Quality improvement initiative: improving obstetric triaging practices in a rural maternal hospital in central India

Abstract

Triaging of obstetric patients by emergency care providers is paramount. It helps provide appropriate and timely management to prevent further injury and complications. Standardised trauma acuity scales have limited applicability in obstetric triage. Specific obstetric triage index tools improve maternal and neonatal outcomes but remain underused. The aim was to introduce a validity-tested obstetric triage tool to improve the percentage of correctly triaged patients (correctly colour-coded in accordance with triage index tool and attended to within the stipulated time interval mandated by the tool) from the baseline of 49% to more than 90% through a quality improvement (QI) process.A team of nurses, obstetricians and postgraduates did a root cause analysis to identify the possible reasons for incorrect triaging of obstetric patients using process flow mapping and fish bone analysis. Various change ideas were tested through sequential Plan-Do-Study-Act (PDSA) cycles to address issues identified.The interventions included introduction and application of an obstetric triage index tool, training of triage nurses and residents. We implemented these interventions in eight PDSA cycles and observed outcomes by using run charts. A set of process, output and outcome indicators were used to track if changes made were leading to improvement.Proportion of correctly triaged women increased from the baseline of 49% to more than 95% over a period of 8 months from February to September 2020, and the results have been sustained in the last PDSA cycle, and the triage system is still sustained with similar results. The median triage waiting time reduced from the baseline of 40 min to less than 10 min. There was reduction in complications attributable to improper triaging such as preterm delivery, prolonged intensive care unit stay and overall morbidity. It can be thus concluded that a QI approach improved obstetric triaging in a rural maternity hospital in India.

Keywords: Control charts/Run charts; Healthcare quality improvement; Maternal Health Services; PDSA.

Figure 1

Fish bone analysis of problem. LR, labour room; JR, junior resident.

Figure 2

New triage protocol. ANC, ante natal care; Anti-D, anti rhesus-D immunoglobulin; BP, blood pressure, DBP, diastolic blood pressure, FHR, fetal heart rate; HR, heart rate; ICU, intensive care unit; MSAF, meconium stained amniotic fluid; NST, non stress test; OT, operation theatre; PV, per vagina; RR, respiratory rate; SBP, systolic blood pressure; Td, tetanus and diphtheria toxoid vaccine.

Figure 3

(A) Time series graph of outcome variables: percentage of women correctly triaged and median triage waiting time. (B, C) Tables for maternal and neonatal outcome indicators. (B) Maternal complications before and after quality improvement (QI). (C) Neonatal complications before and after QI. ICU, intensive care unit; NICU, neonatal intensive care unit; PDSA, Plan-Do-Study-Act.