Manchester Triage System: main flowcharts, discriminators and outcomes of a pediatric emergency care 1

ABSTRACT Objetive: to characterize the care services performed through risk rating by the Manchester Triage System, identifying demographics (age, gender), main flowcharts, discriminators and outcomes in pediatric emergency Method: cross-sectional quantitative study. Data on risk classification were obtained through a search of computerized registration data from medical records of patients treated in the pediatric emergency within one year. Descriptive statistics with absolute and relative frequencies was used for the analysis. Results: 10,921 visits were conducted in the pediatric emergency, mostly male (54.4%), aged between 29 days and two years (44.5%). There was a prevalence of the urgent risk category (43.6%). The main flowchart used in the care was worried parents (22.4%) and the most prevalent discriminator was recent event (15.3%). The hospitalization outcome occurred in 10.4% of care performed in the pediatric emergency, however 61.8% of care needed to stay under observation and / or being under the health team care in the pediatric emergency. Conclusion: worried parents was the main flowchart used and recent events the most prevalent discriminator, comprising the hospitalization outcomes and permanency in observation in the pediatric emergency before discharge from the hospital.


Introduction
The emergency service can be regarded as the more complex health care in Brazil, with a demand for service far greater than its absorption capacity. With this increasing demand, it is visible the imbalance between supply and demand for care in these services, making fundamental the reorganization of the work process. (1) . Moreover, the action must be joint to a regulatory system with reference and counter reference, focused on outpatient care and classification within the hospital environment, providing follow-up sites after treatment in the emergency department (2) .
The nurse is the professional assigned to the evaluation and classification of the patient's risk, guided by a classification protocol, proposing the use of a service flowchart to motivate this professional to reflect on their work process in the context of attention to emergency, replacing the exclusionary screening by a welcoming classification model (5) .
In emergency situations, the child is usually the main victim, as they require special attention on their health characteristics, needing specialized resources for their emergency care (6) . Regarding the risk rating in a pediatric emergency department, it is perceived the need for an organized and systematized health care process to the child's health, plus a structured classification instrument that allows nurses to assess carefully the main complaints of the patient at the time of classification, in order to provide care and proper referral to the suffering, risk and / or harm to the child's health (7) .
The MTS provides a list of 52 flowcharts, 49 suitable for children. Studies conducted in the Netherlands evaluated the validity of the MTS in a pediatric emergency care, aiming to carry out a detailed assessment of specific patient categories. The studies showed that the MTS has moderate sensitivity and specificity in pediatric emergency care, possibly due to lack of organization of specific flowcharts for pediatric patients (8)(9)(10) .
In reviewing the literature, there are no studies on the profile of pediatric patients classified with this protocol; so little research has been reported with the MTS analysis in pediatric emergency. It appears that the nurse responsible for the risk rating is often the same that cares for adults and children, without having a more focused look at this age group, considering the particularities that pediatric patients have. Considering   to the MTS. One can justify the prevalence of this flowchart to the singularized perception of parents about the child's health status and fear of its worsening, together with the certainty of a resolutive service (14) .
Other factors that transform emergency services as a top choice of parents to perform the service to children are: quality and resolutivity of care; accessibility; warranty and service agility; greater technological density offered by the service and medical care performed by a pediatrician (14)(15) .
A study conducted in Brazil in order to know the profile of children and adolescents treated in a pediatric emergency department found that a portion of 47.4% was classified as health situations that could be resolved in primary care level, where patients had symptoms considered "light" and there is no possibility of complicating their health status (15) . It appears that despite the expansion of primary care and the implementation of the Family Health Strategy, the demand for emergency services continues to increase.
It can be attributed to the difference between the way of thinking and acting by health professionals, managers and users seeking care in the emergency department without a clear understanding of what health needs constitute real situations to be resolved in these services (14) .
In a study developed in the Netherlands (16) , on the application of the MTS in a pediatric emergency, five main flowcharts selected in patient risk classification were highlighted: dyspnea in children; diarrhea and vomiting; worried parents; abdominal pain in children; eruptions. Another study (17) , also developed in the Netherlands, found the prevalence of the following flowcharts: General flowcharts; dyspnea in children; worried parents; diarrhea and vomiting; urinary problems. By comparing the results of studies conducted in the Netherlands with this study, it is evident that the flowcharts dyspnea in children, worried parents and diarrhea and vomiting appear in the three studies described. In accordance with the results found in the study (15) held in Brazil, the main pathologies identified in patients who arrived at the pediatric emergency were respiratory diseases (56.2%); gastrointestinal disorders (16.6%) and viruses (13.1%). As these diseases have a direct relationship with main flowcharts found, there is the need for nurses responsible for risk classification to pay attention to these signs and their severity, with the aim of establishing the service and / or appropriate referral of these patients.

Discussion
The results of this study help fill a gap in Brazilian literature regarding the applicability of MTS in the risk classification in a pediatric emergency. The protocol can assist in the nursing practice, giving priority to children who need an immediate health service.
In this investigation, the application of the MTS indicated a prevalence of the Urgent risk category (43.6%), representing the need for evaluation of up to 60 minutes (3) . A study conducted in the Netherlands in order to identify the parent's ability to assess the severity of fever in children and the decision to seek the emergency department, found the following distribution between the categories of MTS: Immediate (2%); very urgent (44%); Urgent (34%); standard (19%); Non-Urgent (1%) (11) . In this study there was a prevalence of the standard and very urgent categories, respectively, to the emergency service lowering the consume of resources that should be directed to patients with more severe health conditions (12)(13) .
As for the main selected flowcharts, there was prevalence of the flowchart worried parents, according www.eerp.usp.br/rlae 5 Amthauer C, Cunha MLC.
In relation to the discriminators, only one study was found in the literature in which the key discriminator selected in the pediatric patients risk classification in an emergency service was described. In order to evaluate the discriminative ability of MTS to identify serious bacterial infections in children with fever, it was possible to detect the following discriminators: fever; increased respiratory effort; ache; recent event; significant medical history; significant respiratory history; Low O2 saturation; and very low O2 saturation (18) . It should be noted that in this study those discriminators were directed to patients with fever at the risk classification moment, with possible progression to severe bacterial infection. This is different from the present study, in which we considered all patients classified in the pediatric emergency.
As for the outcomes of patients in the study in order to check the rates of hospitalization and identify patients with less urgent health, they found that 37% of patients were admitted to pediatric observation and in 63% of patients some kind of procedure was performed (19) . This fact was also observed in the present study, which showed the need for further care in the pediatric procedures room in half of the population treated before discharge from the hospital. With regard to hospitalization for pediatric patients classified by the MTS, a study conducted in the Netherlands, with the aim of assessing whether the flowcharts and the MTS discriminators could be used as markers to identify the risk of hospitalization for pediatric patients with signs of fever found a hospitalization rate of 23% (17) . The results found in the aforementioned study are twice the rate of hospitalization identified in this study, which was 10.4%.
One can consider this difference due to the reason that the Netherlands study included patients who sought pediatric emergency service already showing signs of fever, whereas in our study we included all services performed in the pediatric emergency without the patient showing any signs or installed pathology.
Of the total number of clients cared for in the pediatric emergency during the period of this study, most patients were discharged after an observation period on the premises of the pediatric emergency. Another study (18) obtained similar results, which demonstrates the importance of risk classification of specific care for pediatric patients, suggesting that the classification system used is carried out by a professional with experience in the field.