OB TriageProcess Improvement at a Large Military

Medical Center

Nicole PolinskyCDR, NC, USNClinical Nurse Specialist

Julie HilleryCDR, NC, USNClinical Nurse Specialist

Discuss issues that led to need for process improvement in an OB Triage area.

Discuss findings of literature review for obstetric triage practices, standards, and issues.

Describe each step of the FOCUS-PDCA cycle as it applies to improvement of OB Triage processes.

Identify future implications for clinical nursing and patient safety in OB triage and evaluation.

Objectives

One of three large Navy Medical Centers Annual birth rate = over 4,200 Visits to OB Triage = over 800/month Unit composition:

◦ 10 LDRs◦ 4 high-risk OB beds (“Special Care”)◦ 3 Operating rooms◦ 5-bed PACU◦ 7-bed Triage area

Staffing: ◦ 50 billets for mix of military, civilian, and contract RNs◦ 15 billets for hospital corpsmen and 2 LPNs◦ 5 billets for civilian and contract clerks

About the Medical Center

Floor Plan:

To Labor & Delivery

TR 4(no central

FM)TR 2

Doctor & RN desk space

Check-In

BRTR 3

TR 6

TR 5

TR 7(precip room)

TR 1

To OR

Main Hallway

Waiting room

Vending Machines

(Not to scale)

Received customer and leadership concerns regarding long wait times in OB Triage.

Found that care of patients presenting to OB Evaluation was delayed, which resulted in delay of assessment of fetal and maternal well being

Experienced rash of pregnant women being rushed from OB triage and evaluation to operating suite or labor room with virtually no time in OB triage bed.

Emergency department was modifying triage system around same time.◦ Their findings peaked interest among Nursing

Directorate leaders regarding standardization between ED triage and OB triage.

Discovery of Issues

When a pregnant woman presents for care on labor and delivery, how soon should she be triaged? How soon should she be evaluated?

Who can perform triage and evaluation? What are the staffing standards for OB triage

areas? What is the current process for maternity

patients who present for care? Are the standards of practice for OB triage

different than ER triage standards?

Questions that Surfaced

Initial Steps: Review Process

Patient in

waiting room

Patient presents to triage

Clerk starts record while patient waits in lobby

Clerk notifies RN of patient’s arrival when check-in is complete and chart is ready for use

RN triages patients waiting by reviewing the chart and reason for visit

Initial assessment by RN is completed when patient is assigned a triage bed

Initial Steps: Gather Information

Reached Out◦ Email sent to 1920/1964 Listserve (Mother-Baby and

NICU nursing community) for input and feedback◦ Contacted other hospitals and medical centers for

policies/procedures/protocols on OB Triage Professional organization standards &

guidelines◦ AWHONN

Besuner (2007), Templates for protocols and procedures for maternity services, 2nd Ed.

◦ AAP & ACOG-Perinatal Guidelines, 2007 (6th Ed.)◦ ACOG-review of compendiums for guidelines/

statements in regard to perinatal evaluation

‣Literature Review

Very few current articles found on obstetric/perinatal triage and evaluation (in Fall 2007).

Overall commonalities of articles found:◦ Common reasons for visits◦ Legal requirements◦ Tiering/classification system◦ Unit-developed protocols◦ Patient flow through triage area◦ Which providers can perform medical screening evaluations (MSEs)◦ Documentation

Information mentioned in only one article*:◦ Timeline for triage after presentation◦ Competency requirements for staff

Information not found:◦ Staffing standards

Literature Review-OB Triage

*Mahlmeister & Van Mullem (2000). The process of triage in perinatal settings: Clinical and legal issues. The Journal of Perinatal and Neonatal Nursing, 13: 13-30.

Why review ER Triage? ◦ Obstetric triage falls under the same standards as

emergency room triage.

Limited search to triage systems◦ Many articles found (see bibliography)

Commonalities:◦ Triage defined◦ 5-level v. 3-level acuity scales for triage

5-level preferred; evidence-based system that allows consistency of care, efficient placement of patients, and improved patient flow.

Other findings:◦ Concept of “family waiting or gathering area”

Literature Review-ER Triage

F: Find an Opportunity to Improve

Overall issue identified: Care of maternity patients presenting for evaluation was delayed, leading to delay of assessment of fetal and maternal well being

Specific issues: ◦ Patients presenting to OB Triage:

Were not consistently assessed by an RN within 5 minutes of their arrival.

Were initially seen by the unit ward clerk—RN may be unaware of patient’s arrival for significant period of time

Had to complete the check-in process before RN was notified of patient’s arrival

Waited in the lobby for minutes to several hours before initial assessment was completed

Triage was performed and severity level determined through review of record only

◦ Unlike ER Triage, cannot “eyeball” perinatal patients to estimate level of severity because cannot see into the uterus

O: Organize a Team

Clinical Nurse Specialist, L&D Division Officer, L&D Staff RNs

◦ Proficient and expert in perinatal nursing◦ Routinely work in OB Triage◦ Charge nurses

ER Nursing Department Head◦ Adhoc; for consultation

C: Clarify Current Knowledge—As Is

Already discussed:◦ Review of process◦ Information gathering, literature review.

“Triage” was the term used by all disciplines to describe the entire patient visit.◦ Triage is actually the action taken during and after

the initial (primary) assessment to determine the level of care the patient requires

Current staffing: 1 RN for a 7-bed OB Evaluation area with an average of 800 visits/month

C: Clarify Current Knowledge—As Meant to Be

How process should be:◦ Patient initially triaged by RN within 5 minutes of presenting to

OB Evaluation Area; ward clerk simultaneously completes check-in paperwork

◦ RN categorizes severity of patient’s condition based on chief complaint and assessment findings

◦ RN notifies provider immediately for emergent conditions or upon completion of initial triage for urgent and non urgent conditions

◦ Urgent and Non urgent patients in waiting room are re-assessed every 30-60 minutes (time related to severity category) by an RN

“Triage” is term to use for initial/primary assessment “Evaluation” is term to use for the rest of the visit. Staff with 2 RNs at all times: 1 dedicated to initial

triage, 1 to provide care for patients in evaluation bed

U: Understand Causes of Variation

Limited number of RNs available to meet staffing requirement◦ One (1) RN assigned to 7-bed area with an average of 800 visits/month

Physical space inhibited triage process and smooth flow of ongoing care.

No unit policy/protocol for OB Triage and Evaluation No severity index used to determine treatment needs No form available for documentation of initial RN triage

assessment Poor training and competency validation process in place for

RNs “Triage” is term used by all disciplines to describe the area and

the entire visit vice initial assessment Lack of guidelines from perinatal professional organizations

regarding triage and evaluation of the obstetric patient◦ OB Triage thought of as “the OB ED” but standard of care not in

compliance with ED standards.

S: Select the Process Improvement Patients who present to OB Evaluation will:

◦ Receive an initial triage assessment by an RN within 5 minutes of arrival

◦ Be categorized to level of severity based on chief complaint and assessment findings

◦ Be re-assessed at prescribed times while in the waiting room

Standard of care will be evidence-based and in accordance with ED guidelines

P: Plan Remodel physical space to include room for initial triage and

doors for ease of patient flow Rename space “OB Evaluation Area” Gain 5 additional RN billets and complete hiring process Develop unit policy/protocol of care that includes definition

of severity index for clinical conditions and recommends plan of action

Develop form for documentation of RN’s initial triage assessment

Improve initial training and competency validation for RNs Train nursing staff on new protocol of care Train medical providers on new protocol of care Develop audit tool for review of records.

Floor Plan Modifications:

To Labor & Delivery

TR 4(no central

FM)TR 2

Doctor & RN desk space

Check-In

BRTR 3

TR 6

TR 5

TR 7(precip room)

TR 1

To OR

Main Hallway

Waiting room(Not to scale)

Space converted to exam

room

“Front”

“Back”

Unit Policy & Protocol Area renamed “OB Evaluation (OBE) Area”

◦ “Triage” will be term used to describe initial assessment and determination of care required

◦ Rooms/beds in back will be referred to as “Evaluation” beds OB Evaluation will follow Emergency Department

(ED) guidelines regarding standard of care for patients who present◦ ED standard = patients are seen within 2-5 minutes of

arrival Levels of severity for patient conditions defined. Patient condition will be triaged as red, yellow, or

green based on reason for visit and assessment findings

Levels of Severity

Red Cardio-respiratory

distress Eclampsia Active hemorrhage/

heavy bleeding Urge to push Objects protruding

from vagina No fetal movement Diabetic coma/DKA Other life-

threatening conditions to mother or fetus

Yellow Contractions every 2

minutes & appears uncomfortable

Multipara in active labor

Decreased fetal movement

Abdominal pain Preterm labor or

preterm rupture of membranes

Actual or potential Pre-eclampsia or HELLP syndrome

Rule-out ROM

Green Nausea/vomiting/

diarrhea Urinary complaints Stable gestational

hypertension Wound infection Upper respiratory

infection Vaginal discharge/

vaginitis Wound checks Staple removal Injections, lab draws

**Yellow conditions are listed in order of priority

Actions for Levels of Severity

Red = EmergentNotify Provider Immediately

Move patient directly to room: OBE exam, OR, special care, or LDR room

Yellow = Urgent(Patient must be seen but will not deteriorate with slight delay in care)

Notify provider when RN triage assessment is complete

Green = Nonurgent(Patient can wait for several hours with minimal risk of further injury)

Notify provider when RN triage assessment is complete

Unit Policy & Protocol Patients sent to the waiting room will be re-

evaluated as follows until an OBE room is available:◦ Yellow = every 30 minutes◦ Green = every hour

RN assigned to front is responsible for completing re-evaluations and re-determining condition levels

Documentation will be on the new “OB Evaluation Triage Note” form

Unit Policy & Protocol

Per the new policy, the following patients may go directly to their assigned room on L&D (no OBE visit required):

◦ Scheduled c-section, induction, cerclage, or version

◦ Presenting for direct admission from clinic

◦ Give birth en route to hospital

◦ In transition or second stage of labor

A form was created specifically for documentation of initial assessment by an RN (Title= “NMCP Obstetric Evaluation Triage Note”)◦ Modeled after the ED initial triage note◦ Documentation on current ETR and OB TraceVue will

continue once the patient is placed in an Evaluation bed

Documentation of primary assessment

NMCP OBSTETRIC EVALUATION TRIAGE NOTE

Condition Level: Red Yellow Green

Date: Arrival Time: Triage Time:

Name: FMP/Sponsor SSN:

Age: EDC: EGA: Height: Weight: G: P: T: P: A: L: Barriers to communication: □ No □ Yes: □ Language □ Disability □ Other:___________ Action Taken:_____________

Arrival Via: □ Ambulatory □ Wheelchair □ Gurney □ EMS/Ambulance □ Other

Reason for Visit:

History of cesarean section? Yes No History of/current placenta previa? Yes No

History of/current HSV infection? Yes No Are you seen in the Complicated OB clinic? Yes No

If yes, for what complications?

Allergies/reaction:

Current Medications: Initial Vital Signs & Obstetric Assessment

Time: Temp: HR: BP: RR: FHT:

Pain: rated as __________/10. □ Constant □ Intermittent □ Sharp □ Dull □ Pressure □ Burning Location:__________________________ Radiation to:_______________________

Leaking Fluid? Yes No Unsure Color:___________________________ Time noted: __________

Contractions? Yes No Unsure Frequency: q ____mins or ______ times/hour

Regular? Yes No Date/time started: _____________________ Intensity: mild moderate strong

Rectal pressure? Yes No Urge to push? Yes No Length of last labor: _____________

Vaginal Bleeding? Yes No Unsure Bright red? Yes No Bloody show? Yes No

Fetal Movements? Feeling baby move like he/she normally does? Yes No

Feeling 10 or more fetal movements in one hour without difficulty (kick counts)? Yes No

Fall risk assessment: □ Level I □ Level II □ Level III □ Side rails up □ Bed locked □ Other:__________________

Domestic violence assessment: Do you feel safe at home?: Yes No History of/current physical abuse? Yes No

History of/current sexual abuse: Yes No History of/current verbal abuse? Yes No

Psychosocial: Eye contact?: Yes No Affect: □ Broad □ Flat □ Blunted Mood: □ Depressed □ Labile □ Elated

Hallucinations: □ Auditory □ Visual Ideations: □ Harm to self □ Harm to others

Behavior: □ Cooperative □ Restless □ Agitated Support System: □ Lives Alone □ Family □ Friends □ Significant Others

Vaginal exam: □ Deferred Time:_________ Dil:__________ Eff:___________ St:_________ Pres:_____________ Ongoing Vital Signs & Obstetric Re-assessment

Time: Temp: HR: RR: BP FHT Pain Ctx’s LOF: VB: Condition Level

-- / + -- / +

-- / + -- / +

-- / + -- / +

-- / + -- / +

-- / + -- / +

-- / + -- / +

Provider notified:__________________________________________________ Time:_____________________

Notes:

Primary RN Sign Print

NMCP OBSTETRIC EVALUATION TRIAGE NOTE

Additional Notes:

Signature Initials Signature Initials

Cardio-respiratory distress Eclampsia Active hemorrhage/heavy

bleeding Urge to push Objects protruding from vagina No fetal movement Diabetic coma/DKA Other life-threatening conditions

to mother or fetus

Contractions every 2 minutes & appears uncomfortable

Multiparas in active labor Decreased fetal movement Abdominal pain Preterm labor or preterm rupture of

membranes Pre-eclampsia/ signs/symptoms of Pre-

e/ HELLP syndrome Rule-out rupture of membranes

Nausea/vomiting/diarrhea Urinary complaints Stable gestational hypertension Wound infection Upper respiratory infection Vaginal discharge/vaginitis Wound checks Staple removal Injections, lab draws

Red (Emergent) Notify MO

Immediately

Chief complaint or assessment findings significant for:

Yellow (Urgent) Pt must be seen but will not

deteriorate with slight delay in care Notify MO upon completion of

RN triage assessment

Green (Nonurgent) Pt can wait for several hours with

minimal risk of further injury Notify MO upon completion of

RN triage assessment

Competency Per new SOP, RN skill level requirements to work in

OB Triage & Evaluation were established as:

◦ RNs who have > 1 year of L&D experience and are at a competent, proficient, or expert level of competency may work in OBE independently

◦ RNs who have > 6 months but <1 year of L&D experience may work in OBE with an RN who meets criteria above

◦ RNs who have < 6 months of L&D experience may work in OBE with an assigned preceptor

Other skill level requirements per new SOP:

◦ LPNs and HMs may work in OBE with an RN who has > 1 year L&D experience and is at a competent, proficient, or expert level of competency

Competency Training and competency validation

◦ Healthstream training for all staff◦ Competency checklist created for preceptor to

sign◦ RNs, LPNs, & HMs who work in OBE are required

to complete both prior to working independently

Obstetric Triage & Evaluation Process

When exam room available

Clerk begins ETR

Exam Room

Available?

Medical screening exam performed by provider

Triage RN: Performs initial assessment within 2-5 minutes of patient’s arrival. Categorizes priority of care based on patient complaint & condition.

Red (Emergent) Cardio-respiratory distress Eclampsia Active hemorrhage/heavy bleeding Urge to push Objects protruding from vagina No fetal movement Diabetic coma/DKA Other life-threatening conditions to

mother or fetus

Yellow (Urgent) Pt must be seen but will not deteriorate with slight

delay in care (can wait for short time) Contractions every 2 minutes & appears

uncomfortable Multiparas in active labor Decreased fetal movement Abdominal pain Preterm labor or preterm rupture of membranes Pre-eclampsia/ signs/symptoms of Pre-e/

HELLP syndrome Rule-out rupture of membranes

Green (Nonurgent/ambulatory) Pt can wait for several hours with minimal

risk of further injury Nausea/vomiting/diarrhea Urinary complaints Stable gestational hypertension Wound infection Upper respiratory infection Vaginal discharge/vaginitis Wound checks Staple removal Injections, lab draws

To exam room for evaluation. RN reassesses VS, pain, OB

condition if > 30 minutes since last assessment.

To OBE exam room, operating

room, special care room or LDR room

No Yes

Triage RN reassesses VS, FHTs, pain, and OB condition:

Every 30 minutes if Cat Yellow Every 60 minutes if Cat Green

To waiting area

No

Start pathway of new category

Yes

Priority Level the

Same?

Disposition determined

Discharge Home, Full Duty, Light Duty, OB Quarters with instructions and evidence of

fetal well being as appropriate to gestational age

Admit to Labor & Delivery Notify shift charge RN Give report to admitting RN Escort patient to room

Interventions and re-evaluation performed as indicated

Admit to another unit Notify bed management Notify unit’s shift charge RN Call report to admitting RN Escort patient to room

Patient presents at OBE front desk Modified Triage

and OB Evaluation Process

D: Do Implementation/ “Go Live” date: summer

2008 Teams established to perform data

collection & analysis:◦ Team Leader◦ Day Shift team (2 RNs and 1 WC)◦ Night Shift team (2 RNs and 1 WC)

C: Check Metrics to check:

◦ Arrival time to triage time (is it < 5 minutes?)◦ Was condition categorized appropriately?◦ Were ongoing re-assessments performed while patient was in the

waiting room? Did her category change (to higher level of urgency)? If so, how long was she in the waiting room? If so, why/how did it change?

◦ Were the following assessments completed? (all boxes checked or filled in): Fall Risk assessment Domestic Violence assessment Psychosocial assessment

◦ Does the RN performing triage have competency documented?◦ Reason for visit*◦ Did the RN document procedures performed?*

Audit Plan:◦ 25 records from day shift & 25 records from night shift weekly x 4

weeks◦ Then 50/day shift and 50/night shift each month

A: Act Act to hold the gain/continue improvement Act on the information. Adopt the change. Modify or plan accordingly. Perform in an

improved manner.

Two Years Later… Remodel physical space to include room for initial triage

and doors for ease of patient flow Rename space “OB Evaluation Area” Gain 5 additional RN billets and complete hiring process Develop unit policy/protocol of care that includes definition

of severity index for clinical conditions and recommends plan of action

Develop form for documentation of RN’s initial triage assessment

Improve initial training and competency validation for RNs Train nursing staff on new protocol of care Train medical providers on new protocol of care Develop audit tool for review of records.

Decreased patient wait time for initial assessment from 15 minutes-3 hours to 2-5 minutes.

Precipitous delivery rate decreased from 4-6/month to two in three months.

Measured Outcomes

Improved unit lay-out Improved staffing Enhanced patient safety Streamlined documentation Established policy to close triage beds when

RN staffing insufficient

Turnover of active duty staff Lack of shared vision Deficiency of advanced practice nurses

Successes and Challenges

Implement triage competency

Revisit audits to ensure meeting standards

Expand current Maternal-Infant (1920) core competency to reflect triage practice

Clarify roles of triage staff

Future Goals

Questions?Thank You