The term ‘triage’ derives from an 18th century French word ‘trier’, meaning to pick, choose or sort (Carvel, 2000). This, as we know, is not a new method of managing a department and has been used by the military and emergency departments for a long time. During the Agenda for Change process, Plymouth, like so many other maternity units, underwent a reconfiguration of its service. This involved looking at new patterns of working and, as a result, a triage system of management was put forward.
Plymouth has a delivery rate of approximately 4900 births per year. Prior to the implementation of triage it had an average of 194 non-labouring women admitted to the central delivery suite per month (see table). The goal of triage was to reduce this number of inappropriate admissions. By triaging women effectively, the system would streamline admission to the labour ward in those women in established labour by giving sound and consistent telephone advice, thereby reducing admissions of women in the latent phase of labour and thus not exposing them to unnecessary intervention.
The idea was developed further by the core midwives of the delivery suite. A date was set and training was initiated to all core delivery-suite midwives at band 7. This included ensuring all the team members were proficient with basic ultrasound scanning of the presenting part and that cannulation and obstetric emergency skills were up to date. The team had full input in designing the admission pro forma and ensuring that everyone had consistent communication skills. Once this was in place, the core delivery suite midwives and healthcare assistants implemented triage and rolled it out.
The new system, like many new methods, did encounter some teething problems. The location was difficult as, at first, it shared a ward with day assessment. This did not work as women were too far from the delivery suite and the midwifery workload became too confusing. The project then moved onto one of the mixed maternity wards, but was not successful for the same reasons. We are now in a designated area on the delivery suite with our own beds and a lounge area with immediate access to the delivery suite for transfer.
At the time of the awards entry, triage had been running for just over 12 months and although still in its infancy, it had made a remarkable difference to the service. It is manned 24 hours a day by a band 7 midwife from the delivery suite and a healthcare assistant. Calls come directly to the triage and admissions are invited into the unit by them.
We operate a protected rota system and the whole team is involved in manning it. We also facilitate a band 6 midwife to ‘triage’ during the day to ensure against de-skilling and to aid their professional development. The success of triage is due to the professional embracing of the project by the whole team. It has brought a new and different way of working and it has enabled labour ward resources to be focused on women who are in established labour. It relies heavily on good teamwork and effective but sensitive communication.
These statistics reveal the activity on triage over a 22-day period:
✲ 330 telephone calls were received (approximately 15 calls per eight-hour shift)
✲ 140 admissions (around 39%) were made, the remainder (61%) were triaged
✲ 30% (43) of the 140 women were in labour and delivered within 24 hours
✲ 15% (19) were admitted to the ward.
This activity is only a snapshot of the whole service. Rough estimation at this early stage of the pilot has indicated that triage conducted separately, and by senior staff, works more efficiently and reduces unnecessary admissions. Furthermore, we have not involved our already stretched community colleagues to assist with some of these calls.
Triage has a very high threshold for closure and has only been closed on a handful of occasions. We enjoy using our detection skills, our extended skills like ultrasound scanning and cannulation, and employing masterly inactivity to those women on a normal care pathway. Nor would it run without our maternity healthcare assistants. They help clean and stock up essential items in a timely and professional manner, given the throughput of the unit. They also run to collect notes, make tea and toast, and soothe the disappointed.
In conclusion, triage has been hugely valuable in ensuring the delivery suite co-ordinator can remain in the clinical area and is not being deployed to answer the admission phone or keep the caller anxiously waiting until she is free. The delivery suite is managed with a different ethos and the role of the triage midwife is now seen as a very separate member of the team and not to be utilised on the labour ward. The project has been supported enthusiastically by management and obstetric medical colleagues.
This has been a team effort with very few teething problems and an enjoyable rewarding experience both for midwives, medical colleagues, healthcare assistants and our women. Since its inception we have honed our communication skills and, in the future, we will involve our community colleagues to support more women in their home – although we are mindful of their ever-increasing workload.
It has now become part of the workforce planning, but it will need some tweaking. The next step will be to design a questionnaire for the women to complete, which will gauge their views of the service.
As a team, we have achieved what we set out to do. We have changed current practice and are delivering a more efficient and successful service as a result.
The number of non-labouring women admitted to the Central Delivery Suite prior to triage (JAN-JUNE 08)
Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08
Total 171 191 225 188 213 175
Day 89 84 118 68 111 106
Night 82 107 107 120 102 69
RCM Annual Midwifery Awards 2011If you know of any groundbreaking projects, or an inspirational midwife who is worthy of formal recognition, then visit:
www.rcmawards.com to find out how to enter next year's RCM awards. The 2012 awards also feature five exciting new categories, including employer of the year.
ReferencesCarvel D. (2000) Triage.
British Medical Journal 320(7428): 1535.
Hemminiki E, Simulkka R. (1986) The timing of hospital admission and progress of labour.
European Journal of Obstetrics & Gynecology and Reproductive Biology 22(85): 94.
