out in between) Distribution of severity of disease in those with target condition Other diagnoses in those without target condition Adverse events from index test Adverse events from reference test
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Index test results
Condition
Condition
Threshold=
positive
negative
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Total
Index test positive (T+) Index
test
negative
(T-) Total
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Assessing sensitivity and specificity of the Manchester Triage System in the evaluation of acute coronary syndrome in adult patients in emergency care: a systematic review protocol
Fernanda Ayache Nishi
1,3
Flávia de Oliveira Motta Maia
1,3
Dina de Almeida Lopes Monteiro da Cruz
2,3
1. University Hospital, University of São Paulo, Brazil 2. School of Nursing, University of São Paulo, Brazil 3. The Brazilian Center for Evidence-based Healthcare: a Collaborating Center of the Joanna Briggs Institute
Corresponding author: Fernanda Ayache Nishi [email protected]
Review question/objective The objective of this review is to assess the sensitivity and specificity of the Manchester Triage System in the evaluation of adult patients with acute coronary syndrome in emergency departments.
Background Acute coronary syndrome Acute coronary syndrome (ACS) is a group of clinical conditions that include myocardial infarction with 1
or without elevation of the ST segment and unstable angina. The term acute myocardial infarction (AMI) can be applied when there is evidence of myocardium necrosis with a clinical sign compatible with myocardial ischaemia. Acute myocardial infarction can be identified using clinical methods including electrocardiography (ECG), elevation in myocardium necrosis biomarkers, and imaging.
2
Acute myocardial infarction is one of the leading causes of death and disability worldwide, and may be 2
the first manifestation of coronary artery disease.
3
Estimating the prevalence of coronary diseases in the general population is quite a complex task. In 2010, the prevalence of coronary diseases was reported as 6.4% among the general population in the United States.
4
One of the main manifestations of ACS is chest pain. However, even in the presence of this typical symptom, early diagnosis of ACS is a challenge for health care professionals who initially attend to
doi: 10.11124/jbisrir-2015-2213
Page 64
JBI Database of Systematic Reviews & Implementation Reports
2015;13(11):64-73
these patients. Several authors have indicated the importance and difficulty of recognizing chest pain of cardiac origin, where immediate medical attention is required.
5,6
Manchester Triage System Triage, or risk classification, is a clinical management tool used in emergency services to guide patient 7
flow when the need for medical attention exceeds that available. The Manchester Triage Group was developed in 1994 in the United Kingdom. The aim was to establish a consensus among physicians and nurses in the emergency room by creating a triage pattern focused on the development of the following:
7
• Common nomenclature • Common definitions • A sound triage methodology • A professional training program. Thus, the Manchester Triage System (MTS) was created. The MTS simplifies the clinical management of each patient, and consequently, the whole service, by utilizing a system that defines the clinical priority for adults and children. The assessment of clinical priority needs to be fast; therefore, it is separated from the process of medical diagnosis. Restricting the time allocated for patient classification prevents an attempt to make a medical diagnosis at the time of classification.
7
The main goal of the MTS is to set a time limit for each patient to be attended to safely, that is, with no 7
risk to the patient’s health. One of the main principles of the system is the higher the perceived risk to 8
the patient’s health, the shorter the waiting time for medical attendance. The MTS comprises a scale of five priority levels (Table 1). Table 1: MTS scale of five priority levels and maximum response time limits for medical attendance
Maximum response time (minutes)
Evaluation
Color
Immediate
RED
0
Very urgent
ORANGE
10
Urgent
YELLOW
60
Standard
GREEN
120
Non-urgent
BLUE
240
Table adapted from Sistema Manchester de Classificação de Risco - Classificação de Risco na Urgência e Emergência, 2010, p .26.
The MTS is composed of 52 distinct flowcharts that “guide” the triage decision-making process. Based on the main presenting symptom of the patient seeking emergency care, the health care professional
doi: 10.11124/jbisrir-2015-2213
Page 65
JBI Database of Systematic Reviews & Implementation Reports
2015;13(11):64-73
must choose one of the 52 flowcharts in order to proceed with evaluation. Classification into one of the 7,9
five clinical priority levels is set for each patient using the selected flowchart.
The lack of a risk classification system within an emergency room implies attendance on a first-come, first-served basis, which in many cases may jeopardize a patient’s safety, as patients whose health status is more unstable or severe are not prioritized. MTS sensitivity and specificity The MTS is a tool that aims to define the degree of severity and associated safe waiting time for patients in the emergency department, establishing an order of priority for medical care. It determines the clinical priority of every patient who comes to the emergency department. It is possible to evaluate the sensitivity and specificity of the MTS by calculating the frequency of appropriately assigned clinical priority levels to patients presenting at the emergency department. A “diagnostic test” can be understood as a laboratory or imaging test: however, the concepts related to “test” also apply to clinical information from other findings, such as physical examination and patient history.
11,12
The sensitivity of a test is understood as the capacity of the test to detect individuals who 10
present with a particular condition,
or the proportion of individuals with a particular condition who
have been tested positive for this condition (true positive). Highly sensitive tests can be used at the beginning of the diagnostic process, when a great number of possibilities are being considered, with the intention of excluding as many options as possible.
11
The specificity of a test is defined as the
capacity of the test to identify individuals who do not have a particular medical condition, or the proportion of individuals without the condition who have a negative test (true negative).
11
A triage
system that presents a good sensitivity can minimize the occurrence of undertriage, the same way, systems with suitable specificity can avoid the occurrence of overtriage. Acute Coronary Syndrome triage The assessment of patients with ACS suspected using the MTS, can occur through different flow charts, since the patient does not always have typical symptoms and concerns such as chest pain as the main complaint. For this reason, in addition to the flowchart “chest pain”, other flowcharts, including “shortness of breath in adults”, “unwell adult”, “collapsed adult”, and “palpitations”, enable distinguishing chest pain and other urgent conditions from non-urgent conditions, and can assist the appraiser to establish the highest priority level to treat patients with these urgent conditions. According to the algorithm from the American Heart Association, every patient who presents symptoms of chest discomfort suggestive of ischaemia must receive medical attention within 10 minutes.
13
Therefore, in order to recognize patients in those conditions, the health care professional
applying MTS must establish priority levels of “red” or “orange”, thereby setting a safe waiting time for these patients. Although there are well-established criteria for the prioritization of patients with suspected ACS, 6,14,15
several studies have reported the difficulties of evaluating patients with these conditions.
Various
factors can interfere with the outcome of this process, such as atypical presentation of symptoms, AMI classification, patient age, and professional skill. Primary studies have addressed the issue from different perspectives. Studies have been conducted to 6
evaluate the ability of nurses using MTS to detect high-risk patients with chest pain, the impact of
doi: 10.11124/jbisrir-2015-2213
Page 66
JBI Database of Systematic Reviews & Implementation Reports
2015;13(11):64-73
8
MTS on short-term mortality in AMI, and the sensitivity and specificity of MTS for patients with ACS,
13
and to assess whether the MTS was used effectively in patients admitted to the hospital with a diagnosis of acute coronary syndrome.
15
These studies concluded that use of the MTS by nurses is a sensitive method for identifying high risk cardiac chest pain, but further studies are required to assess whether additional training can improve 6
the sensitivity of MTS. The MTS safeguards patients with typical AMI presentation and ST elevation 8
during myocardial infarction, and who are under 70 years of age. The MTS has a high sensitivity in prioritization (immediate/very urgent) of patients with ACS.
14
Additionally, most patients admitted for
ACS are initially triaged as “orange” or “yellow”, an indication for prompt assessment in the emergency department. This has a positive effect on time to first medical assessment, but has no effect on time to hospital admission.
15
A systematic review addressing a similar theme was published.
16
The review evaluated the efficacy of
MTS for all groups of patients and included studies that evaluated the MTS in relation to different outcomes. This proposed review is different as it will include primary studies with a specific sub-population (patients with ACS). Another important difference lies in the fact that the published review did not include critical appraisal of the primary studies included in review. A systematic review that synthesizes the available evidence on the sensitivity of MTS to evaluate patients with an ACS medical diagnosis is necessary to guide decisions related to the use or adoption of the instrument, as well as providing data that can contribute to improvements to the system.
Keywords acute coronary syndrome; myocardial infarction; emergency department; Manchester Triage System; sensitivity and specificity
Inclusion criteria Types of participants This review will consider studies that include adult patients (over 18 years) who have sought emergency care with any complaint, have been classified by MTS, and have received a medical diagnosis of ACS. Studies involving children (18 years or under) will be excluded, as although the instrument can be used for evaluating children, this is a population with very specific characteristics, and the inclusion of studies conducted on children could bias the results. Furthermore, ACS generally affects the adult population and incidences are highly related to risk factors such as age, sex, smoking, hypertension 2,3
and diabetes.
Types of intervention(s)/phenomena of interest This review will consider studies that evaluate the use of the MTS without modifications in risk classification of patients. No comparator will be used. Types of outcomes This review will consider studies that include the following outcome measures:
Priority level established by MTS in the evaluation of patients with medical diagnosis of ACS.
doi: 10.11124/jbisrir-2015-2213
Page 67
JBI Database of Systematic Reviews & Implementation Reports
2015;13(11):64-73
Analysis of the sensitivity or specificity of MTS in the evaluation of patients with ACS.
The MTS can be seen as a test; in the case of evaluation of patients with ACS, the test will be considered “positive” when the classification of these patients is “red” or “orange” (establishing medical attention within a safe time limit). The sensitivity of MTS will be determined by assessing the MTS classification in diagnosed cases of ACS (true positives and false negatives). The specificity of MTS will be determined by assessing the MTS classification in cases without ACS diagnosis (true negatives and false positives). Types of studies This review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies for inclusion. This review will also consider descriptive epidemiological study designs including case series, individual case reports and descriptive cross sectional studies for inclusion.
Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in all languages will be considered for inclusion in this review. Studies published after 1994 (the year when MTS was created) will be considered for inclusion in this review. The databases to be searched include: MEDLINE, CINAHL, Web of Science, EMBASE, Scopus, LILACS, Bandolier, Clinical Evidence, Science Direct, IBECS, ProQuest and Cochrane Central Register of Control Trials. The search for unpublished studies will include: Google scholar, Banco de Teses – CAPES and Digital Dissertations. Initial keywords to be used will be: Acute Coronary Syndrome, Myocardial Infarction, Triage System, Severity Index, Manchester Triage System, sensitivity, specificity
Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute, the JBI Critical Appraisal Checklist for Diagnostic Test Accuracy Studies (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
doi: 10.11124/jbisrir-2015-2213
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2015;13(11):64-73
Data extraction Data will be extracted from papers included in the review using the JBI standardized data extraction tool for accuracy of diagnostic test studies
17
(Appendix II). The data extracted will include specific
details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
Data synthesis Sensitivity, specificity, true positives (TP), false positives (FP), true negatives (TN) and false negatives (FN) will be extracted directly from the papers. If this is not possible, values will be calculated from the data that was provided. Positive and negative likelihood ratios, diagnostic odds ratios, and 95% confidence intervals will be calculated. The data will be displayed on forest and ROC plots. Quantitative data will, where possible be pooled in statistical meta-analysis using Revman 5 (Cochrane Collaboration) The decision to conduct meta-analysis will consider the methodological and clinical basis of the primary studies.
10,17
All results will be subject to double data entry. Heterogeneity will be
assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.
Conflicts of interest No conflict of interest is declared from the researchers.
Acknowledgements The authors would like to acknowledge post graduate staff of School of Nursing of University of São Paulo for their assistance. The authors would also like to acknowledge the nursing staff of University Hospital for their encouragement in pursuing this project.
doi: 10.11124/jbisrir-2015-2213
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References 1. Kumar A, Cannon CP. Acute coronary syndromes: diagnosis and management, part I. Mayo Clin Proc. 2009;84(10):917-38. 2. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al. Third universal definition of myocardial infarction. Circulation. 2012;126(16):2020-35. 3. Ferreira-González I. The Epidemiology of Coronary Heart Disease. Rev Esp Cardiol. 2014;67(2):139-44. 4. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, et al. Executive summary: heart disease and stroke statistics--2014 update: a report from the American Heart Association. Circulation. 2014;129(3):399-410. 5. Rohacek M, Bertolotti A, Grützmüller N, Simmen U, Marty H, Zimmermann H, et al. The challenge of triaging chest pain patients: the bernese university hospital experience. Emerg Med Int. 2012;2012:975614. 6. Speake D, Teece S, Mackway-Jones K. Detecting high-risk patients with chest pain. Emerg Nurse. 2003;11(5):19-21. 7. Mackway-Jones K, Marsden J, Windle J. Sistema Manchester de Classificação de Risco Classificação de Risco na Urgência e Emergência. 2 ed. Belo Horizonte: Grupo Brasileiro de Classificação de Risco; 2010. 8. Providência R, Gomes PL, Barra S, Silva J, Seca L, Antunes A, et al. Importance of Manchester Triage in acute myocardial infarction: impact on prognosis. Emerg Med J. 2011;28(3):212-6. 9. Grouse AI, Bishop RO, Bannon AM. The Manchester Triage System provides good reliability in an Australian emergency department. Emerg Med J. 2009;26(7):484-6. 10. White S, Schultz T, Enuameh YAK. Synthesizing Evidence of Diagnostic Accuracy. Philadelphia: Lippincott Williams & Wilkins; 2011. 11. Benseñor IM, Lotufo PA. Epidemiologia: abordagem prática. São Paulo: Sarvier; 2005. 12. Fletcher RH. Epidemiologia clínica: elementos essenciais. Porto Alegre: Artmed; 2006. 288 p. 13. O'Connor RE, Brady W, Brooks SC, Diercks D, Egan J, Ghaemmaghami C, et al. Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S787-817. 14. Pinto D, Lunet N, Azevedo A. Sensitivity and specificity of the Manchester Triage System for patients with acute coronary syndrome. Rev Port Cardiol. 2010;29(6):961-87. 15. Matias C, Oliveira R, Duarte R, Bico P, Mendonça C, Nuno L, et al. The Manchester Triage System in acute coronary syndromes. Rev Port Cardiol. 2008;27(2):205-16. 16. Azeredo TR, Guedes HM, Rebelo de Almeida RA, Chianca TC, Martins JC. Efficacy of the Manchester Triage System: a systematic review. Int Emerg Nurs. 2015;23(2):47-52. 17. Campbell JM, Klugar M, Ding S, Carmody DP, Hakonsen SJ, Jadotte YT, et al. Diagnostic test accuracy: methods for systematic review and meta-analysis. Int J Evid Based Healthc. 2015;13(3):154-62.
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Appendix I: Appraisal instruments JBI critical appraisal checklist for diagnostic test accuracy studies
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Appendix II: Data extraction instrument Author/Date Inclusion/exclusion criteria: i.e. presenting
Inclusion:
symptoms, results from previous tests Exclusion:
Sample size Participant demographics (i.e. age, sex, spectrum
of
presenting
symptoms,
comorbidity, current treatments, recruitment centers) Study methodology ( consecutive or random; retrospective or prospective) Period that study was carried out (beginning and end date) Index test description (including criteria for positive test) Reference test description (including criteria for positive test) Geographical location of data collection Setting of data collection Persons executing and interpreting index tests (numbers, training, and expertise) Persons executing and interpreting reference test Index/reference time interval (and treatments carried out in between) Distribution of severity of disease in those with target condition Other diagnoses in those without target condition Adverse events from index test Adverse events from reference test
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Index test results
Condition
Condition
Threshold=
positive
negative
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Total
Index test positive (T+) Index
test
negative
(T-) Total
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