OB Triage

1. OB Triage Nicole Polinsky CDR, NC, USN Clinical Nurse Specialist Julie Hillery CDR, NC, USN Clinical Nurse Specialist Process Improvement at a Large Military Medical Center

2. 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.

3. 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

4. Floor Plan: Main Hallway (Not to scale) TR 7 (precip room) Waiting room Check-In TR 6 Doctor & RN desk space Vending Machines TR 5 To Labor & Delivery To OR TR 4 (no central FM) TR 3 TR 2 TR 1 BR

5. 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.

6. 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?

7. Initial Steps: Review Process 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 Patient in waiting room 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

8. 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

9. 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.

10. 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”

11. 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

12. 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

13. 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

14. 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

15. 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.

16. 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

17. 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.

18. Floor Plan Modifications: Main Hallway (Not to scale) TR 7 (precip room) Waiting room “Front” Check-In TR 6 Space converted to exam room Doctor & RN desk space TR 5 “Back” To Labor & Delivery To OR TR 4 (no central FM) TR 3 TR 2 TR 1 BR

19. 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

20. 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 Levelsof Severity 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

21. Red = Emergent Notify Provider Immediately Move patient directly to room: OBE exam, OR, special care, or LDR room Actions for Levels of Severity 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

22. 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

23. 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

24. 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

26. 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 OBEindependently • 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 OBEwith 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

27. 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

28. Modified Triage and OB Evaluation Process

29. 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)

30. 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

31. 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.

32. 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.

33. 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.

34. 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

35. 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

36. Questions? Thank You