J Perinat Neonat Nurs
Vol. 21, No. 4, pp. 315–322
c 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright A Systems Analysis of Obstetric Triage
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Jeanette Zocco, MSN, RN; Mary Jane Williams, PhD, RN;
Diane B. Longobucco, MSN, APRN; Bruce Bernstein, PhD
Objective: The purpose of this study is to examine some of the variables involved in
obstetric triage in an effort to develop a more efficient patient care delivery system in a
high-volume obstetric unit. An efficient triage system is essential to a busy labor and
delivery unit for the evaluation of unscheduled patient visits. In hospitals that lack an
efficient obstetric triage system, it is very difficult to regulate patient flow and wait
times. Method: The study was designed to determine whether a triage room and/or
standing orders decreased length of stay as compared to the existing system of
evaluating women in labor rooms. In 2 separate phases, women who met triage criteria
were randomly assigned to either the triage room or the standard care labor room.
During phase 1, the effect of room assignment was evaluated. During phase 2, the
effect of room assignment and the intervention of standing orders in common obstetric
problems were utilized. The total sample size was 398 patients. The study took place
on a midsize labor and delivery unit, in an academic medical center averaging 3600
births per year. Results: Results showed that using a triage room and/or standing orders
did not significantly decrease length of stay. Conclusion: The results of this study
suggest that the triage process in this setting is strongly dependent on the provider’s
availability to assess, triage, and discharge patients. Key words: obstetrics, standing
orders, triage, triage room
T
riage and the use of a separate triage area are characteristically associated with emergency department nursing. However, triage as a concept is used
daily in many labor and delivery (L&D) units. Triage
was initially formulated by the military in field hospitals
to quickly and efficiently evaluate wounded soldiers.1
The L&D unit often functions like an emergency department for pregnant women. Women are seen for
complaints ranging from vaginal discharge to placen-
Author Affiliations: Saint Francis Hospital and Medical
Center (Ms Zocco), Neonatal/Perinatal Nursing
(Ms Longobucco), and Pediatrics and Surgery (Dr Bernstein),
Yale University School of Nursing, Hartford, CT; and
Department of Nursing, University of Hartford, CT
(Dr Williams).
Corresponding Author: Jeanette Zocco, MSN, RN, Department of
Maternal/Child Nursing, Saint Francis Hospital and Medical Center, Yale University School of Nursing, 114 Woodland Str, Hartford,
CT 06105 (Jeanettezocco@hotmail.com).
Submitted for publication: July 27, 2006
Accepted for publication: April 24, 2007
tal abruption. A significant number of undelivered patients are discharged to home, admitted to L&D, or
transferred to another unit within the hospital after
being triaged.2–4
In hospitals that lack an efficient obstetric triage
system and a separate triage area, it is very difficult to
regulate patient flow. Women are triaged in labor beds.
Studies have cited the following as problems: unit
congestion due to inappropriate use of beds, increased
length of stay (LOS), patient dissatisfaction with long
waiting times, increased hospital expenditure, inefficient use of staff, and staff dissatisfaction.4,5 Thus, the
overall problem is an inefficient utilization of obstetric
triage in L&D. The purpose of this study was to explore
the relationship between the LOS of a triage room managed by registered nurses and a traditional labor room.
The effect of standing orders for common obstetric
problems on LOS in both a triage room and a traditional labor room was also examined. Standing orders
refer to physician-approved orders for interventions
routinely performed, including intravenous (IV) fluids and laboratory tests. They were developed for
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common obstetrical complaints and would allow the
nurses to potentially facilitate patient flow by initiating
the triage process at an earlier point in the patient’s
care.
LITERATURE REVIEW
Obstetric triage
There is limited research in the management of obstetric triage by registered nurses. Studies describe the development of separate triage areas in obstetric units
and the use of certified nurse midwives and nurse practitioners as primary care providers in triage units.1–8
Both concepts demonstrate positive results in terms of
patient and staff satisfaction, improving patient flow,
and efficiently utilizing staff and resources. Angelini
et al2 describe the development of a separate triage
room, in a tertiary facility, within a large L&D unit servicing more than 10 000 births per year. This was considered necessary to reduce the high volume of nonlaboring women evaluated in the labor room. Statistics
showed that one third of all women evaluated in L&D
remained undelivered. The evaluation of these patients
can create a strain on hospital resources, including the
nursing and environmental staff involved in their care.
In another study, a national survey of midwives as primary care providers of obstetric triage services was
performed. The following central features to having a
separate triage area emerged: efficient management of
volume in L&D units and emergency departments, decreased LOS, enhanced continuity of care, improved
screening and evaluation, and better use of staff and
resources.6
Settings and outcomes were examined in a teaching hospital in the early 1990s that originally triaged
all women in labor-birth recovery rooms.4 Statistics
showed that 27% of the women evaluated in the
birthing unit were either discharged to home or transferred to another unit undelivered. The study examined the effects of introducing a triage unit, managed
by registered nurses, with the use of a patient acuity
system as a guideline. The obstetric triage unit was
developed in response to multiple factors—financial
constraints, misuse of L&D beds, patient and staff frustration, and an overall increase in the number of deliveries. Results showed positive satisfaction from women
with the unit’s physical design, promotion of comfort
and support measures, and patient education. Nurses
and physicians overwhelmingly supported the triage
unit, citing positive effects in the following areas: workload, their own role in the process, patient and support
person’s satisfaction with care, and physical layout.
Two studies described the responsibilities of nurse
midwives in performing obstetric triage within a tertiary hospital’s obstetric emergency unit.1,7 Midwives
worked alongside residents in providing primary obstetric care to women who presented for evaluation of
a wide range of conditions. These include but are not
limited to decreased fetal movement (DFM), uterine
contractions/labor evaluation, vaginal bleeding, hyperemesis gravidarum, urinary tract infections, preterm
labor (PTL), premature rupture of membranes, and
acute abdominal pain (nonobstetric related). Women
were evaluated initially in triage and then their disposition was decided—labor room, fetal evaluation unit,
or home. Additional role responsibilities included assessing high-risk patients and performing ultrasound
evaluation. The diverse role of midwives in obstetric
triage was also explored in various settings across the
country.3
Arnold et al8 discussed a perinatal evaluation center
staffed with nurse practitioners within a tertiary innercity hospital. The services that were provided included
obstetric triage/evaluation and antenatal testing. System inefficiencies, resulting from the high volume of
impoverished women seeking episodic prenatal care in
L&D, initiated the development of this service delivery
model. Outcomes showed that women were more satisfied with their care, and the average wait time was
decreased by 1 hour and 41 minutes from the standard
model of care.
Emergency department triage and
standing orders
Rinderer9 examined factors influencing patient flow
and LOS in a general emergency department. The use of
a separate triage room was found to be moderately effective and strongly supported by task force members.
Another study discussed the implementation of a formalized obstetric–gynecologic triage process including
an acuity system and a separate triage room.10 The setting was a hospital containing both a gynecology emergency clinic and an L&D emergency area. The nurses
were responsible for initiating standard interventions
in response to nursing assessments—blood work, urine
samples, and IV lines. The findings indicated that more
acute patients were recognized faster and cared for
in a more efficient manner. Thus, research in both
standard and obstetric–gynecologic emergency department triage supports the use of a separate triage area
and incorporation of standard interventions. Findings
demonstrate positive benefits including improved patient flow, efficient use of medical care, and decreased
LOS.
A Systems Analysis of Obstetric Triage
Authors describe the effects of implementing an advance triage system in which nurses initiated protocols,
based on algorithms authorized by physicians, before
patients were evaluated by the physician.11 Patients
were also categorized by acuity—emergent, urgent,
and nonurgent. Results showed a 46-minute decrease
in LOS for all participants, and a 74-minute decrease
in LOS for participants in the urgent category. In this
study, the initiation of standing orders by nurses upon
arrival of the patient created a positive impact by substantially decreasing LOS and improving patient flow.
When examining this topic, the following content areas were noted as gaps in the research: limited literature, lack of quantitative research evaluating LOS in
relation to an obstetric triage area, and limited data on
the use of standing orders in obstetric triage. Although
there are studies that discuss the roles of nurse midwives and nurse practitioners in managing obstetric
triage units, there is limited research on the use of registered nurses in obstetric triage areas. The data that exist on standing orders in obstetric triage are limited to
obstetric–gynecologic emergency department triage.
METHODS
An interdisciplinary task force was developed with
members of hospital management, nursing, and physicians. Midwives were not part of this team, given the
small number of women serviced and their standard
practice of triaging patients in an expedited manner.
Responsibilities of the task force included disseminating the triage study to colleagues and addressing any of
their concerns with the task force, developing an education plan for physicians and nurses, preparing the
triage room for use, creating standing orders, and assisting with the implementation and ongoing progress
of the study.
Select charge nurses were responsible for evaluating women for inclusion criteria. In addition, all
staff nurses were responsible for completing the audit
sheets for data collection. To prepare the staff for this
study, the nurses were educated by the hospital’s institutional review board (IRB) as well as the primary investigator. When patients presented to the unit, the designated charge nurse determined whether the women
met inclusion criteria for the study, they were consented in a semiprivate area, and then taken to the assigned room where routine care was provided.
The study was designed to determine whether a
triage room (both independent of and with standing orders) and standing orders alone decreased LOS in comparison to the existing system, in which women are
317
triaged in a standard labor room. Under the existing system, a provider evaluates the woman, orders are written and then performed by a nurse, and the woman is
reevaluated before being admitted or discharged. Obstetric residents are the primary providers performing triage in this setting; a small number of women
are evaluated by attending physicians or nurse midwives. Standing orders enabled routine interventions
(eg, IV fluids, laboratory tests) to be initiated before
the woman was initially evaluated by the provider.
Two separate phases were employed in this study for
those women who met triage criteria. During phase
1, women were randomly assigned to either the triage
room or a standard labor room. During phase 2, women
were randomly assigned to either the triage room or
a standard labor room, with the intervention of standing orders in the following diagnostic categories: PTL,
term labor, nausea/vomiting/diarrhea, and rule-out preeclampsia. During both phases, nurses were responsible for the care of additional women on the labor unit
as well as triage. Other factors and care remained unchanged.
For all women in both phases, an initial evaluation
by an obstetric resident was required within 1 hour of
admission and prior to discharge. It is a standard practice that the obstetric resident confers with the attending physician after the patient is initially evaluated and
prior to discharge. Data were tracked via audit sheets
completed by nursing staff that contained various information including time of admission (first contact by
nurse), time of first evaluation by a provider, time of
discharge/admission/transfer, and total LOS. Both
phases lasted approximately 2 months and were implemented on all 3 nursing shifts. The IRB at both the
participating hospital and the University of Hartford approved the study.
In the present research, the following hypotheses
were examined: (1) women evaluated in a room specifically designated to triage patients will have significantly
decreased LOS, (2) women evaluated and treated utilizing standing orders will have significantly decreased
LOS (regardless of setting), and (3) women evaluated
in a triage room and treated using standing orders will
have decreased LOS.
Setting
The study was conducted on an intrapartum unit
within a 617-bed teaching hospital in an urban area
of the Northeast. The hospital averages approximately
3600 births per year. There is no separate women’s
emergency department, and the L&D unit evaluates
women at 14 weeks’ gestation and greater. There is
an observation area originally designated for triage but
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Journal of Perinatal & Neonatal Nursing/October–December 2007
seldom used because of its small size, limited fetal monitoring via a central computer, and relative lack of privacy. This area was used as the triage room for the
purposes of this study, with revisions made in patient
accommodations and nursing supplies prior to implementation.
The L&D unit consists of a 14-bed unit that is in close
proximity to a level 3 neonatal intensive care unit. Obstetric residents are primarily the care providers in this
setting. Infrequently, women are evaluated by attending physicians. Nurse midwives evaluate all women
within their own practice. Midwives and attending
physicians evaluated approximately 5% of all study participants. The study did not differentiate care given
to women by residents, attending physicians, and/or
midwives.
Sample
Inclusion criteria for the sample population consisted
of the following characteristics: medically stable, more
than 18 years of age, English literate, 14 weeks’ gestation and greater, and evaluation in L&D for PTL,
premature rupture of membranes, term labor, term
rupture of membranes, vaginal discharge, urinary tract
infection, nausea/vomiting, upper respiratory tract
infection, rule-out pre-eclampsia, vaginal bleeding,
abdominal trauma, pyelonephritis, sexually transmitted diseases, asthma, abdominal pain (nonpregnancy
related), and DFM. Exclusion criteria included minors,
non-English literate, less than 14 weeks’ gestation, and
medically unstable women. During phase 2, standing orders were used for women being evaluated for
PTL, term labor, rule-out pre-eclampsia, and nausea/
vomiting.
In phase 1, a computer-generated random sample
was used with regard to patient assignment to groups.
Women were divided into a control group or an experimental group. These patients were evaluated simultaneously during a 2-month period. For example, women
who presented to L&D for triage would give consent
for the study and be randomly assigned to a room. It
was typical to have approximately 3 women per shift
included in the study and being evaluated concurrently.
The control group consisted of those women currently
being evaluated in the standard fashion in regular labor rooms. The experimental group consisted of those
women who were being evaluated in the triage room.
In phase 2, a computer-generated random sample
was also used with regard to patient assignment to
groups. Women were divided into 2 experimental
groups, and were evaluated simultaneously during another 2-month period. The first experimental group in
phase 2 consisted of those women who were evalu-
ated in the labor rooms utilizing newly created standing orders. The second experimental group in phase
2 consisted of those women who were evaluated in
the triage room utilizing newly created standing orders.
The projected sample size was 400 women; a sample of
200 women was the goal for each phase. In those analyses comparing phase 1 and phase 2, group size was
200 per group, indicating differences of 19% or greater
were required for statistical significance (power = 80%,
1-tailed α = .05). In analyses within phases, the group
sizes are 100 each and the critical difference in proportions was 13%.
Private providers cared for the majority of study participants (72.7%). Approximately one quarter of participants were under the care of obstetric residents in
a clinic setting. The hospital clinics serve clients of
low socioeconomic status, largely of African American
and Hispanic ethnicities. The majority of participants
in both phases were multiparas with a mean age of
27 years.
INTERVENTION
Phase 1 of this study explored the relationship of a
triage room to LOS. Women who met triage criteria
were randomly assigned to either the triage room or
labor beds. From this point, women were triaged in
the standard fashion: external fetal monitoring was applied, and nursing assessment and admission paperwork were completed. Then the women awaited the
providers to evaluate, order tests/labs and obtain results, and decide the disposition.
Phase 2 of this study explored the relationship of
nursing standing orders, in both the triage room and
the existing system (labor beds), to LOS. Standing orders, based on the Association of Women’s Health Obstetric and Neonatal Nurses/American College of Obstetricians and Gynecologists guidelines and provider
approved, included various diagnostic tests and treatments performed for commonly occurring obstetric
complaints. Women who met triage criteria were randomly assigned to either the triage room or labor
beds. From this point, women were triaged in the new
method: external fetal monitoring was applied, nursing
assessment and admission paperwork were completed,
standing orders were utilized if appropriate, laboratory
tests were obtained and processed, the provider evaluated the patient with laboratory results available or
pending, and the disposition was decided.
Data collection
LOS was tracked via audit sheets attached to every
chart. Staff nurses were responsible for recording the
A Systems Analysis of Obstetric Triage
319
Table 1. Distribution of Diagnoses With Associated Triage Times
Phase 1
Phase 2
Diagnosis
N
Mean triage min (SD)
N
Mean triage min (SD)
PTL
Term labor
Rule-out pre-eclampsia
DFM
PPROM
OTHER
MULT DX
33
56
8
11
6
60
25
164.6 (72.2)
104.6 (64.9)
204.4 (66.0)
111.0 (53.4)
85.2 (53.1)
132.2 (79.1)
142.1 (105.7)
51
60
14
9
8
39
18
168.5 (83.2)
101.8 (74.9)
125.7 (53.8)
74.2 (23.9)
73.1 (38.3)
123.0 (74.8)
135.8 (94.2)
data on the audit sheets for all women. The audit sheets
contained the following information: demographics
(age, gravity, parity, diagnosis, provider), LOS, room
assignment, reason for delay, use of standing orders,
medications administered, laboratory tests obtained,
IV fluid administered, tests/procedures, name of the
nurse, years of nursing experience in L&D, and name
of the provider.
RESULTS
The sample size included 200 women in phase 1 and
200 in phase 2, for a total of 400 women. Total triage
time was not recorded for one woman in each phase,
resulting in a final sample size of 398. The following diagnostic categories were documented for each
woman: PTL, term labor, rule-out pre-eclampsia, DFM,
preterm premature rupture of membranes (PPROM),
and OTHER. The diagnostic category OTHER encompassed any condition beyond the above stated categories, such as pyelonephritis, abdominal trauma, upper respiratory tract infection, etc. Women who had
more than 1 diagnosis were subsequently categorized
as MULT DX. The distribution of diagnoses with associated triage times for phases 1 and 2 is provided in
Table 1.
During phase 1, the following hypothesis was tested:
woman triaged in a room specifically designated as
triage will have significantly decreased LOS. Results
from t tests from phase 1 showed that there was no statistical significance between the mean LOS in a labor
room versus the triage room (Fig 1).
The mean LOS for labor rooms was 133.55 minutes,
and for the triage room 129.16 minutes (P = .7). Thus,
room assignment did not affect LOS. In evaluating LOS
in relation to diagnostic categories, the values in table
1 (phase 1) provide a baseline LOS and illustrate that
rule-out pre-eclampsia and PTL have the longest triage
times.
Provider unavailability, increased patient census, and
delayed laboratory results were most often cited as reasons for delay. These causes were equally distributed
across groups. In addition, there were 61 cases in
which ultrasounds were performed. As a result of this
procedure, delays in progression of the triage process
were noted. Room assignment with respect to diagnostic category showed almost equal results; thus, different diagnoses were unlikely to skew the results. In
addition, the small percentage of laboratory tests, IV
fluids, and medications administered likely had a minimal effect on LOS. Most of laboratory work and IVs was
performed by the nurses, 86% and 98%, respectively.
This expedited the process because nurses performing these tasks facilitate rapid progression of the process. Previously, laboratory work was often performed
by phlebotomy.
During phase 2, the following hypotheses were
tested: (1) women triaged regardless of setting utilizing standing orders will have significantly decreased
LOS and (2) women triaged in a room specifically designated as triage and using standing orders will have
an additional decreased LOS. Results from t tests indicated no statistically significant difference between a
triage versus labor room LOS in phase 2 (P = .1, see
Fig 1). The mean LOS for labor rooms was 134 minutes, and 116 minutes for the triage room. Thus, room
Figure 1. Total length of stay by phase and room
assignment.
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Journal of Perinatal & Neonatal Nursing/October–December 2007
Figure 2. Total length of stay: Phase 1 versus phase 2.
assignment did not significantly affect LOS. The next
analysis compared the total LOS during phase 1 (no
standing orders) to phase 2 (standing orders). In this
perspective, both labor and triage room patients in
phase 1, in which there were no standing orders, were
compared to both labor and triage room patients in
phase 2, in which there were standing orders for the
majority of women. The Student t tests showed that
the mean difference between the groups was not statistically significant, with a P = .3. This is pictured in
Figure 2.
Another strategy utilized was comparing for selected
diagnostic categories—for example, comparing term
labor in phase 1 with term labor in phase 2. PTL and
term labor were the only categories with an adequate
amount of cases to analyze data. Results from t tests indicated no statistically significant difference between
the mean LOS in phase 1 versus phase 2: phase 1
PTL = 164.6 minutes, phase 2 PTL = 168.5 minutes,
phase 1 term labor = 104.6 minutes, and phase 2 term
labor = 101.8 minutes. These results are shown in
Figure 3.
There was a decrease in the mean LOS of 78.7 minutes in phase 2 rule-out pre-eclampsia patients. The
sample sizes in these groups (rule-out pre-eclampsia
phases 1 and 2) were small; however, the difference
using a t test was statistically significant (P = .006).
Figure 3. Total length of stay by preterm and term labor.
This difference can be explained by the standing
orders, which enabled the nurses to obtain laboratory
tests and urine samples with rapidity for diagnostic purposes. This would have to be validated with a larger
sample size.
Similar to phase 1, there were a minimal number
of medications, IVs, and laboratory tests (with the exception of urinalysis—81 cases = 39.9%) being administered. In addition, the majority of IVs and laboratory tests were obtained by the nurses, thus expediting the process. The main reasons for delay of staff in
both phases of the study included increased patient
census, physician unavailability, lengthy processing
times for laboratory results, and prolonged duration of
contractions.
The association of years of nursing experience with
LOS was analyzed using a 1-way analysis of variance
(ANOVA) in both phases 1 and 2. Experience level was
categorized into the following ranges: 0–5, 6–10, 11–
20, and 21 or more years of experience. During phase
1, women with the shortest LOS (123 minutes) were
cared for by nurses having 6 to 10 years of experience.
The women with the longest LOS (142 minutes) were
cared for by nurses having 10 to 20 years of experience.
LOS was not significantly different by experience category in the phase 1 sample (P = .72). During phase 2,
the women cared for by nurses having 10 to 20 years of
experience had the shortest LOS (101 minutes). Those
women with the longest LOS (151 minutes) were cared
for by nurses with 21 or more years of nursing experience. ANOVA indicated a significant relationship between experience category and LOS in phase 1 (P =
.042). A post hoc test (the Tukey Honestly Significant
Difference Test), however, found none of the pairs of
experience groups to be statistically different.
DISCUSSION
The results of this study suggest that there are other
variables in addition to room assignment and nursing care that drive the triage process. The use of a
triage room staffed by registered nurses does not decrease LOS alone. When standing orders were viewed
as a group, LOS was not decreased. However, when
standing orders were broken down into diagnoses, LOS
was decreased by 78.7 minutes in the rule-out preeclampsia category. The nurses initiating laboratory
work earlier in the process may explain this.
The following hypotheses are refuted on the basis
of the results: women evaluated in a room specifically
designated to triage patients will have significantly decreased LOS, and women evaluated in a triage room and
A Systems Analysis of Obstetric Triage
treated using standing orders will have decreased LOS.
The remaining hypothesis that women evaluated and
treated utilizing standing orders will have significantly
decreased LOS (regardless of setting) requires further
study with larger sample sizes.
Staff observed that provider and nurse coverage were
the 2 variables that affected the triage process. For
example, on a typical night both the nurses and the
providers had other responsibilities in addition to the
triage room/triage patient. The nurses were caring for
additional women on the labor unit. The providers
were responsible for women on the labor, antepartum,
and postpartum units, emergency department, and the
operating room. If the provider was involved in a delivery, then the triage patient had to wait to be evaluated
if no other provider was available. The study showed
that women were being initially evaluated in a timely
manner (less than 1 hour) but it was observed that
reevaluation took longer. For instance, the average LOS
for women being evaluated for decreased fetal movement (DFM) in phase 1 was 111.0 minutes. Treatment
for these women involves a nonstress test and at times
an ultrasound to evaluate amniotic fluid volume. Hypothetically, this could take an estimated 45 minutes
with an ultrasound and a cooperative fetus. Waiting for
a provider to perform an ultrasound and/or reevaluate
the fetal heart tracing contributed to a LOS of almost
2 hours. It is hypothesized (for future study) that the
need for a provider to perform ultrasounds may extend
stays due to multiple responsibilities. Thus, staff observed that the triage process was strongly dependent
on provider availability.
LIMITATIONS
Limitations of the study include the following: nurse
follow-through with standing orders, the clinical presentation of the patient, data collection in one hospital, researcher bias, and other variables that could not
be controlled. First, it is possible that there was a lack
of initiation of standing orders by a minority of nurses.
This may have been due to resistance to change and
the given time it takes to acquire a change in practice.
In addition, this may have affected the overall failure to
decrease LOS. Charge nurses did oversee to ensure that
standing orders were utilized. It is a standard practice
that a nurse evaluates newly admitted patients immediately. There would have been minimal delay between
admission and nurse evaluation. A delay between the
nurse evaluation and initiation of standing orders may
have occurred. These fractional times were not evaluated. Second, the clinical presentation refers to the fact
321
that, given the patient condition, it may simply take
the allotted amount of time for evaluation. For example, women under evaluation for PTL who were having contractions required a certain amount of time to
ensure contractions stopped and the cervix was not
dilated. Third, the data were collected in one hospital, thus limiting the generalization of results. Next,
researcher bias refers to the researcher participating
in the study as a staff nurse. This may have expedited
the speed of care administered to the women under
the researcher’s care. Finally, other variables that could
not be controlled included increased patient census
and lengthy processing times for laboratory results. The
patient census fluctuates greatly. During high-census
times, the nursing staff is often caring for additional
women; therefore, it is more difficult to triage efficiently because of competing demands. In addition, it
also affects the provider’s coverage and makes it difficult for them to triage efficiently. Finally, laboratory
results may take up to 2 hours to be processed.
Recommendations for further research
Areas for future study include longitudinal studies evaluating the same variables with a triage room staffed
by nurses solely dedicated to that area, including registered nurses and a nurse midwife/nurse practitioner.
This coincides with the majority of obstetric triage literature. In addition, larger sample sizes with respect to
the standing order diagnostic categories (PTL, term labor, rule-out pre-eclampsia, nausea/vomiting/diarrhea)
would be necessary. Other recommendations for further research include examining other selected diagnostic categories in relation to LOS, and evaluating a
complete breakdown on patient flow. Another area for
further study is the relation of advanced practice nurses
or sonographers in performing ultrasounds/amniotic
fluid volumes to LOS. This could potentially eliminate
the waiting time for obstetric residents to perform
ultrasounds.
Implications for practice
The results of this study suggest that a dedicated
provider (or an additional sonographer) in triage, with
the ability to perform limited ultrasound/amniotic fluid
index and labor rechecks, may be a more efficient system of obstetric triage. Bypassing the provider in the
triage process if possible, or additional providers, may
also be more efficient. Further investigation is necessary to determine whether these changes would benefit patient flow. In addition to these options, comprehensive staff education with a focus on new policies/
procedures and Emergency Medical Treatment and
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Journal of Perinatal & Neonatal Nursing/October–December 2007
Active Labor Act compliance is being further developed at this institution. Plans for the development of a
women’s emergency department, including a separate
triage area, are also being explored. Furthermore, the
role responsibilities of the certified nurse midwives at
this participating hospital have expanded to include as-
sisting the obstetric residents in the triage process. The
triage room was renovated to accommodate patients
better. Implications of this research have motivated a
collaborative effort between nursing staff, physicians,
and other institutions to foster the development of a
specialized triage area with dedicated staff.
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