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OB Triage

Process Improvement at a Large Military


Medical Center

Nicole Polinsky Julie Hillery


CDR, NC, USN CDR, NC, USN
Clinical Nurse Specialist Clinical Nurse Specialist
Objectives
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.
About the Medical Center
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
Floor Main Hallway

Plan:
(Not to scale)
Waiting room
TR 7
(precip room)

Check-In

TR 6
Vending
Machines Doctor &
RN desk
space

TR 5

To Labor & Delivery

To OR

TR 4
(no central TR 3 TR 2 TR 1 BR
FM)
Discovery of Issues
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.
Questions that Surfaced
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?
Initial Steps: Review Process
Patient presents to triage

Clerk starts record while patient waits in lobby

Clerk notifies RN of patients arrival when check-in is complete


and chart is ready for use
Patient
in
waiting
RN triages patients waiting by reviewing the chart and reason for visit room

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
Literature Review-OB
Triage
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
*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.
Literature Review-ER
Triage
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
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 clerkRN may be unaware
of patients arrival for significant period of time
Had to complete the check-in process before RN was notified of
patients 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 KnowledgeAs 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 patients 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 RNs 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: Main Hallway

(Not to scale)
Waiting room
TR 7 Front
(precip room)

Space Check-In
converted
TR 6 to exam
room
Doctor &
RN desk
space

TR 5

To Labor & Delivery Back

To OR

TR 4
(no central TR 3 TR 2 TR 1 BR
FM)
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 Yellow Green
Cardio-respiratory Contractions every 2 Nausea/vomiting/
distress minutes & appears diarrhea
Eclampsia uncomfortable Urinary complaints
Active hemorrhage/ Multipara in active Stable gestational
heavy bleeding labor hypertension
Urge to push Decreased fetal Wound infection
Objects protruding movement Upper respiratory
from vagina Abdominal pain infection
No fetal movement Preterm labor or Vaginal discharge/
Diabetic coma/DKA preterm rupture of vaginitis
Other life- membranes Wound checks
threatening Actual or potential Pre- Staple removal
conditions to mother eclampsia or HELLP
syndrome
Injections, lab draws
or fetus
Rule-out ROM
**Yellow conditions are listed in order of priority
Actions for Levels of
Severity
Red = Emergent
Notify 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
Documentation of primary
assessment
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
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
Modified
Triage and
OB
Evaluatio
n 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 RNs 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.
Measured Outcomes
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.


Successes and Challenges
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
Future Goals
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
Questions?
Thank You