title: Manchester triage in acute pulmonary embolism: can it unmask the grand impersonator?
abstract: BACKGROUND
  Acute pulmonary embolism (PE) is associated with high mortality risk. Early diagnosis is difficult because of non-specific clinical presentation and delay in imaging confirmation. Manchester Triage (MT) prioritises patients on the basis of illness severity and potentially recognises those with higher mortality risk. No studies of the role and impact of MT on rapid PE diagnosis and in-hospital mortality (IHM) have been carried out.
  
  
  OBJECTIVE
  To assess the appropriateness of MT in this set of patients presenting acutely to the emergency department (ED), and to determine whether it assists in a rapid diagnosis, acts as a protective triage tool and affects short-term mortality.
  
  
  METHODS
  Single-centre retrospective study of 176 consecutive patients with PE, assessed by MT in the ED between January 2006 and October 2010 (mean age 70.5±15.7 years, 38.6% men). The primary outcome measure was all-cause IHM.
  
  
  RESULTS
  IHM was seen in 30 (17%) patients. More than half of the patients with PE (54%) were classified as target time for first medical observation (MOb) ≤10 min. 73.3% of IHM occurred in this group (p=0.020) with several increased markers of illness severity. MOb ≤10 min was not associated with faster PE imaging confirmation. The average door-to-diagnosis time (PEDx) was 26.8±36.8 h and PEDx >17.0 h was associated with higher IHM (p=0.017). On multivariate analysis, thrombolysis and MOb ≤10 min were included in an IHM predictor model.
  
  
  CONCLUSIONS
  MT has high sensitivity in identifying patients with PE at risk. Those patients assigned as MOb ≤10 min have increased markers of illness severity and higher IHM. MT acts as a protective system in this challenging set and should be used as a patient's first assessment, aiding the emergency medical team to recognise those in need of urgent assessment and treatment.
authors.affiliation: Cardiology Department, Coimbra's Hospital Centre, Quinta dos Vales, 3041-801 S. Martinho do Bispo, Coimbra 3041-801, Portugal. luisvpaiva@gmail.com
authors.forename: L
authors.initials: L
authors.lastname: Paiva
authors.forename: R
authors.initials: R
authors.lastname: Providencia
authors.forename: A
authors.initials: A
authors.lastname: Faustino
authors.forename: S
authors.initials: S
authors.lastname: Barra
authors.forename: A
authors.initials: A
authors.lastname: Botelho
authors.forename: A M
authors.initials: AM
authors.lastname: Leitao-Marques
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D010043:Outcome and Process Assessment, Health Care; D011655:Pulmonary Embolism / Q000175:diagnosis* / Q000401:mortality; D012372:ROC Curve; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D014218:Triage / Q000592:standards*