Triage Versus Obstetric Emergency Department and Main Emergency Department: Best Practices.

An obstetric emergency department (OBED) allows for timely, standardized and quality care by a clinician for pregnant patients presenting unscheduled to a hospital. Understanding the differences between a traditional labor and delivery triage model and an OBED are important in developing a successful, safe, and quality obstetric program that meets the needs of the community with appropriate resource allocation. The benefits in an OBED of every patient seen in a timely fashion by a clinician, and ultimately the impact on outcomes are noteworthy and should be considered when developing a labor and delivery unit.

Midwife-led obstetric triage to increase providers' knowledge and improve timeliness of care: A pre and posttest design.

BACKGROUND: Research in low- and middle-income countries has shown that maternal mortality is directly related to inadequate or absent obstetric (OB) triage systems. Standard triage systems and knowledge on triaging for obstetric emergencies are often absent or lacking in most healthcare systems in Liberia. OBJECTIVE: The objective of this research was to address the third delay defined as receiving adequate, quality care when a facility is reached by increasing knowledge through the establishment of a midwife-led, hospital-based OB triage system to stratify care based on risk and imminence of birth and to improve timely assessment at two district referral hospitals. METHODS: A quasi-experimental study design using a pre/post survey was employed for a midwife-led OB triage training course. Using a train-the-trainer model, five midwives were trained as champions, who in turn trained an additional 62 providers. Test results were analyzed with the R statistical software using paired sample t-test and descriptive statistics. RESULTS: Pretest results revealed a knowledge and practice gap among OB providers on key components of the standard triage package. However, post-test mean scores were significantly higher (M = 79.6, SD = 2.32) than pre-test mean scores (M = 59.0, SD = 2.30) for participants following a 2-day training (p = <0.001). DISCUSSION: Following a structured OB triage training, participants showed significant improvement in post-test OB triage scores. CONCLUSION: Standard OB triage protocols incorporated into the policies and procedures of obstetric wards have the potential to improve knowledge and practice, addressing the third delay and reducing preventable, obstetrics-related deaths.

The design of an Obstetric Telephone Triage Guideline (OTTG): a mixed method study.

BACKGROUND: Clarifying the dimensions and characteristics of obstetric telephone triage is important in improving the quality of services in the health system because researchers can evaluate the effectiveness of treatment, care and diagnostic measures in the form of obstetric telephone triage by developing a guideline. Therefore, this study aimed to design an Obstetric Telephone Triage Guideline (OTTG) using a mixed-method study. METHODS: The present study was carried out using an exploratory sequential mixed method study in two qualitative and quantitative phases. An inductive-deductive approach was also used to determine the concept of obstetric telephone triage. In this respect, a qualitative study and a literature review were used in the inductive and deductive stages, respectively. Moreover, the validity of the developed guideline was confirmed based on experts' opinions and results of the AGREE II tool. RESULTS: The guideline included the items for evaluating the severity of obstetric symptoms at five levels including "critical", "urgent", "less urgent", "no urgent", and "recommendations". The validity of the guideline was approved at 96%, 95%, 97%, 95%, 93%, and 100% for six dimensions of AGREE II including scope and purpose, stakeholder involvement, the rigor of development, clarity of presentation, applicability, and editorial independence, respectively. CONCLUSION: The OTTG is a clinically comprehensive, easy-to-use, practical, and valid tool. This guideline is a standardized tool for evaluating the severity of symptoms and determining the urgency for obstetrics triage services. By using this integrated and uniform guideline, personal biases can be avoided, leading to improved performance and ensuring that patients are not overlooked. Additionally, the use of OTTG promotes independent decision-making and reduces errors in triage decision-making.

Satisfaction with maternity triage following implementation of the Birmingham Symptom-Specific Obstetric Triage System (BSOTS): Perspectives of women and staff.

AIM: To explore the satisfaction and experiences of women and staff with the BSOTS in an Australian hospital. DESIGN: Cross-sectional descriptive survey. METHODS: Surveys were distributed to women and staff between February and May 2022. Survey questions reflected satisfaction with triage and provision of care under the BSOTS system (for women) and confidence in using the BSOTS system and its impact on triage-related care (for staff). Survey data were summarized using descriptive statistics, and qualitative responses were analysed using content analysis. RESULTS: There were 50 women and 40 staff (midwives and doctors) survey respondents. Most women were satisfied with triage wait times, the verbal information they received and the time it took for them to receive care. Nearly all midwife participants indicated they had high knowledge and confidence in using the BSOTS. Most staff indicated that the BSOTS supported the accurate assessment of women and had benefits for women, staff and the hospital. CONCLUSION: The findings showed that women and staff were satisfied with receiving and providing care in a maternity triage setting under the BSOTS system. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Implementing standardized maternity triage approaches such as the BSOTS in health settings delivering care to pregnant women is recommended for improving flow of care and perceptions of care quality by women. IMPACT: Quality of maternity triage processes is likely to impact the satisfaction of women attending services and the staff providing care. The BSOTS was shown to improve maternity triage processes and was associated with satisfaction of women and staff. Maternity settings can benefit from implementing triage approaches such as the BSOTS as it standardizes and justifies the care provided to women. This is likely to result in satisfaction of women and staff engaged in maternity triage and improve the birth outcomes of women and babies. REPORTING METHOD: The reporting of this paper has followed SQUIRE guidelines. PATIENT OR PUBLIC CONTRIBUTION: Women engaged with maternity services were participants in the study but did not contribute to the design, conduct or publication of the study.

Implementation matters: assessing the effectiveness and sustainment of an obstetric triage program at a high-volume facility in Ghana.

BACKGROUND: Maternal mortality remains stubbornly high in Ghana. Current national efforts are focused on improving the quality of care offered in health facilities. Obstetric triage is one intervention that has been proposed to improve the timeliness and appropriateness of care, two key elements of quality. In this study, we describe and evaluate a theory-based implementation approach to introduce obstetric triage into Tema General Hospital, a high-volume maternity hospital in Greater Accra, that blends concepts from implementation science and quality improvement. This implementation project was a first attempt to scale this intervention into a new facility, following initial development in the Greater Accra Regional Hospital (formerly Ridge Hospital) in Accra. METHODS: This was a retrospective mixed-methods evaluation of two stages of implementation: active implementation and sustainment. We triangulated monitoring data captured during active implementation with clinical outcome data (timeliness of first assessment, accuracy of diagnosis, and appropriateness of care plan) from direct observation or patient obstetric triage assessment forms at baseline, at the completion of the active implementation stage, and following a 12-month "washout" period with no contact between hospital staff and the purveyor organization. Finally, we assessed embeddedness of the new triage procedures using the NoMad, a quantitative assessment of constructs from normalization process theory (NPT). RESULTS: Patient waiting time decreased substantially during the study. At baseline, the median arrival-to-assessment waiting time was 70.5 min (IQR: 30.0-443.0 min). Waiting time decreased to 6.0 min (IQR: 3.0-15.0 min) following active implementation and to 5.0 min (IQR: 2.0-10.0 min) during the sustainment period. Accuracy of diagnosis was high at the end of active implementation (75.7% correct) and improved during the sustainment period (to 77.9%). The appropriateness of care plans also improved during the sustainment period (from 66.0 to 78.9%). Per NoMad data, hospital staff generally perceive obstetric triage to be well integrated into the facility. CONCLUSIONS: This theory-based implementation approach proved to be successful in introducing a novel obstetric triage concept to a busy high-volume hospital, despite resource constraints and a short implementation window. Results proved long-lasting, suggesting this approach has high potential for engendering sustainability in other facilities as well. Our approach will be useful to other initiatives that aim to utilize program data to create and test implementation theories.

Acceptability of a Whatsapp Triage, Referral, and Transfer System for Obstetric Patients in Rural Liberia.

Background: Maternal mortality continues to disproportionately affect low- and middle-income countries, including Liberia. Though the relationship between obstetric triage systems and improved maternal outcomes is well documented, standardized triage protocols are lacking in rural Liberia. Mobile health interventions are a promising method to triage obstetric patients. Objectives: This study explores the acceptability of a WhatsApp Triage, Referral, and Transfer (WAT-RT) system among Liberian midwives and community health assistants. Methods: Individual interviews and focus group discussions were conducted among midwives (n = 18) and community health assistants (n = 112). Interviews were designed to understand the current referral system in rural Liberia, how a WAT-RT System can address referral limitations, and the acceptability of the WAT-RT System. Data were audio recorded, transcribed, and translated into English. Data analysis was conducted via NVivo12 with independent and cooperative techniques among multiple researchers. Findings: The current referral system is not standardized with limitations including a lack of triage protocols, transportation difficulties, and inconsistent communication of patient information, which could be addressed by a WAT-RT System. The acceptability for the WAT-RT System was high. Facilitators to implementation included utilizing a pre-existing communication and referral infrastructure, access and competency surrounding mobile phones, and increased opportunities for training and inter-provider collaboration. Barriers included disproportionate phone access between midwives and community health assistants, network reliability, and a lack of data standards. Recommendations for successful implementation included centralizing phone financing and standardizing triage protocols. Conclusions: The WAT-RT System demonstrated high acceptability among frontline health care providers in rural Liberia. Barriers to program success could be reasonably addressed with simple interventions and planning. Multiple benefits included addressing care delays for obstetric patients, promoting bidirectional provider communication, and increasing the quality of obstetric triage. Future studies should focus on piloting the WAT-RT System among this population and recruiting other key stakeholders to determine intervention feasibility.

The obstetric and gynecological service providers' and recipients' perception and experience of the quality of obstetric triage services during the COVID-19 pandemic in Iran.

BACKGROUND: Enhancing the quality of obstetric triage services requires a clear perception of the current situations and problems, this issue gained more importance during the COVID-19 pandemic. The purpose of this study was to explore the obstetric and gynecological service providers' and recipients' perception and experience of the quality of obstetric triage services during the COVID-19 pandemic. METHODS: This research was a qualitative study carried out using conventional content analysis. Participants were selected through purposive sampling, and data collection was conducted using in-depth semi-structured interviews. Data were analyzed using MAXQDA software and conventional content analysis. Validity of the data was approved based on four criteria: credibility, dependability, conformability and transferability. RESULTS: Five themes emerged through analysis: "unpreparedness to deal with the COVID-19 resulting in disorganized triage", "threat to the physical and mental health of personnel during the COVID-19 pandemic", "degradation of the quality of services due to improper triage structure during the COVID-19 pandemic", "communicating with patients which is neglected during the COVID-19 pandemic" and finally "accountability required to improve the provision of services during the COVID-19 pandemic. CONCLUSION: Obstetrics and gynecology service providers and recipients faced formidable challenges in the triage department during this pandemic caused by the complex and ambiguous nature of the Coronavirus. Identifying the problems, barriers and challenges in providing services to patients in this situation especially in triage, can lead to an improvement in the outcome of services.

Evaluating the implementation of the Birmingham Symptom-specific Obstetric Triage System (BSOTS) in Australia.

BACKGROUND: Obstetric triage is usually undertaken by a midwife and involves conducting a physical assessment to identify a woman's presenting problem. The Birmingham Symptom-specific Obstetric Triage System (BSOTS) was developed in the United Kingdom (UK) to overcome challenges associated with triaging women by standardising the maternity triage process. The Australian study site is the first hospital outside the UK to implement this approach. AIM: To evaluate the implementation of the BSOTS in an Australian tertiary maternity service. METHODS: A multi-method approach including pre-implementation BSOTS education evaluations (n = 26), post-implementation clinical data audit (n = 660), and staff focus groups (n = 9) was undertaken. Participants included midwives who worked in the Maternity Assessment Centre. Data of women who had attended the service during BSOTS implementation was analysed in the audit component. FINDINGS: Staff valued the BSOTS standardised approach to maternity triage, particularly for midwives new to the role. The retrospective audit showed that time to triage and time to care outcomes for women improved from pre-implementation audits and were mostly adhering to auditable standards. Lack of knowledge amongst staff (especially medical staff) regarding the BSOTS was considered a barrier to the effective flow of care of women through the centre. DISCUSSION: The BSOTS is a useful approach for prioritising women's care. Ensuring that all staff are aware of the system and its benefits is likely to enhance implementation and improve triage outcomes. CONCLUSION: The BSOTS is an innovative midwife led practice change that is applicable to the Australian context, and benefits women, midwives, and the maternity service.

'A tool we need': Midwives' descriptions and recommendations of an ideal obstetric triage tool.

Background: The obstetric triage tool (OBTT) is used to record the clinical findings following obstetric triage (OBT). The recorded OBTT provides midwives with clinical information leading to diagnosis of existing and potential maternal and foetal problems that may lead to intrapartum complications, planning of specific midwifery care and communication among the midwifery team about the woman in labour. Aim: This study aimed to explore and describe midwives' experiences of the OBTT used during admission of women in labour in the Bojanala district. Setting: This study was conducted in the two selected facilities in Bojanala district in North West province. Methods: This study is a derivative of a major study, entitled 'Midwives' experiences of OBT by midwives in the Bojanala district'. A qualitative, explorative and descriptive research design was followed. Nine purposefully sampled midwives with over 5 years of clinical midwifery experience, employed in the Bojanala district, attended a semistructured interview. Data obtained were analysed using Colaizzi's descriptive method of data analysis according to the themes and categories which emerged. Results: One central theme with 10 subthemes emerged. Midwives verbalised their dissatisfaction with the current OBTT and made recommendations for the revision of the tool. Conclusion: The study highlighted midwives' experiences of the OBTT and recommendations for an ideal tool based on their knowledge of admission of a woman in labour. Contribution: This study provides a new OBTT from midwives' perspectives that could be useful in improving pregnancy and labour outcomes in clinical midwifery practice.

Implementation of the Maternal Fetal Triage Index to Improve Obstetric Triage.

OBJECTIVE: To compare implementation and effectiveness of the Maternal Fetal Triage Index (MFTI) in an urban academic hospital and a suburban private hospital. DESIGN: A pre-/postintervention, hybrid Type 3 effectiveness-implementation study design was used. Data collected 2 months preceding the intervention served as preintervention data. The MFTI was implemented for 2 months at each hospital, generating postintervention data for comparison. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework was used to guide the implementation and evaluation. SETTING/LOCAL PROBLEM: The volume of and various reasons women present for emergency evaluation on maternity units requires systematic triage. Women are typically seen based on when they arrive with limited exceptions, rather than triaged according to acuity, hindering the responsiveness needed to address potentially life-threatening conditions. The term women refers strictly to the biological and anatomic female sex characteristics that are required for intrauterine pregnancy. PARTICIPANTS: Medical records of pregnant women presenting for emergency evaluation and physician and nurse documentation were used for data collection. INTERVENTIONS/MEASUREMENTS: The intervention was triage with the MFTI, acuity level assignment, and screenings within predetermined time frames. Fidelity to protocols and the timeliness of nurse contact and screenings were measured. RESULTS: Implementation across all shifts was associated with greater adherence. The MFTI was associated with a significant reduction in the time from arrival to registered nurse contact for all acuity levels and time to screening foracuity levels overall, as well as for "prompt" and "urgent" acuities independently. CONCLUSION: This project provides a benchmark for quality obstetric triage and a roadmap for further exploration of the MFTI's clinical impact. Through systematic triage, the MFTI establishes effective prioritization and safety, supports favorable health outcomes, and is becoming the standard of practice for obstetric triage.

Obstetric triage improvement process using the Donabedian model of quality care: a quality improvement initiative.

Obstetric triage has become one of the most crucial innovations in the field of perinatal care in the past 15 years. In lower- middle- income countries (LMICs), the pregnant patients are seen in a conventional way based on the time of their arrival; this divergent, unbalanced and inequitable approach results in delayed initial evaluation, prolonged length of stay (LOS) and affected clinical outcomes.This project aimed at implementing an effective and efficient obstetric triage system with improved throughput and care processes within six months to facilitate timely decision making according to the individualized needs of pregnant patients.A pre-implementation audit was completed for the core evaluation of existing obstetric triage services, followed by a fishbone analysis. Following the Donabedian model for quality care, a quality improvement project was initiated to redesign the obstetric triage system. The project strategy was implemented as part of six PDSA (Plan- Do -Study- Act) cycles to optimize the structure, processes, and obstetric triage outcomes. The triage paradigm moved from time-based care delivery to priority care, and processes were improved based on Angelini's recommendations of best practices in obstetric triage. During the initial phase of improvement, the identified outcome measures were waiting time of 5 minutes from arrival to initial assessment, LOS of 120 minutes, and acuity-based care for at least 50% of patients. A post-implementation audit was conducted to assess improvements. The results showed that the LOS at triage reduced from 240 min (4 hours) to 60 min (1 hour) within 6 months. Furthermore, wait times for triage decreased significantly to 5 min in 65% of patients, compared with 6% in traditional triage practice.The results indicate that the traditional triage model of the 'order of arrival' process is inefficient in providing adequate obstetric care. This quality initiative facilitated the successful incorporation of the Donabedian model and best practice triage practices and helped achieve desired outcomes of improved LOS and reduced waiting time with acuity-based care. Therefore, the design of an efficient,and the appropriate obstetric triage system can be adopted by other healthcare institutions in a local setting that can facilitate patient centric care.

Evaluation of Normalization After Implementation of the Digital Dutch Obstetric Telephone Triage System: Mixed Methods Study With a Questionnaire Survey and Focus Group Discussion.

BACKGROUND: The Dutch Obstetric Telephone Triage System (DOTTS) was developed to improve the quality of acute obstetric care. To achieve optimal effect, the DOTTS should be adopted in the daily care process by triage staff. OBJECTIVE: The primary aim was to evaluate the degree of implementation (ie, normalization) of the DOTTS, and the secondary aim was to evaluate which lessons can be learned from its current implementation in Dutch hospitals. METHODS: An evaluation study with a mixed methods design was performed. All triage staff in 9 Dutch hospitals that implemented the DOTTS before September 1, 2019, were invited to complete the Normalization Measure Development (NoMAD) questionnaire between December 2019 and July 2020. The questionnaire is based on the Normalization Process Theory (NPT). This self-reported questionnaire provides insights into the work people do in order to integrate and embed new practice in routine care. The NPT is based on the following 4 constructs: coherence, cognitive participation, collective action, and reflexive monitoring. Within the questionnaire, each construct is represented by 4-7 questions. Questions are scored on a 5-point normalization process scale. Descriptive statistics were used for analysis of questionnaire scores. Subsequently, the questionnaire findings were discussed during a focus group. Template analysis following the 4 constructs was used for analyzing the results of the focus group. RESULTS: Overall, 173 of 294 (58.8%) triage staff members completed the NoMAD questionnaire, and 90.2% (156/173) of the participants had used the DOTTS for over 6 months. The digital application was used as much as possible or always by 137 of 173 (79.2%) participants. The overall normalization process score was 3.77 (SD 0.36). The constructs coherence, cognitive participation, collective action, and reflexive monitoring scored 4.01 (SD 0.47), 4.05 (SD 0.45), 3.5 (SD 0.45), and 3.72 (SD 0.47), respectively. Analysis of the focus group discussion showed that the added value of the DOTTS was seen as a quality improvement for the care of pregnant women. Dedication of the complete multidisciplinary implementation team was important for facilitating normalization. Support from the medical staff and proper use by all disciplines involved in the triage were seen as facilitating factors. Participants appreciated training and evaluation, and indicated a need for ongoing training and evaluation in relation to goal achievement. CONCLUSIONS: The DOTTS has been integrated into normal care in daily practice. Evaluation by the NoMAD questionnaire provided a positive overall score. These results are in line with or, in some aspects, better than the results of other evaluation studies. Key factors in the normalization process of the DOTTS in obstetric triage are the shared added value for stakeholders, the dedication of the complete multidisciplinary implementation team, and implementation plans that are tailor made in the practical context of the hospital.

The midwives' experiences of the use of obstetric triage and obstetric triage tool during labour in Bojanala district.

Background: Obstetric triage (OBT) is a standardised procedure, which plays a vital role in identifying women with obstetric risks upon admission for labour worldwide. In the last few years, considerable attention has been paid to perinatal problem identification programmes, and it has been determined that the inconsistent use of OBT delays midwives' responses to both existing and potential clinical problems amongst women in labour. This delay results in negative and serious perinatal outcomes that could have been prevented. This study was conducted to explore and describe midwives' experiences with OBT in Bojanala district. Aim: This study aimed to explore and describe midwives' experiences with OBT in Bojanala district. Setting: This study was conducted in Bojanala district of the North West Province. Two public healthcare facilities were selected where midwifery care and OBT services are rendered. Methods: A qualitative, descriptive, explorative research design was followed. Nine purposefully sampled midwives participated in a one-on-one in-depth interview. Data were analysed using Collaizi's descriptive method based on the themes and categories that emerged. Results: Three themes emerged. Midwives experienced the OBT tool to be inadequate; and that the low staff number contributes to an imbalance in the midwife-patient ratio. Midwives were also dissatisfied with less support they receive from their management. Conclusion: The study highlighted midwives' experiences of the use of OBT, as presented through their lived experiences. The midwives experienced challenges, which hindered them from practicing OBT to the best of their abilities. Contribution: The study highlighted challenges experienced by midwives regarding OBT, which directly influence the outcomes of pregnancy and labour.

Development of a clinical prediction model for perinatal deaths in low resource settings.

BACKGROUND: Most pregnancy-related deaths in low and middle income countries occur around the time of birth and are avoidable with timely care. This study aimed to develop a prognostic model to identify women at risk of intrapartum-related perinatal deaths in low-resourced settings, by (1) external validation of an existing prediction model, and subsequently (2) development of a novel model. METHODS: A prospective cohort study was conducted among pregnant women who presented consecutively for delivery at the maternity unit of Zanzibar's tertiary hospital, Mnazi Mmoja Hospital, the Republic of Tanzania between October 2017 and May 2018. Candidate predictors of perinatal deaths included maternal and foetal characteristics obtained from routine history and physical examination at the time of admission to the labour ward. The outcomes were intrapartum stillbirths and neonatal death before hospital discharge. An existing stillbirth prediction model with six predictors from Nigeria was applied to the Zanzibar cohort to assess its discrimination and calibration performance. Subsequently, a new prediction model was developed using multivariable logistic regression. Model performance was evaluated through internal validation and corrected for overfitting using bootstrapping methods. FINDINGS: 5747 mother-baby pairs were analysed. The existing model showed poor discrimination performance (c-statistic 0·57). The new model included 15 clinical predictors and showed promising discriminative and calibration performance after internal validation (optimism adjusted c-statistic of 0·78, optimism adjusted calibration slope =0·94). INTERPRETATION: The new model consisted of predictors easily obtained through history-taking and physical examination at the time of admission to the labour ward. It had good performance in predicting risk of perinatal death in women admitted in labour wards. Therefore, it has the potential to assist skilled birth attendance to triage women for appropriate management during labour. Before routine implementation, external validation and usefulness should be determined in future studies. FUNDING: The study received funding from Laerdal Foundation, Otto Kranendonk Fund and UMC Global Health Fellowship. TD acknowledges financial support from the Netherlands Organisation for Health Research and Development (grant 91617050).

Implementation of an obstetric triage decision aid into a maternity assessment unit and emergency department.

BACKGROUND: The obstetric triage decision aid (OTDA) consists of 10 common pregnancy complaints with key signs and symptoms generating a triage score based on targeted questioning responses. It was developed to provide a standardised approach for obstetric triage conducted by midwives and emergency nurses as neither professional group are expert in the triage of pregnant and postpartum women. AIM: To evaluate implementation of the OTDA into an emergency department (ED) and maternity assessment unit (MAU). METHODS: The OTDA was introduced to the ED and MAU of a hospital in Australia. A range of implementation strategies were utilised and assessed by pre and post staff survey, and a three-month post-audit of unscheduled maternity presentations. The primary outcome was adoption rate of the OTDA. Secondary outcomes were staff confidence and waiting times. Analyses were undertaken using SPSS (v24). Paired analysis was conducted on staff surveys. RESULTS: There were a total of 2829 unscheduled presentations: ED (n=708) and MAU (n=2121), 88.1% were triaged using the OTDA, used more in the MAU than the ED (93.2% vs 72.7%; p<.001). In the MAU, women seen within 15min of arrival improved significantly from 42.0% to 78.0%. There was improvement in the self-rated confidence (p=.002) and competence (p=.004) by nurses and midwives to conduct obstetric triage. CONCLUSION: The introduction of the OTDA required different approaches to change practice. There were improvements in staff self-rated confidence and competence, a reduction in clinical risk associated with under-triage in the ED and improved prioritisation of care in the MAU.

The development and validation of an obstetric triage acuity index: a mixed-method study.

BACKGROUND: There is uncertainty about the applicability of developed country triage scales in the developing population. OBJECTIVE: To develop and validate an obstetric triage scale in Iran. METHODS: This exploratory sequential mixed-method study was conducted on experienced gynecologists, emergency medicine, midwives, and nurses as evaluators, and pregnant or parturient women as sample. Development of obstetric triage acuity index was done using qualitative study and literature review. Thirty-two evaluators in two rounds evaluated the clinical impact score, content validity ratio, and content validity index. The tool performance was compared with a standard reference in 415 women. The association of urgency levels with hospitalization, resource utilization, and emergency department length of stay were assessed in 599 women. Five midwives independently double-triaged 234 convenience women to estimate inter-rater reliability. RESULTS: Out of 191 items in the initial draft, 9 (4.7%) items in the face validity, 33 (18.1%) in the first, and 5 (3.2%) in the second content validity round were removed because not meeting the expected thresholds. Nine items added based on evaluators' suggestions. Finally, total items had a kappa above 0.74, and S-CVI/Ave, S-CVI/UA were 0.99 and 0.86, respectively. There was a significant correlation between the two tools (r = 0.661, p < 0). Level 1 mothers had a higher chance of using ≥ 2 resources (OR = 16.4, 95% CI = 2.06-129.98) and hospitalization (OR = 18.0, 95% CI = 3.96-81.51) compared to the level 5, after adjusting for gestational age/postpartum, and referral method. Sensitivity, specificity, and accuracy of the scale in predicting hospitalization were 74.8% (95% CI = 69.73-79.49), 80.8% (95% CI = 73.60-86.74), and 76.7% (72.67-80.48), respectively. The over and under-triage rates were 6.1% and 17.1%, respectively. The absolute agreement inter-raters was 86.8%, and the linear weighted kappa was 0.86 (95% CI = 0.81-0.91). CONCLUSION: The designed OB triage scale showed good validity and reliability in the tertiary teaching hospital. Studying this tool at lower levels, non-educational, and public hospitals are recommended for external validity testing.

Factors influencing the implementation of obstetric triage: a qualitative study.

OBJECTIVE: To identify factors influencing the OB triage implementation in Iran DESIGN: Qualitative study of conventional content analysis SETTING: A teaching tertiary referral hospital in Ahvaz, Khuzestan, Iran PARTICIPANTS: 37 professional midwives, nurses, gynecologists, and specialists of emergency medicine, and 6 patients MEASUREMENTS AND FINDINGS: Semi-structured interviews were conducted individually and face-to-face. Interviews were audio recorded, transcribed, and analyzed using conventional content analysis. Four overarching categories and nine themes emerged from the content analysis of the interviews and observations. Overarching categories were the guideline, individual, cultural and social context, and organization. The development and structure were themes of the guideline. Knowledge, attitudes, and behaviors were related to the category of individuals. The cultural and social context included cultural and social changes. Implementation and monitoring strategies and executive infrastructure were organizational themes. Participants had differences and similarities in understanding influencing factors. CONCLUSION: The guideline, individual, cultural and social context, and organization were key factors influencing the OB triage implementation in Iran. Some variety was detected between the different occupational groups' perceptions of influencing factors. Providing human resources and training and empowerment of them was the most significant factor influencing, which was acknowledged by almost all participants in all occupational groups. IMPLICATION FOR PRACTICE: Identifying the influencing factors from the perspective of all stakeholders can improve the process of OB triage implementation by eliminating barriers and enhancing facilitators.

Exploring the concept and structure of obstetric triage: a qualitative content analysis.

BACKGROUND: Obstetric triage is a new idea, so the design and implementation of it requires identification of its concept and structure. The aim of this qualitative study was to explore the concept and structure of the obstetric triage in Iran. METHODS: The purposive sampling was done and it continued until reaching the theoretical saturation. Thirty-seven semi-structured interviews were conducted individually and face-to-face. Interviews were audio recorded, transcribed, and analyzed using conventional content analysis. RESULTS: Two themes, 8 main categories, and 16 subcategories emerged from the content analysis of the interviews and observations. The themes were the concept and structure of obstetric triage. The concept of obstetric triage consisted of three categories of nature, process, and philosophy of obstetric triage. The structure of obstetric triage included five categories of assessment criteria, emergency grading, determining the appropriate location for patient guidance, initiation of diagnostic and therapeutic measures, and timeframe for initial assessment and reassessment. CONCLUSION: Findings highlighted that obstetric triage is a process with a dual and dynamic nature. This process involves clinical decision making to prioritize the pregnant mother and her fetus based on the severity and acuity of the disease in order to allocate medical resources and care for providing appropriate treatment at the right time and place to the right patient. The results of this study could be used for the design and implementation of the obstetric triage system.

A protocol for evaluating a multi-level implementation theory to scale-up obstetric triage in referral hospitals in Ghana.

BACKGROUND: Ghana significantly reduced maternal and newborn mortality between 1990 and 2015, largely through efforts focused on improving access to care. Yet achieving further progress requires improving the quality and timeliness of care. Beginning in 2013, Ghana Health Service and Kybele, a US-based non-governmental organization, developed an innovative obstetric triage system to help midwives assess, diagnosis, and determine appropriate care plans more quickly and accurately. In 2019, efforts began to scale this successful intervention into six additional hospitals. This protocol describes the theory-based implementation approach guiding scale-up and presents the proposed mixed-methods evaluation plan. METHODS: An implementation theory was developed to describe how complementary implementation strategies would be bundled into a multi-level implementation approach. Drawing on the Interactive Systems Framework and Evidenced Based System for Implementation Support, the proposed implementation approach is designed to help individual facilities develop implementation capacity and also build a learning network across facilities to support the implementation of evidence-based interventions. A convergent design mixed methods approach will be used to evaluate implementation with relevant data drawn from tailored assessments, routinely collected process and quality monitoring data, textual analysis of relevant documents and WhatsApp group messages, and key informant interviews. Implementation outcomes of interest are acceptability, adoption, and sustainability. DISCUSSION: The past decade has seen a rapid growth in the development of frameworks, models, and theories of implementation, yet there remains little guidance on how to use these to operationalize implementation practice. This study proposes one method for using implementation theory, paired with other kinds of mid-level and program theory, to guide the replication and evaluation of a clinical intervention in a complex, real-world setting. The results of this study should help to provide evidence of how implementation theory can be used to help close the "know-do" gap. Every woman and every newborn deserves a safe and positive birth experience. Yet in many parts of the world, this goal is often more aspiration than reality. In 2006, Kybele, a US-based non-governmental organization, began working with the Ghanaian government to improve the quality of obstetric and newborn care in a large hospital in Greater Accra. One successful program was the development of a triage system that would help midwives rapidly assess pregnant women to determine who needed what kind of care and develop risk-based care plans. The program was then replicated in another large hospital in the Greater Accra region, where a systematic theory to inform triage implementation was developed. This paper describes the extension of this approach to scale-up the triage program implementation in six additional hospitals. The scale-up is guided by a multi-level theory that extends the facility level theory to include cross-facility learning networks and oversight by the health system. We explain the process of theory development to implement interventions and demonstrate how these require the combination of local contextual knowledge with evidence from the implementation science literature. We also describe our approach for evaluating the theory to assess its effectiveness in achieving key implementation outcomes. This paper provides an example of how to use implementation theories to guide the development and evaluation of complex programs in real-world settings.

Implementing an Obstetrics-Specific Triage Acuity Tool to Increase Nurses' Knowledge and Improve Timeliness of Care.

OBJECTIVE: To implement an obstetrics-specific triage acuity tool called the Maternal Fetal Triage Index (MFTI) in two maternity units, test the change in nurses' knowledge of triage assessment, and improve timeliness of care. DESIGN: A quality improvement project that included pre- and posttesting of nursing knowledge using the MFTI and measuring the difference in time based on time stamps from pregnant women's intake sheets. SETTING/LOCAL PROBLEM: Two hospitals that are part of a large multi-campus hospital system in the Southeastern United States. PARTICIPANTS: Obstetric triage nurses who have worked in obstetrics for more than 2 years. INTERVENTION/MEASUREMENTS: Participants watched a clinical module about the MFTI and took a pretest; then, 2 months after implementation of the MFTI, they took a posttest. Comparisons of means of the tests were analyzed for a knowledge increase. A retrospective analysis of pre-implementation triage times was conducted using chart reviews from the previous year. This time was then compared with the weekly mean times on the patient flow sheets to assess for timeliness of care. RESULTS: Participants received the educational session, took a pretest, and followed up with completion of a posttest 2 months later. There was an increase in nursing knowledge from a pretest mean score of 79% to a posttest mean score of 95%. Once the MFTI was implemented, timeliness of care improved; the result was a pre-implementation mean time of 19 minutes compared with a post-implementation mean time of 10.4 minutes. CONCLUSION: The educational sessions effectively increased nursing knowledge, and the timeliness of care component showed an improvement from pre- to post-implementation time.