Electronic and manual registration of Manchester System: reliability, accuracy, and time evaluation*

Objective: to evaluate the degree of reliability, accuracy and timing to perform the Manchester Triage System in electronic and manual records. Method: exploratory-descriptive research. Case series corresponded to a total of 20 validated simulated clinical cases applied to a sample of 10 nurses. For data collection each participant received 4 clinical cases in 2 different phases of the study, using manual and electronic registration. The variables related to the triage were: incomplete data filling, discriminator, flowchart, priority level, vital signs and triage timing. Results: moderate reliability for choosing flowcharts and substantial reliability for determining discriminators in both records; substantial and moderate, for priority, respectively, in manual and electronic registration. For vital signs, it was weak in manual recording and substantial in electronic. Accuracy showed a statistically significant difference related to vital signs. The average timing on triage was shorter with the use of electronic registration. Conclusion: the use of electronic registration has advantages regarding reliability, accuracy and timing to perform the triage, pointing to the importance of adopting technologies in the management and care work process in health services.

Those who, during data collection, were not on the institution (on dismissal, leave or vacation) and the researcher herself were excluded from the study.
After applying these criteria, 5 people were excluded, with 38 nurses remaining. The opportunity selection process was performed according to simple systematic random probability sampling through electronic draw.
The amount of cases and nurses were determined from calculations performed in the R 3.3.0 system with the irr package, to obtain a Cohen kappa coefficient greater than or equal to 0.5, 95% confidence and test power of 80%, considering the number of patients classified at each clinical priority level at HU-USP in 2016, that is, 4800 (60%) green, 1440 (18%) yellow, 1120 (14%) blue, 4% (320) orange, 3.5% (280) white and 0.5% (40) red*.
A minimum sample of 19 simulated cases to be distributed to a minimum of 5 participants was estimated. For a fair distribution, a sample of 20 simulated clinical cases and 10 nurses was adopted, with 4 cases for each of them.
The study sample corresponded to a total of 20 simulated clinical cases applied to a sample of 10 nurses.

Each participant received 4 clinical cases in 2 different
phases of the study.
In this way, the clinical cases used were requested to GBCR by this group in the classifier training courses in Brazil and which had been evaluated by specialists.
According to an agreement between the group's representatives, the researcher and the advisor, the  For the analysis of the triage timing, the Wilcoxon-Mann-Whitney test was used, with a 95% confidence interval and p value less than or equal to 0.05.

Results
Regarding the characterization of the sample, the average age of the participants was 38.7 years. The other results are presented in Table 1. The average time working in the units was 7.6 years in the current unit and 6.5 years in the previous one. The average time of computer use was 4.2 hours daily.
Regarding missing data, patient identification data, beginning and end of triage and physician referral were recorded in all triages performed. Regarding the triage variables, there was a lack of records regarding priority (phase 1) and vital signs (in both phases).
Reliability data are shown in Table 2.   Regarding priority errors, it was observed that in most cases higher priority levels of triage were considered, as shown in Table 5. Nurses, due to their historical role of mediators between the patient and the health system, are increasingly using electronic records as a health work tool to provide support for patient care and clinical and managerial decision making. in nursing, which justifies the mastery of these abilities (29) .
Regarding the knowledge on computer by the nurses in the study there was a homogeneity. Informational competence is the ability to identify the information necessary for a specific purpose, to locate, evaluate and correctly apply the relevant information.
Information management competence encompasses the process of collecting, processing, presenting and communicating data as information or knowledge (30)(31) . To determine the causes of the difference in interrater priority determination, a more detailed analysis of each of the triage and the correlations between its characteristics and raters is required.

Considering this definition of nursing informatics
Other studies have shown differentiation as to the priority variable and the ways of application of In a study on the Pediatric Canadian Triage and Acuity Scale (PedCTAS), a pediatric triage system, no statistically significant differences were found between the electronic and manual records in determining priority. The agreement between the nurses and the gold standard obtained values equal to 57% in the manual registration and 55% in the electronic one (37) .
Despite the high agreement between the raters and the gold standard regarding priority in manual and electronic records, errors related to this variable can result in harm to patients and emergency services. And when analyzing these cases where errors occurred, it was found that most were due to overtriage.
In cases of overtriage, excessive resources are shifted to patients with non-emergent problems, resulting in increased costs and delayed care of the most severely ill patients (39)(40) .
In undertriage, the most severe patients would take longer to be seen by the doctor, which could lead to complications to their health (39)(40) .
Analyzing the types of errors related to the registration of vital signs, it is noted that most were denoted by failing to register one particular vital sign.
A study on the use of an institutional triage protocol with manual registration also found problems regarding the registration of vital signs. In 221 (58%) cases, no vital signs were recorded; however, in this institution, In the present study, the average time spent with triage on manual recording was slightly above the 3-minute time interval recommended by the GBCR (44) .
It can be assumed that the differences found in the time spent with the classification are due to the need for the individual to check guides or manuals during triage in phase 1 and be dependent on their memory (45)(46) .
Electronic registration have the same information as the MTS book; however, users can access them quickly and directly with just a few clicks. In addition, the large number of errors related to vital sign recording, as discussed, may have made the manual process take longer.
A study describing the DSS shows that these systems are faster compared to the activities performed on paper (29) . And the shorter time spent on triage in the electronic registration can bring important advantages to the process.
Patients with a higher level of urgency will be evaluated in a shorter time and, consequently, referred sooner to medical care; those arriving at the emergency service will wait a shorter time in the waiting room for triage; the safety time for the classification (3 minutes) is respected. The DSS make it possible to contribute to the work process of nurses, assisting in decision making, time optimization, accessibility and integration of information, as well as in the creation of indicators (29,(47)(48) . The