Process Improvement at a Large Military
Medical Center
Nicole Polinsky
CDR, NC, USN
Clinical Nurse Specialist
Julie Hillery
CDR, NC, USN
Clinical Nurse Specialist
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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.
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One of three large Navy Medical Centers
Annual birth rate = over 4,200
Visits to OB Triage = over 800/month
Unit composition:
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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
Main Hallway
(Not to scale)
TR 7
(precip room)
Waiting room
Check-In
TR 6
Vending
Machines
Doctor &
RN desk
space
TR 5
To Labor & Delivery
To OR
TR 4
(no central
FM)
TR 3
TR 2
TR 1
BR
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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.
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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?
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
Patient
in
waiting
room
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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
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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
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Very few current articles found on obstetric/perinatal
triage and evaluation (in Fall 2007).
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Overall commonalities of articles found:
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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
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Information mentioned in only one article*:
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Information not found:
◦ Timeline for triage after presentation
◦ Competency requirements for staff
◦ 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.
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Why review ER Triage?
◦ Obstetric triage falls under the same standards as
emergency room triage.
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Limited search to triage systems
◦ Many articles found (see bibliography)
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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.
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Other findings:
◦ Concept of “family waiting or gathering area”
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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
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Clinical Nurse Specialist, L&D
Division Officer, L&D
Staff RNs
◦ Proficient and expert in perinatal nursing
◦ Routinely work in OB Triage
◦ Charge nurses
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ER Nursing Department Head
◦ Adhoc; for consultation
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Already discussed:
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“Triage” was the term used by all disciplines to
describe the entire patient visit.
◦ Review of process
◦ Information gathering, literature review.
◦ Triage is actually the action taken during and after
the initial (primary) assessment to determine the
level of care the patient requires
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Current staffing: 1 RN for a 7-bed OB
Evaluation area with an average of 800
visits/month
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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
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“Triage” is term to use for initial/primary assessment
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“Evaluation” is term to use for the rest of the visit.
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Staff with 2 RNs at all times: 1 dedicated to initial triage,
1 to provide care for patients in evaluation bed
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Limited number of RNs available to meet staffing requirement
◦ One (1) RN assigned to 7-bed area with an average of 800 visits/month
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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.
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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
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Standard of care will be evidence-based and
in accordance with ED guidelines
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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.
Main Hallway
(Not to scale)
TR 7
(precip room)
Waiting room
Space
converted
to exam
room
TR 6
“Front”
Check-In
Doctor &
RN desk
space
TR 5
To Labor & Delivery
“Back”
To OR
TR 4
(no central
FM)
TR 3
TR 2
TR 1
BR
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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
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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
Red
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Cardio-respiratory
distress
Eclampsia
Active hemorrhage/
heavy bleeding
Urge to push
Objects protruding
from vagina
No fetal movement
Diabetic coma/DKA
Other lifethreatening
conditions to mother
or fetus
Yellow
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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 Preeclampsia or HELLP
syndrome
Rule-out ROM
Green
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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
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
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Patients sent to the waiting room will be reevaluated as follows until an OBE room is
available:
◦ Yellow = every 30 minutes
◦ Green = every hour
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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
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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
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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
Condition Level:
Red
Date:
Name:
Arrival Time:
Yellow
Green
Chief complaint or assessment findings significant for:
Triage Time:
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
If yes, for what complications?
Allergies/reaction:
Current Medications:
No
Are you seen in the Complicated OB clinic?
Yes
No
Time:
Temp:
Initial Vital Signs & Obstetric Assessment
HR:
BP:
Pain: rated as __________/10. □ Constant
Location:__________________________
RR:
□ Intermittent □ Sharp □ Dull
□ Pressure
Radiation to:_______________________
 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 Pree/ 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
FHT:
□ Burning
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
Feeling baby move like he/she normally does? Yes No
Fetal Movements?
Feeling 10 or more fetal movements in one hour without difficulty (kick counts)? Yes No
Red (Emergent)
Notify MO
Immediately
Yellow (Urgent)
Green (Nonurgent)
Pt must be seen but will not
deteriorate with slight delay in care
Notify MO upon completion of
RN triage assessment
Pt can wait for several hours with
minimal risk of further injury
Notify MO upon completion of
RN triage assessment
Additional Notes:
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
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
Time:_________ Dil:__________ Eff:___________ St:_________ Pres:_____________
Vaginal exam: □ Deferred
Ongoing Vital Signs & Obstetric Re-assessment
Condition Level
Time:
Temp:
HR:
RR:
BP
FHT
Pain
Ctx’s
LOF: VB:
-- / + -- / +
-- / + -- / +
-- / + -- / +
Psychosocial: Eye contact?: Yes
-- / +
-- / +
-- / +
-- / +
-- / +
-- / +
Provider notified:__________________________________________________ Time:_____________________
Notes:
Primary RN
Sign
Print
Signature
Initials
Signature
Initials
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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
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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
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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
Evaluation
Process
Patient presents at OBE front desk
Triage RN:
 Performs initial assessment within 2-5 minutes of patient’s arrival.
 Categorizes priority of care based on patient complaint & condition.
Clerk begins ETR
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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
To OBE exam
room, operating
room, special care
room or LDR room
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
Exam
Room
Available?
Yes
To exam room for evaluation.
RN reassesses VS, pain, OB
condition if > 30 minutes
since last assessment.
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
No
To waiting area
When exam room available
Triage RN reassesses VS, FHTs,
pain, and OB condition:
 Every 30 minutes if Cat Yellow
 Every 60 minutes if Cat Green
Medical screening exam
performed by provider
Priority
Level the
Same?
Interventions and re-evaluation
performed as indicated
Yes
No
Disposition determined
Start pathway of
new category
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
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Admit to another unit
Notify bed management
Notify unit’s shift charge RN
Call report to admitting RN
Escort patient to room
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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)
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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?*
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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
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Act to hold the gain/continue improvement
Act on the information.
Adopt the change.
Modify or plan accordingly. Perform in an
improved manner.
 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.
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Decreased patient wait time for initial
assessment from 15 minutes-3 hours to 2-5
minutes.
Precipitous delivery rate decreased from 46/month to two in three months.
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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
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Implement triage competency
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Revisit audits to ensure meeting standards
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Expand current Maternal-Infant (1920) core
competency to reflect triage practice
Clarify roles of triage staff
Thank You