OB Triage [PPTX] - Awhonn-af.org

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OB Triage [PPTX] - Awhonn-af.org Powered By Docstoc
					Process Improvement at a Large Military
            Medical Center


 Nicole Polinsky             Julie Hillery
 CDR, NC, USN                CDR, NC, USN
 Clinical Nurse Specialist   Clinical Nurse Specialist
   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.
   One of three large Navy Medical Centers
   Annual birth rate = over 4,200
   Visits to OB Triage = over 800/month
   Unit composition:
    ◦   10 LDRs
    ◦   4 high-risk OB beds (“Special Care”)
    ◦   3 Operating rooms
    ◦   5-bed PACU
    ◦   7-bed Triage area
   Staffing:
    ◦ 50 billets for mix of military, civilian, and contract RNs
    ◦ 15 billets for hospital corpsmen and 2 LPNs
    ◦ 5 billets for civilian and contract clerks
                                                                            Main Hallway


 (Not to scale)
                                               Waiting room
                                 TR 7
                             (precip room)


                                                                 Check-In

                 TR 6

                                              Vending
                                              Machines           Doctor &
                                                                 RN desk
                                                                  space

                 TR 5



To Labor & Delivery


                                                                                     To OR

                  TR 4
               (no central       TR 3        TR 2         TR 1         BR
                   FM)
   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.
   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
                                                                          Patient
                                                                             in
                                                                          waiting
RN triages patients waiting by reviewing the chart and reason for visit    room




        Initial assessment by RN is completed when patient is
                        assigned a triage bed
   Reached Out
    ◦ Email sent to 1920/1964 Listserve (Mother-Baby and
      NICU nursing community) for input and feedback
    ◦ Contacted other hospitals and medical centers for
      policies/procedures/protocols on OB Triage
   Professional organization standards & guidelines
    ◦ AWHONN
      Besuner (2007), Templates for protocols and procedures for
       maternity services, 2nd Ed.
    ◦ AAP & ACOG-Perinatal Guidelines, 2007 (6th Ed.)
    ◦ ACOG-review of compendiums for guidelines/
      statements in regard to perinatal evaluation
‣ Literature Review
   Very few current articles found on obstetric/perinatal
    triage and evaluation (in Fall 2007).
   Overall commonalities of articles found:
    ◦   Common reasons for visits
    ◦   Legal requirements
    ◦   Tiering/classification system
    ◦   Unit-developed protocols
    ◦   Patient flow through triage area
    ◦   Which providers can perform medical screening evaluations (MSEs)
    ◦   Documentation
   Information mentioned in only one article*:
    ◦ Timeline for triage after presentation
    ◦ Competency requirements for staff

   Information not found:
    ◦ Staffing standards

                                   *Mahlmeister & Van Mullem (2000). The process of triage in perinatal
                                   settings: Clinical and legal issues. The Journal of Perinatal and Neonatal
                                   Nursing, 13: 13-30.
   Why review ER Triage?
    ◦ Obstetric triage falls under the same standards as
      emergency room triage.

   Limited search to triage systems
    ◦ Many articles found (see bibliography)

   Commonalities:
    ◦ Triage defined
    ◦ 5-level v. 3-level acuity scales for triage
      5-level preferred; evidence-based system that allows
       consistency of care, efficient placement of patients, and
       improved patient flow.

   Other findings:
    ◦ Concept of “family waiting or gathering area”
   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
   Clinical Nurse Specialist, L&D
   Division Officer, L&D
   Staff RNs
    ◦ Proficient and expert in perinatal nursing
    ◦ Routinely work in OB Triage
    ◦ Charge nurses
   ER Nursing Department Head
    ◦ Adhoc; for consultation
   Already discussed:
    ◦ Review of process
    ◦ Information gathering, literature review.

   “Triage” was the term used by all disciplines to
    describe the entire patient visit.
    ◦ Triage is actually the action taken during and after
      the initial (primary) assessment to determine the
      level of care the patient requires

   Current staffing: 1 RN for a 7-bed OB
    Evaluation area with an average of 800
    visits/month
   How process should be:
    ◦ Patient initially triaged by RN within 5 minutes of presenting to OB
      Evaluation Area; ward clerk simultaneously completes check-in
      paperwork
    ◦ RN categorizes severity of patient’s condition based on chief
      complaint and assessment findings
    ◦ RN notifies provider immediately for emergent conditions or upon
      completion of initial triage for urgent and non urgent conditions
    ◦ Urgent and Non urgent patients in waiting room are re-assessed
      every 30-60 minutes (time related to severity category) by an RN

   “Triage” is term to use for initial/primary assessment
   “Evaluation” is term to use for the rest of the visit.
   Staff with 2 RNs at all times: 1 dedicated to initial triage,
    1 to provide care for patients in evaluation bed
   Limited number of RNs available to meet staffing requirement
    ◦ One (1) RN assigned to 7-bed area with an average of 800 visits/month
   Physical space inhibited triage process and smooth flow of
    ongoing care.
   No unit policy/protocol for OB Triage and Evaluation
   No severity index used to determine treatment needs
   No form available for documentation of initial RN triage
    assessment
   Poor training and competency validation process in place for RNs
   “Triage” is term used by all disciplines to describe the area and
    the entire visit vice initial assessment
   Lack of guidelines from perinatal professional organizations
    regarding triage and evaluation of the obstetric patient
    ◦ OB Triage thought of as “the OB ED” but standard of care not in
      compliance with ED standards.
   Patients who present to OB Evaluation will:
    ◦ Receive an initial triage assessment by an RN within
      5 minutes of arrival
    ◦ Be categorized to level of severity based on chief
      complaint and assessment findings
    ◦ Be re-assessed at prescribed times while in the
      waiting room

   Standard of care will be evidence-based and
    in accordance with ED guidelines
   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)
                                               Waiting room
                                 TR 7                              “Front”
                             (precip room)


                                                Space            Check-In
                                              converted
                 TR 6                          to exam
                                                 room
                                                                 Doctor &
                                                                 RN desk
                                                                  space

                 TR 5



To Labor & Delivery
                                “Back”

                                                                                      To OR

                  TR 4
               (no central       TR 3        TR 2         TR 1         BR
                   FM)
   Area renamed “OB Evaluation (OBE) Area”
    ◦ “Triage” will be term used to describe initial assessment
      and determination of care required
    ◦ Rooms/beds in back will be referred to as “Evaluation”
      beds
   OB Evaluation will follow Emergency Department
    (ED) guidelines regarding standard of care for
    patients who present
    ◦ ED standard = patients are seen within 2-5 minutes of
      arrival
   Levels of severity for patient conditions defined.
   Patient condition will be triaged as red, yellow, or
    green based on reason for visit and assessment
    findings
          Red                        Yellow                          Green
   Cardio-respiratory        Contractions every 2            Nausea/vomiting/
    distress                   minutes & appears                diarrhea
   Eclampsia                  uncomfortable                   Urinary complaints
   Active hemorrhage/        Multipara in active             Stable gestational
    heavy bleeding             labor                            hypertension
   Urge to push              Decreased fetal                 Wound infection
   Objects protruding         movement                        Upper respiratory
    from vagina               Abdominal pain                   infection
   No fetal movement         Preterm labor or                Vaginal discharge/
   Diabetic coma/DKA          preterm rupture of               vaginitis
   Other life-                membranes                       Wound checks
    threatening               Actual or potential Pre-        Staple removal
    conditions to mother       eclampsia or HELLP
    or fetus                   syndrome                        Injections, lab draws
                              Rule-out ROM
                           **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
   Patients sent to the waiting room will be re-
    evaluated as follows until an OBE room is
    available:
    ◦ Yellow = every 30 minutes
    ◦ Green = every hour
   RN assigned to front is responsible for
    completing re-evaluations and re-determining
    condition levels
   Documentation will be on the new “OB
    Evaluation Triage Note” form
   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
   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                               Yellow                          Green                                     Chief complaint or assessment findings significant for:
Date:                                            Arrival Time:                         Triage Time:
Name:                                                                   FMP/Sponsor SSN:
Age:                EDC:                       EGA:             Height:                    Weight:
G:                  P:                 T:                 P:                  A:                  L:                            Cardio-respiratory distress            Contractions every 2 minutes &            Nausea/vomiting/diarrhea
Barriers to communication: □ No □ Yes: □ Language □ Disability □ Other:___________ Action Taken:_____________                   Eclampsia                               appears uncomfortable                     Urinary complaints
Arrival Via: □ Ambulatory □ Wheelchair □ Gurney □ EMS/Ambulance □ Other                                                         Active hemorrhage/heavy                Multiparas in active labor                Stable gestational hypertension
Reason for Visit:                                                                                                                bleeding                               Decreased fetal movement                  Wound infection
                                                                                                                                Urge to push                           Abdominal pain                            Upper respiratory infection
                                                                                                                                Objects protruding from vagina         Preterm labor or preterm rupture of       Vaginal discharge/vaginitis
History of cesarean section?      Yes      No                    History of/current placenta previa?              Yes     No
                                                                                                                                No fetal movement                       membranes                                 Wound checks
History of/current HSV infection? Yes      No                    Are you seen in the Complicated OB clinic?       Yes     No    Diabetic coma/DKA                      Pre-eclampsia/ signs/symptoms of Pre-     Staple removal
If yes, for what complications?                                                                                                 Other life-threatening conditions       e/ HELLP syndrome                         Injections, lab draws
Allergies/reaction:                                                                                                              to mother or fetus                     Rule-out rupture of membranes
Current Medications:
                                        Initial Vital Signs & Obstetric Assessment
Time:                  Temp:                 HR:             BP:                           RR:             FHT:
Pain: rated as __________/10. □ Constant    □ Intermittent □ Sharp □ Dull       □ Pressure           □ Burning
Location:__________________________             Radiation to:_______________________                                                   Red (Emergent)                            Yellow (Urgent)                            Green (Nonurgent)
Leaking Fluid? Yes No Unsure                 Color:___________________________ Time noted: __________                                    Notify MO                          Pt must be seen but will not              Pt can wait for several hours with
Contractions? Yes No Unsure                      Frequency: q ____mins or ______ times/hour                                             Immediately                     deteriorate with slight delay in care           minimal risk of further injury
Regular? Yes No              Date/time started: _____________________            Intensity: mild moderate strong                                                         Notify MO upon completion of                 Notify MO upon completion of
Rectal pressure? Yes No          Urge to push? Yes No                     Length of last labor: _____________                                                                  RN triage assessment                        RN triage assessment
Vaginal Bleeding? Yes No Unsure                        Bright red? Yes No            Bloody show? Yes No
Fetal Movements?           Feeling baby move like he/she normally does? Yes No                                                   Additional Notes:
Feeling 10 or more fetal movements in one hour without difficulty (kick counts)? Yes No
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
Psychosocial: Eye contact?: Yes    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
Vaginal exam: □ Deferred           Time:_________ Dil:__________ Eff:___________ St:_________ Pres:_____________
                                     Ongoing Vital Signs & Obstetric Re-assessment
 Time:     Temp:     HR:    RR:         BP        FHT       Pain         Ctx’s       LOF: VB:             Condition Level
                                                                                     -- / + -- / +
                                                                                     -- / + -- / +
                                                                                     -- / + -- / +
                                                                                            -- / +     -- / +
                                                                                                                                 Signature                                    Initials         Signature                                Initials
                                                                                            -- / +     -- / +
                                                                                            -- / +     -- / +
Provider notified:__________________________________________________ Time:_____________________
Notes:



                Sign                                                      Print
Primary RN
   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

   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
   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                                                     Patient presents at OBE front desk


Triage and
    OB                                   Clerk begins ETR
                                                                                 Triage RN:
                                                                                  Performs initial assessment within 2-5 minutes of patient’s arrival.

Evaluation
                                                                                  Categorizes priority of care based on patient complaint & condition.



 Process                                                                      Yellow (Urgent)                                    Green (Nonurgent/ambulatory)
                          Red (Emergent)                     Pt must be seen but will not deteriorate with slight           Pt can wait for several hours with minimal
                Cardio-respiratory distress                       delay in care (can wait for short time)                             risk of further injury
                Eclampsia                                    Contractions every 2 minutes & appears                        Nausea/vomiting/diarrhea
                Active hemorrhage/heavy bleeding              uncomfortable                                                 Urinary complaints
                Urge to push                                 Multiparas in active labor                                    Stable gestational hypertension
                Objects protruding from vagina               Decreased fetal movement                                      Wound infection
                No fetal movement                            Abdominal pain                                                Upper respiratory infection
                Diabetic coma/DKA                            Preterm labor or preterm rupture of membranes                 Vaginal discharge/vaginitis
                Other life-threatening conditions to         Pre-eclampsia/ signs/symptoms of Pre-e/                       Wound checks
                 mother or fetus                               HELLP syndrome                                                Staple removal
                                                              Rule-out rupture of membranes                                 Injections, lab draws



                    To OBE exam
                                                                                                                      Exam
                   room, operating
                                                                        Yes                                          Room                      No
                  room, special care                                                                                Available?
                 room or LDR room

                                                            To exam room for evaluation.
                                                             RN reassesses VS, pain, OB                                                  To waiting area
                                                              condition if > 30 minutes            When exam room available
                                                                since last assessment.
                                                                                                                              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
                                                            Interventions and re-evaluation                                                 Level the
                                                                performed as indicated                                                       Same?


                                                                                                                                                           Yes
                                                                                                                                 No

                                                               Disposition determined
                                                                                                                      Start pathway of
                                                                                                                       new category




                      Discharge Home, Full Duty,                Admit to Labor & Delivery                      Admit to another unit
                     Light Duty, OB Quarters with              Notify shift charge RN                      Notify bed management
                      instructions and evidence of             Give report to admitting RN                 Notify unit’s shift charge RN
                     fetal well being as appropriate           Escort patient to room                      Call report to admitting RN
                            to gestational age                                                              Escort patient to room
   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)
   Metrics to check:
    ◦ Arrival time to triage time (is it < 5 minutes?)
    ◦ Was condition categorized appropriately?
    ◦ Were ongoing re-assessments performed while patient was in the waiting
      room?
       Did her category change (to higher level of urgency)?
       If so, how long was she in the waiting room?
       If so, why/how did it change?
    ◦ Were the following assessments completed? (all boxes checked or filled
      in):
       Fall Risk assessment
       Domestic Violence assessment
       Psychosocial assessment
    ◦ Does the RN performing triage have competency documented?
    ◦ Reason for visit*
    ◦ Did the RN document procedures performed?*
   Audit Plan:
    ◦ 25 records from day shift & 25 records from night shift weekly x 4 weeks
    ◦ Then 50/day shift and 50/night shift each month
   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.
   Decreased patient wait time for initial
    assessment from 15 minutes-3 hours to 2-5
    minutes.
   Precipitous delivery rate decreased from 4-
    6/month to two in three months.
   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
   Implement triage competency
   Revisit audits to ensure meeting standards
   Expand current Maternal-Infant (1920) core
    competency to reflect triage practice
   Clarify roles of triage staff
Thank You

				
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