Maternity triage needed due to blocking of beds

Medical researchers auditing Mater Dei Hospital’s maternity admissions believe well over 53% of women who make ‘unplanned presentations’ to the central delivery suite, would be blocking beds inside the labour ward without a proper assessment in triage.

The researchers said that with limited number of delivery rooms at MDH, a maternity unit triage room could allow for better utilisation of labour wards and resources being used for those most in need.

Most maternity units in the UK already have a maternity triage room, where all incoming pregnant women with acute presentations are assessed, as well as telephone referrals, and where blood tests or internal examinations can take place if required.

The quantitative analysis of 490 women admitted at the MDH central delivery suite took place over four weeks, where researchers analysed data from all admissions, which included women with different acute presentations – contractions, decreased foetal movements, bleeding per vagina, high blood pressure, or spontaneous rupture of membranes (SROM), as well as other accidents, or itching, vomiting and diarrhoea.

Women who had a planned lower-section caesarean section (LSCS) or induction of labour (IOL) – 122 patients (or 25%) – were excluded from the audit.

366 patients (75%) presented to the labour ward with an acute complaint. Of these, 224 patients (61.2%) were admitted, and 142 patients (38.8%) were discharged after review by basic specialist trainee. Out of the 224 patients admitted, 171 patients (76.3%) delivered during that admission and 53 patients did not deliver.

Currently, there is one admission room at MDH’s central delivery suite which is used to review pregnant women at 22 weeks’ gestation or more who self-admit or are referred by the obstetric team either because one is in active labour or needs intrapartum management for pregnancy-related complications.

Of the 366 admissions with acute presentations, these included 38.8% with an acute complaint to the labour ward, who were discharged after initial assessments. The vast majority of these women occupied a delivery room which could have been available to women that really needed it.

Of the 224 admitted following an acute presentation, 53 did not deliver but were kept in the room for observation or transferred to an obstetric ward. These women were also blocking a delivery bed and could have been managed elsewhere.

MDH’s central delivery suite is a specialised ward of nine delivery rooms, and an operating theatre equipped for caesarean sections and other birth procedures, as well as a neonatal resuscitation room.

“It is not just mothers in labour who are admitted here, but any expecting mother from 22 weeks’ gestation onwards may be referred for assessment and will be reviewed by an obstetric team and discharged or admitted as necessary,” researchers Dr Elaine Camilleri, Dr Sharona Falzon, and Mandy Collict, wrote on The Malta Medical Journal.

“Unfortunately, this puts additional stress on the bed availability and may lead to burnout of the team members. The various functions of the labour ward demand a sound organisational structure to maximise the limited resources available whilst providing the best care. This could be optimised by providing a maternity unit triage room prior to admission to Central Delivery Suite.”

The doctors say that apart from better management of high-dependency beds, a maternity triage system reduces waiting and transfer times, improves patient satisfaction, and reduces unplanned admissions or readmissions within the first 48 hours.

“Common presentations documented in this audit could have been handled in a maternity triage room. Most of the presentations were of low acuity. 38.8% of acute presentations did not need an admission and were discharged after initial review…

“Also, 23.7% of the admitted women following an acute presentation did not deliver. These women could have been directed directly to an obstetric ward instead of occupying a room in the delivery suite for their assessment. This means that 53.3% of women in this audit who had an unplanned admission to the labour ward could have been handled in a maternity triage room and did not need to block a bed in the labour ward.

“If MDH had this system we would be using our limited delivery room beds better.”

However, the researchers believe that one triage room may not be sufficient, due to simultaneous admissions, which are a common occurrence. The doctors say patients inflow can be reduced with a proper telephone service that allows pregnant women and GPs to phone for queries, with midwives and obstetricians redirecting non-urgent cases – such as vaginal spotting or minor trauma – which are the majority of the acute presentations.

“One must also ensure that an efficient triage system is in place. Midwives should be trained properly in triaging and a doctor, ideally senior, should be present at triage to evaluate the situation upon encounter and treat immediately without any delays.

“A fast-track system should be in place. Patients that have low acuity presentations should be assessed in one room by a team of midwives that when necessary involve an obstetrician.”

The commonest acute presentation to the labour ward were contractions, which was documented 131 times. 76.3% of the time, women were admitted.

The remaining 23.7% occupied a bed in the labour ward for initial assessment and were then discharged home.