Obstetrical Triage: It ’ s Not First-Come, First-Served

1. Obstetrical Triage: It’s Not First-Come, First-Served Suzanne McMurtry Baird, DNP, RN

2. Disclosures • Speaker has no relevant disclosures • Speaker has no commercial support • Speaker does not endorse any product, service, or system

3. Objectives • Review common issues related to obstetrical triage and medical screening exams. • Outline an acuity scoring tool that may be utilized to prioritize treatment for women who present for evaluation to a labor and delivery or triage unit. • Discuss process implementation and outcome measures of an acuity scoring tool and triage process.

4. Obstetric Triage Unit Functions • Labor assessment • Holding unit for L & D • Evaluation of medical and OB complaints • Initial stabilization of OB complications • Infusions • Evaluation of OB referrals and transports • Telephone triage • Off/After hours OB/GYN care • Antepartum testing • External Version

5. Separate Obstetric Triage Unit • Evolved over time • Benefits • Bed utilization • Efficient care • Improved patient flow

6. Common Issues Related to Obstetric Triage • Prioritization • Emergency Medical Treatment and Active Labor Act (EMTALA) regulations • Medical Screening Exams by a Qualified Medical Provider (QMP) • Provider preference – model of care

7. Common Issues Related to Obstetric Triage (continued) • Lack of established nursing/medical protocols and policies • Variability in patient flow • Legal • By-laws • Medical Staff policy • Provider availability • Time frame for patient to be examined • On-call • Role of the OB/GYN hospitalist

8. Common Issues Related to Obstetric Triage (continued) • Legal/Risk Management • Assessment • Appropriate, complete, and timely patient assessment • Plan • Complete and timely communication to patient’s provider (or to whomever is on call), charge nurses, and relevant resources • Delayed access to relevant consultants (e.g. neuro, cardiac) • Interventions • Failure to respond to Category II and III EFM tracing • Inconsistency in practices • Delayed or incomplete resuscitative measures • Delayed access to indicated laboratory or imaging studies

9. Common Issues Related to Obstetric Triage (continued) • Legal/Risk Management • Evaluation • Communication • Consultation services • Testing • Safe transfer

10. Without an established process to triage and prioritize patients who present for evaluation: • Patients presenting with complaint (s) are assessed in the order of presentation ‘first-come, first-served’ • Wait in the waiting room until adequate staffing or bed available

11. Without an established process to triage and prioritize patients who present for evaluation: • Inconsistency in practice (variation) • Potential delays • Assessment • Problem identification • Initiation of stabilizing treatment Potential Patient Compromise

12. If You Build It, They Will Come…

13. 1st Patient in Women’s Triage • 66 y/o GYN/ONC • Stage 4 ovarian cancer • Bowel obstruction, abdominal distention • Refractory emesis • Port-a-cath • Plan • NG tube and gastric decompression • Management of nausea and vomiting

14. Staff RN

15. Fran & Suzanne

16. Obstetric Triage Scenario • Woman presents complaining of severe abdominal pain (8/10) • She appears to be in distress, sitting on a towel, leaning to one side in the wheelchair, and panting as she breathes rapidly • EGA 40 2/7 weeks

17. Security Team Member

18. Plan We needed a better one, and FAST!

19. Women’s Triage - Plan • Engage Key Stakeholders • Staff RNs • Admissions • Security • Nurse and physician leaders • Quality and Safety • Risk Management • Senior organizational leaders

20. Better Understanding of Existing Processes: • Questions to answer: • Volume of patients by hour of day & day of week • Cycle time from presentation to triage • Cycle time from presentation to roomed • Cycle time from presentation to first of triage or roomed • Cycle time from triaged to roomed

23. Plan - Literature Review • Focus on advanced practice nurse models • Limited regarding staff RN in triage Angelini, D.J. & LaFontaine, D. (Eds.) (2013) Obstetric Triage and Emergency Care Protocols. Springer; New York.

24. EMTALA Purpose: to ensure that patients with medical emergencies or women in active labor are not denied treatment based on any reason other than those that reflect the hospital’s capacity to examine, conduct tests, and treat the medical emergency (including active labor).

25. EMTALA (continued) • Labor - defined as the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta.

26. EMTALA (continued): Hospital Obligationto Treat any Emergency Medical Condition (EMC) Assess for presence of EMC Provide stabilizing treatment within capability of facility Transfer patient out if needed

27. Transfer Outside of Hospital Reasons for transfer: Based on capacity or capability as determined by a physician, appropriate care is not available at the institution Patient requests transfer

28. Transfer Outside of Hospital Transferring facility and physician are responsible for patient until arrival at the receiving facility Some states/facilities require written transfer agreement prior to transfer

29. MSE: Medical Screening Exam Performed by a ‘qualified medical person’ (QMP) MD, DO, PA, NP, midwife, RN* Anyone defined by hospital privileges as QMP Effective October 1, 2006 MSE cannot be delayed to inquire about payment or insurance status * RN: refers only to Registered Nurses credentialed as QMP in Women’s Assessment Center (triage)

30. Obstetric Medical Screening Exam • Obstetrical MSE: • Evaluation of maternal status • Evaluation of uterine contractions • Evaluation of fetal status • Fetal presenting part, position, and station • Cervical dilation • Status of membranes • Presence of any pregnancy risk factors and/or complications

31. Would you consider any of these descriptors as a Pregnancy Risk Factor? Gestational diabetes - Blood sugar 132 Previous myomectomy Maternal HR 112 bpm EGA 36 2/7 with UTI symptoms Vaginal bleeding – small amount, bright red Maternal BP 140/92 Yes – diabetes with hyperglycemia Yes – risk of uterine rupture Yes – tachycardia Yes – preterm gestational age and risk of preterm labor Yes – unknown bleeding cause Yes - hypertension

32. Women’s Triage: Plan • Reached out to national experts and other institutions to assess process and tools utilized for triage • Reviewed process and triage tools utilized by local institutions

33. Women’s Triage: Plan • Reviewed and discussed TCH Emergency Center process and practice with nursing leaders. • Aligned proposed PFW triage color code with of TCH EC.

34. WAC Triage Project: Plan

35. WAC Triage Project: Plan

36. Women’s Assessment Acuity and Triage Tool Developed in 2012 by Texas Children’s Hospital Pavilion for Women Women’s Assessment Center Project Committee

37. Goal: Primary AssessmentBy RN Within 10 minutes of Patient Arrival • Time of primary triage assessment • Gravida and parity (G T P AB L) • Estimated gestational age (EGA), if pregnant • Vital signs • Visual distress • Pain Assessment • Based upon the woman’s chief complaint or reason for visit, ask whether there are significant health issues that we should know about in planning her care?

38. Initial Information: Patient name Provider name Chief complaint/Reason for visit (check boxes) Are you pregnant? If yes, how many weeks? Pain assessment Current medications

39. Immediate 15 Minutes Urgent 30 Minutes Semi-Urgent 60 Minutes Less Urgent

40. TCH-PW: Women’s Assessment Center Acuity Tool ***Initial assessment must be done within 10 min. of patient arrival*** I

41. Notify provider regarding RN assessment findings. Acuity levels must be reassessed every 30 minutes after initial assessment if the woman is in the waiting area.

42. Patient Disposition Process: • Provider facilitates plan of care in collaboration with the woman, RN, and other disciplines or services as needed • Disposition of the woman is determined by the provider, as follows: • Assigned a status of admission as an inpatient, or • Assigned a status of observation, or • Assigned a status of outpatient, or • Discharged without physical examination by provider

43. Patient Disposition Process (con’t): • NOTE: If the patient is to be discharged, each of the discharge criteria must be satisfied, or the patient must be evaluated by an OB/GYN provider prior to discharge. • Prenatal care (has been seen by her provider in past 4 weeks) • Did not present in acuity category Orange or Red based upon primary triage/acuity assessment • Is not in labor • Is not preterm (< 37 weeks of gestation) with unresolved complaint(s)

44. Patient Disposition Process (con’t): • Does not have: • Ruptured membranes • Vaginal bleeding (more than bloody show) or purulent vaginal discharge • Category II or Category III fetal heart rate tracing (2nd RN must confirm assessment) • Vital signs outside defined limits (Temp <100.4F, SBP < 90 or > 140, DBP < 60 or > 90, HR 60-110, RR 14-24) • Epigastric or right upper quadrant pain, visual disturbance(s), or headache

45. Patient Disposition Process (con’t): • Does not have: • Severe pain (≥ 7 on scale) • Insulin dependent diabetes mellitus (IDDM), unless presenting for antepartum testing • Altered blood glucose, if applicable • Continued vomiting or diarrhea, if applicable • Successful completion of scheduled outpatient testing/procedure • Primary RN has no unresolved concerns regarding plan of care and disposition

46. Preparing to Implement Triage Tool • Phase I • BLS • ACLS • EFM • Workflow • Acuity Tool • Phase II • Charge RN development • PACE game • QMP Competencies Education

47. Education

48. PACE Assessment Game -Notify PAR Button Identifying Patient Acuity that is Safe, Effective, Patient Centered, Timely, Efficient and Equitable Triage 1 Patient Flow Scenario PhysicianOrders Triage 2 Available Resources Treatment/ Assessment Room Triage 3 Triage 4 5 Triage 5 4 3 Triage 6 Triage 11 2 Triage 7 START Triage 10 Winner 1 Triage 8 Waiting Room/ Lounge Triage 9 Assessment Scenario Reception Developed by: The Women’s Assessment Center Project Committee at Texas Children’s Hospital Pavilion for Women: 2012 Patient Arrives

49. Survey

50. Women’s Triage Population