International Emergency Nursing (2009) 17, 143– 148

available at www.sciencedirect.com

journal homepage: www.elsevierhealth.com/journals/aaen

Manchester Triage in Sweden – Interrater

reliability and accuracy
Pia Olofsson BSc, RN (Leader of Research and Development Team) a,
Martin Gellerstedt PhD (Senior Lecturer) b,
c,*
Eric D. Carlström PhD, MA, RN (Senior Lecturer, Director of Research)

a
Department of Emergency Medicin, Nu-sjukvården, Trollhättan, Sweden
b
Statistics/Informatics, University West, Department of Informatics, Trollhättan, Sweden
c
Health Management, Policy and Economics, Director of Research, University West, Department of Nursing,
Health and Culture, SE-461 86 Trollhättan, Sweden

Received 30 July 2008; received in revised form 29 November 2008; accepted 30 November 2008

KEYWORDS Abstract
Triage; Introduction: This study investigates the interrater reliability and the accuracy of Manchester
Reliability;
Triage (MTS) at emergency departments in Western Sweden.
Emergency care;
Methods: A group of 79 nurses from seven emergency departments assessed simulated patient
Sweden
cases and assigned triage categories using the same principles as in their daily work. K statis-
tics, accuracy, over-triage and under-triage were then analyzed. The nurses performed 1027
triage assessments.
Results: The result showed an unweighted j value of 0.61, a linear weighted j value of 0.71,
and a quadratic weighted j value of 0.81. The determined accuracy was 92% and 91% for the
two most urgent categories, but significantly lower for the less urgent categories.
Conclusions: Patients in need of urgent care were identified in more than nine out of 10 cases.
The high level of over-triage and under-triage in the less urgent categories resulted in low
agreement and accuracy. This may suggest that the resources of emergency departments
can be overused for non-urgent patients.
ª 2008 Elsevier Ltd. All rights reserved.

Introduction

Triage, i.e., prioritizing and sorting at emergency depart-

ments, has been attracting increasing attention. In particu-
* Corresponding author. Tel.: +46 702738126; fax: +46 520223099. lar, older patients with multiple diagnoses are becoming
E-mail address: eric.carlstrom@hv.se (E.D. Carlström). more common (Goodacre et al., 1999; Beveridge et al.,

1755-599X/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ienj.2008.11.008
144
1999; Palmquist and Lindell, 2000; Göransson, 2006). The
prioritization carried out has, therefore, also become more
complex. More parameters have been introduced for the or-
der in which patients are treated (Baldursdottir and Jons-
dottir, 2002; Fernandes et al., 2005; Göransson, 2006).
The triage models, which were developed during the
1990s have been refined and have become national standards
in some countries (Fernandes et al., 2005; Worster et al.,
2004). Australia was the first to introduce a triage model,
‘‘The National Triage Scale’’. The model was developed by
The Australasian College for Emergency Medicine in 1993.
At the beginning of the 21st century its name was changed
to ‘‘The Australasian Triage Scale’’ (ATS). In Canada a triage
model was developed in the mid-1990s, which was based on
the Australian model ATS, ‘‘The Canadian Emergency
Department Triage and Acuity Scale’’ (CTAS). In the USA an-
other triage model, ‘‘The Emergency Severity Index’’ (ESI)
has been in existence since the end of the 1990s (Beveridge
et al., 1998; Gilboy et al., 2005; McCallum Pardey, 2006).
This study focuses on a fifth national standard model,
‘‘Manchester Triage’’ (MTS) (Mackway-Jones, 1997) which
is accepted as a standard at emergency departments in
Great Britain, Holland and Portugal (Lipley, 2005). In this
article we examine the interrater reliability and accuracy
using MTS at emergency departments in Western Sweden
where the model has been implemented. There have been
no earlier studies of the method applicable to Western Swe-
den. There was, therefore, a need to research the case.
Background
At the beginning of the 21st century discussions began at
emergency departments in Western Sweden with regards
to implementing a common triage model. At this time most
departments used the Swedish National Board of Health and
Welfare criteria document which only provided three prior-
itization levels (Socialstyrelsen, 1994). When the waiting
times increased due to an increased patient influx at the
emergency departments in Western Sweden, discussions ar-
ose that led to the conclusion that the criteria document did
not satisfy the requirements for emergency departments. In
order to find a structured triage model, which more effec-
tively met the needs of the emergency departments, foreign
triage models were studied. MTS was the one chosen. It was
hoped that patient safety would increase where the patients
needed immediate care. It was also hoped that an order of
treatment based on clinical need could be achieved for
remaining patients (Dann et al., 2005). The aim of this study
was to find out whether patients in need of urgent care were
identified by means of MTS.
MTS
Prioritization times in MTS are associated with colours. The
model has five triage categories and time intervals specified
in minutes. The time corresponds to the longest recom-
mended time based on clinical indicators. The patients tri-
aged in the highest category (red) are in need of
immediate care. The next two categories (orange and yel-
low) have longer recommended time allowance (10 and
60 min, respectively). The two lowest categories (green
P. Olofsson et al.
and blue) have the longest recommended time allowances
of 120 and 240 min from the patient’s arrival to seeing a
physician.
The decision model for MTS consists of 52 flow charts
based on the most common reasons for emergency visits.
The flow charts are designed so that the most urgent cate-
gory is presented first in order for the most serious clinical
indicators to be identified as fast as possible (MackWay-
Jones, 1997; Widfeldt, 2005).
Measuring reliability and validity
Existing triage studies principally measure the model’s reli-
ability or validity (Gilboy et al., 2005). The validity corre-
sponds to the model’s sensitivity and specificity. One way
to measure this is to compare the triage category assessed
by the nurse with a standard value. This includes the re-
sources used and the end result of the triage. It could in-
clude the hospitalization of a patient or biological markers
such as test results and fatalities (Altman, 1999; Cooke
and Jinks, 1999; Stenstrom et al., 2003; Dong et al., 2007).
If the triage model is reliable, the end result of the triage
will be the same, independent of which nurse makes the
assessment. This is often defined as the kappa value (j)
and measures the degree of agreement between obtained
and predicted values (Altman, 1999; Jakobsson and Wester-
gren, 2005). The ranking order is from 0 to 1, where 0 means
that there is no agreement other than what is random, and 1
means complete agreement. The range 0.8–1.0 is consid-
ered excellent agreement, 0.6–0.8 good agreement, 0.4–
0.6 moderate agreement, 0.2–0.4 fair agreement, and less
than 0.2 poor agreement (Altman, 1999; Goodacre et al.,
1999; Jakobsson and Westergren, 2005).
Weighted and unweighted j values
Two kinds of j values, weighted and unweighted, appear in
the studies. The difference is that unweighted j values only
include identical assessments as acceptable. Weighted j
values are more ‘‘flexible’’ since assessments deviating
somewhat from the predicted are considered partially
acceptable (Altman, 1999; Jakobsson and Westergren,
2005).
There are relatively few studies of MTS reliability, and
those in existence are limited. Two studies are presented
here (Goodacre et al., 1999; Versloot and Luitse, 2007).
The first of these was retrospective and dealt with four
experienced emergency physicians with no prior MTS expe-
rience. They analyzed the notes of the triage nurses and
then assessed the triage category according to MTS flow
charts. The agreement between the four physicians was
measured by calculating the j values between different
pairs of assessments. The j values presented varied be-
tween 0.31 and 0.63. It was not specified whether the j val-
ues were weighted or unweighted (Goodacre et al., 1999).
The second study presented the interrater reliability
using simulated patient cases. Eight nurses with MTS experi-
ence each assessed 50 patient cases. The obtained un-
weighted linear j value was 0.76 and the obtained
weighted quadratic j value was 0.82 (Versloot and Luitse,
2007). Two kinds of unweighted j values, quadratic and lin-
Manchester Triage in Sweden – Interrater reliability and accuracy
ear, appear in the studies. In the quadratic set weights are
higher than in the linear. Consequently the quadratic j va-
lue is more allowing than the linear (Cohen, 1968). Kappa
with quadratic weights is easier to interpret since it is
equivalent to the intraclass correlation coefficient (ICC)
(Fleiss and Cohen, 1973).
In one of the few triage studies performed in Sweden,
nurses assessed simulated patient cases according to CTAS
time priorities (Göransson et al., 2005). CTAS is similar to
MTS but with shorter waiting times (Beveridge et al.,
1998). When the study was carried out, only a few emer-
gency departments were using a full-scale triage model.
The nurses had no CTAS training and their actions had no
medical basis. The study indicates an unweighted j value
of 0.46 and a weighted j value of 0.71, i.e., a moderate
to good agreement. It was not specified whether the
weighted j value was linear or quadratic (Göransson
et al., 2005).
Accuracy, over-triage and under-triage
Accuracy is another measure used in triage studies (Consi-
dine et al., 2000, 2004; Grafstein et al., 2003; Göransson
et al., 2005; Manos et al., 2002). It specifies the assess-
ment to a predicted triage category. An expert panel
chooses triage categories for a number of simulated pa-
tient cases. If the assessments carried out in the study
are in agreement with these predicted values, it would sug-
gest a high accuracy. In the above-mentioned Swedish
study, the accuracy did not exceed 57.7% (Göransson
et al., 2005).
Other measures often presented in studies are over-tri-
age and under-triage. They are triage categories that are
higher or lower than the predicted category considered
the reference value. If patients are given high priority with-
out reason, the increased resources applied for these pa-
tients can mean long waiting times for other patients.
Over-triage and under-triage are presented as percentages.
Göransson et al. (2005) present, for example, an over-triage
of 28.4% and an under-triage of 13.9%. In another study per-
formed at a pedriatic emergency department using ATS
(similar to CTAS time priorities), an over-triage of 22.6%
and an under-triage of 15.7% were obtained (Crellin and
Johnston, 2003).
Method
The research design was a prospective and descriptive sur-
vey based on simulated patient cases. The data was col-
lected by asking triage nurses (n = 79) to assess simulated
patient cases and determine a triage category according
to the same principles used in their daily triage work. The
cases had been given reference values by two expert panels.
An analysis subsequently took place of the j values, the
accuracy, the over-triage and the under-triage.
Nine emergency departments in Western Sweden use the
MTS triage model. These all had trained instructors who in
turn had trained nurses in using MTS. All the emergency
departments used flow charts that had been translated to
Swedish from the original version. Only one of the depart-
ments declined to participate in the study.
145
The capacity varied from 22,000 to 50,000 visitors per
year and the numbers of nurses employed were between
30 and 60 per emergency department. One of the emer-
gency departments was excluded since it only accepted
children. The rest had mixed specialties, such as internal
medicine, surgery, and orthopedics.
In this study, a random day was selected for data collec-
tion at the remaining seven emergency departments. Only
nurses normally working in triage participated in the study.
An inclusion criterion was that at least ten nurses with at
least six months triage work experience should participate
from each department during the selected day.
Simulated patient cases were presented in a survey con-
sisting of two parts. The first part included questions about
the nurse’s background while the second part listed patient
cases similar to those the nurse experiences in her daily
routine.
Patient cases
Nine of the patient cases were taken from an Australasian
study (Considine et al., 2000). They were revised, however,
to resemble patient cases at Swedish emergency depart-
ments. An additional five patient cases were developed
from authentic scenarios extracted through studies of pa-
tient journals. A total of 14 simulated patient cases were
used in the study, all designed to reflect the distribution
of triage categories normal at emergency departments.
Special attention was given to categories risking both
over-triage and under-triage. They corresponded to orange,
yellow, and green categories. Therefore, only one of the pa-
tient cases was reported as red, while as many as three
were orange, six were yellow, and three were green. The
blue triage category was not represented by any of the pa-
tient cases in the study. This was because a ‘‘blue patient’’
did not match the criteria of an emergency department.
The majority of the patients visiting an emergency depart-
ment are in the orange, yellow and green categories (Gilboy
et al., 2005).
Those constructing the simulated patient cases assessed
each case and predicted the triage category according to a
consensus discussion. Two independent expert panels were
subsequently formed. One panel consisted of two chief phy-
sicians with considerable experience in emergency care and
an introduction to MTS applications. One of these physicians
had been responsible for the Swedish translation of MTS.
The other panel consisted of three nurses who were trained
and had long experience in MTS. These two panels assessed
(1) the triage category for each patient case, (2) if the pa-
tient cases were suitable for emergency departments in
Western Sweden, and (3) if the presentation was under-
standable. They registered to what level they reached con-
sensus. The expert panels were in disagreement about the
predicted outcome of one of the cases, and it was therefore
excluded (Twomey et al., 2007). There were no changes re-
quired for the remaining patient cases.
The survey
The seven emergency departments participating in the
study used different nomenclature for flow chart, selection
146 P. Olofsson et al.

criterion, and triage category. Because of this, a pilot study
was performed where those representing the various emer-
gency departments gave their opinions on the choice of
word so that all participants would understand the formula-
tions. Minor adjustments were made to the survey in accor-
dance with the pilot group’s opinions.
The survey contained an introductory sheet where the
background of the study was described. It also contained
detailed instructions and information stating that participa-
tion was voluntary. The study was considered exempt from
formal ethics, as it did not impact on patient care. Only the
researchers had access to the survey results that were sub-
sequently coded.
The following analysis was performed: the interrater reli-
ability was given as j values, whereas accuracy, over-triage,
under-triage, and distribution of triage categories were gi-
ven in percentages. The j values were presented as un-
weighted and weighted values. Weighted j values were
further divided into linear and quadratic values (Altman,
1999).
to excellent (0.8–1.0) agreement. Between the various
emergency departments, the unweighted j value varied be-
tween 0.56 and 0.65, the linear weighted j value between
0.68 and 0.75, and the quadratic weighted j between 0.78
and 0.85 (Table 1). Two of the departments thus showed a
moderate agreement, i.e., an unweighted j of just under
0.6. The rest showed good agreement. The quadratic
weighted j values, however, indicate excellent agreement
at six of the emergency departments.
Table 2 shows the distribution of over-triage (14%) and
under-triage (13%). This meant that almost as many cases
were given higher priority as cases given lower priority in
comparison with the predicted outcome. The mean accu-
racy for the emergency departments was 73%. It was partic-
ularly high for the red (92%) and the orange (91%)
categories, but significantly lower for the less urgent cate-
gories. Over-triage and under-triage results showed greater
values for the yellow and green than for the more urgent red
and orange categories. Within the green category, incorrect
estimates occurred over two stages of over-triage.

Results Discussion

Seven emergency departments took part in the study. The
nurses (n = 79) assessed 13 patient cases each. A total of
1027 triage assessments were analyzed. There were 82% fe-
male and 18% male participants, and 91% were older than 25
years of age. The majority of the nurses had worked more
than two years after completing their basic training.
The participating nurses from the seven emergency
departments together presented an unweighted j value of
0.61 (SD 95%, CI 0.57–0.65), a linear weighted j value of
0.71, and a quadratic weighted j value of 0.81. The j val-
ues, across departments, thus indicate a good (0.6–0.8)
Deviation from predicted category
The deviation from the predicted triage categories red and
orange was nearly one out of 10. These results would sug-
gest that patients in need of urgent care were identified
as such at the emergency departments covered in the study.
However, there is still a group of severely ill patients that
are not assigned to the predicted categories.
The high percentages of over-triage and under-triage in
the yellow and green categories implied that the order of
priority was disrupted. It can be significant for a patient

Table 1 Presentation of j values for each emergency department.

Emergency departments Unweighted j value Linear weighted j value Quad. weighted j value
A 0.56 0.68 0.78
B 0.59 0.69 0.80
C 0.60 0.70 0.81
D 0.62 0.70 0.80
E 0.62 0.71 0.82
F 0.64 0.74 0.83
G 0.65 0.75 0.85

Mean 0.61 0.71 0.81

Table 2 The distribution of triage to predicted values (in bold).

Triage done by nurses Accuracy vs. predicted
Red (%) Orange (%) Yellow (%) Green (%) Blue (%) Over-triage (%) Under-triage (%) Accuracy (%)
Red 92 8 8 92
Orange 5 91 4 5 4 91
Yellow 11 66 22 11 22 66
Green 4 30 63 3 34 3 63

Mean 14 13 73
Manchester Triage in Sweden – Interrater reliability and accuracy
Table 3 Current study compared to Versloot and Luitse (2007).
Olofsson et al.
Unweighted j value 0.61
Quadratic weighted j value 0.81
Number of participants 79
Number of assessments 1027
whether they are assigned the yellow category (60 min max-
imum waiting time) or the green category (120 min maxi-
mum waiting time). It can mean that the resources at the
emergency departments are used for non-urgent patients,
forcing patients in need of urgent care to wait. These two
triage categories need further study.
The study does not indicate any clear connections be-
tween level of training and triaging. A more extensive data
collection of training levels should clarify if such connec-
tions exist. There was, however, a difference in the results
from the various emergency departments. This can point to
varying work habits, cultures, internal training, or other dif-
ferences may affect the result. This, however, needs to be
studied more in detail.
Simulated patient cases
The orange category, which had 91% accuracy, was repre-
sented by three patient cases and the triage category red,
which had 92% accuracy, was represented only by one pa-
tient case in the study. This could be a weakness in the
study. On the other hand, an over-representation of red pa-
tient cases can lead to unreasonably high j values because
over-triaging is not possible. This reduces the probability
for mistakes. Since the greatest numbers of simulated pa-
tient cases were in categories, which had the highest risk
of incorrect assessments the study was carried out under
greater pressure than would have been the case if the
majority of the patient cases had been red or blue. The yel-
low triage category contained most of the simulated patient
cases. Gilboy et al. (2005) believe that 1–3% of the patients
are assigned to category one (red), 20–30% to category two
(orange), 30–40% to category three (yellow), and 20–35% to
categories four (green) and five (blue).
This study used the opinion of the expert panel as the
predicted result (‘‘gold standard’’). The mean accuracy
was 73% compared to the predicted category. It may be
questioned whether a five person expert panel is more accu-
rate in predicting the category than a group of 79 nurses
who assess patients in their daily triage work. The high
accuracy, however, implies that both the expert panel and
the nurses had a relatively similar perception of how MTS
should be applied.
Simulated patient cases have limitations since the nurse
is unable to question or examine the patient in person. A
prospective study, i.e., to follow the daily work of a triage
nurse, would have ethical limitations and also be more time
consuming. The advantage in simulated patient cases is that
all those involved in the study receive similar information
and it is easier to obtain a large sample (Considine et al.,
2000).
It is the authors’ opinion that, from the three different j
values discussed (unweighted, linear weighted, and qua-
147
Versloot and Luitse
0.76
0.82
8
400
dratic weighted), only the unweighted j value could be
compared with models with similar triage categories. When
the weighted j value is provided, the agreement is also
specified if the assessment falls one or two categories from
the predicted value. In such a case, an orange patient being
assessed as yellow can result in a relatively high agreement.
In practice, a critically ill patient that should be seen by a
physician within 10 min, instead has to wait 60 min. This
means that a statistical analysis can point to a deviation
that may seem negligible. In a clinical context, however,
this can be of great importance for the patient. Over-triage
and under-triage can thus have greater consequences than a
statistical study would suggest. For triage models like CTAS
and ATS which have shorter distances between categories
than MTS, a weighted j value could be more suitable.
A weakness in comparing j values is that the result de-
pends on (1) the number of nurses participating in the study,
(2) the characteristics of the simulated patient cases, and
(3) the total number of triage assessments (Altman, 1999;
Jakobsson and Westergren, 2005). The recent MTS study
by Versloot and Luitse (2007) is the only one that examined
simulated patient cases and therefore could be compared
with the current study (Table 3).
The unweighted j values 0.61 and 0.76 could be used in
this comparison. The criterion for choosing the eight nurses,
or their level of experience, is not specified in the study by
Versloot and Luitse (2007). The distribution of patient cases
is another variable that could have contributed to the dif-
ference in j values. The majority of the patient cases in
our study were distributed across categories where an incor-
rect assessment could be done in two directions (over-triage
and under-triage). Only in one of the patient cases that
were of category red could an incorrect assessment have
been done in just one direction (under-triage). The study
by Versloot and Luitse (2007) does not specify the distribu-
tion of patient cases. In a study containing a large amount of
red cases, the limitation of distribution will lead to higher j
values.
Conclusions
In this MTS study we found good interrater reliability at
emergency departments in Western Sweden. The accuracy
was high (73%). The triage categories red and orange
showed the highest values (92% and 91%), which imply that
MTS could identify patients in need of early intervention in
more than nine out of 10 cases.
This study indicates that the implementation of a struc-
tured clinical decision support system could increase the
interrater reliability and the accuracy while decreasing
over-triage. A recommendation to the clinical practice,
therefore, is to use structured clinical decisions. One weak-
148
ness, however, is that the yellow (60 min maximum waiting
time) and green (120 min maximum waiting time) triage cat-
egories resulted in low agreement and accuracy. It implies
that they are difficult to differentiate. Subsequently, a lim-
itation of clinical practice is that the resources of the emer-
gency department can be overused for non-urgent patients.
It suggests a need to further develop the model, focusing on
these categories.
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