Triaging Perinatal Patients in the Emergency Department: Advancement of Care Through a Nursing Algorithm

Aim: : The aim of this quality improvement initiative was to decrease door-to-proper-bed-placement time for perinatal patients in an Emergency Department (ED). Safe perinatal care in the ED requires accurate triage and bed placement decisions. In 2019, ED nurses identified variability in timing and accuracy of perinatal nursing assessments and triaging, resulting in sub optimal bed placement and care delivery.

Framework:: The Plan-Do-Study-Act (PDSA) approach guided this initiative.

Setting:: Level 3 Trauma Center in a Midwestern teaching hospital.

Stakeholder Team:: Administrative Directors, ED and Perinatal Services: convened team, set timeline, approved final algorithm
Clinical Operations Managers, ED and Perinatal: identified interunit barriers to communication and trust, provided resources, contributed leader perspectives, developed policies
Clinical Nurses: developed algorithm based on clinical expertise, planned testing cycles
Perinatal and ED providers: offered medical perspectives
Data Analyst: retrieved and trended project data
Information Technologist: designed communication options

Methods: : An interprofessional team designed an assessment-and-activation algorithm for triaging perinatal patients and assigning bed placement to ensure timely, optimal care. The team identified key assessments for three obstetrical (OB) categories of perinatal patients in the ED, specifically OB-1, OB-2, or OB Alert. OB-1 patients were too unstable for transport to L&D, typically related to trauma, seizures, or imminent delivery. An L&D team came to ED to assist in care. OB-2 patients were over 20 weeks pregnant or less than six weeks postpartum, acutely symptomatic for complications, or in active labor. If stable, an RN escorted the patient directly to L&D. OB Alert patients were 20 weeks pregnant or less, stable, or with non-perinatal complaints. OB Alert patients remained in the ED with an OB provider consulting. Step by step, the team reviewed outcome data and evolved the algorithm. In successive cycles, the team developed guidelines for interunit phone communication and later adopted an alarm button that alerted L&D of OB-1 patients in the ED. Integration of the algorithm with existing protocols and policies followed. Unit leaders introduced the algorithm to staff via principles of implementation science. ED nurses completed mandatory education on perinatal assessment and complications. L&D nurses trained on providing care in the ED. Unlicensed staff completed role-appropriate education.

Outcomes:: The primary outcome was time in minutes from door-to-proper-bed-placement in the ED or L&D. After four quarters, door-to-proper-bed placement time decreased by 16% and by 31% in the eighth quarter. Audits revealed nurses quickly adopted the algorithm, with all qualified patients receiving algorithm-driven care within one month.

Implications:: Interprofessional development of an algorithm following the PDSA framework improved timely, accurate bed placement for perinatal ED patients. Lessons learned included the importance of (a) collaboration across continua of care, (b) integration of technology for communication and data management, (c) the team’s quick review of data and agreement on testing cycles, (d) tailored education for staff competencies, and (e) education for nurses floating to the ED during the pandemic. Leaders can replicate the algorithm and design process in diverse ED settings where professionals commit to adopt a standardized, efficient triage process for perinatal patients.