Obstetric Triage Improvement Process

Abstract

In recent years, there has been an increase in patient census and acuity at The Johns Hopkins Hospital’s labor and delivery (L&D) unit. The traditional approach to triage is on the basis of a first-come, first-served process. This process results in filling all available triage rooms with less acute patients when more acute patients present for care, resulting in nontriaged high-acuity patients waiting in the lobby. There are six triage rooms with one assigned nurse. One nurse could be responsible for up to six roomed triage patients while nontriaged patients wait. (a) To analyze how nurse-managed, acuity-based obstetric triage facilitates patient leveling and deceases time from presentation to nurse assessment. (b) To understand how to assess current workload and staffing to support implementation of AWHONN’s recommended triage-nurse:patient ratios. The team referenced AWHONN-recommended staffing guidelines and triage literature. In 2015, expert L&D nurses developed and tested an acuity-based triage tool and patient rooming process. The goal was to decrease time from patient presentation to nurse assessment and improve care coordination on the basis of patient acuity. Outcome data were shared with staff and administration who conceptually supported the process. In 2017, current unit workload and staffing was evaluated to identify staffing to support an acuity-based triage process. There were two data-measurement tools created to track unit workload and staffing. The charge nurse recorded, in 2-hr increments, number of roomed triage patients, number of patients waiting to be triaged, overall unit census, and available staff. AWHONN’s recommended staffing guidelines were used to identify the indicated number of triage nurses needed on the basis of the number of triage patients. The process increased global awareness of triage census and acuity. Time from presentation to nurse assessment decreased by more than 50%. This result demonstrated that, with the current triage census, two triage nurses were needed to implement an acuity-based triage process and meet AWHONN’s staffing recommendations. The project supported a change to acuity-based obstetric triage to improve patient safety. Administration approved a workflow redesign and an increase in staffing to support the acuity-based triage process.