Episode 178 Maternity Triage

Maternity triage plays an essential role in providing urgent care to pregnant women, ensuring timely and appropriate responses to potentially life-threatening situations. The episode discusses the BSOTS system, its implementation, challenges, and the importance of maintaining relationships with GPs and midwives while prioritising urgent care needs.

• Overview of maternity triage and its significance 
• Introduction to the Birmingham Symptom Specific Obstetric Triage System (BSOTS) 
• Importance of timely assessment for maternal and fetal health 

Want to know more?

https://www.rcog.org.uk/media/p13lrr3n/gpp17-final-publication-proof.pdf

https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-017-1503-5

https://www.cqc.org.uk/publications/maternity-services-2022-2024/triage

Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
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Its easy to explore my back catalogue of episodes here https://padlet.com/WhoseShoes/TheObsPod I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
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Chapters

• 0:00 Maternity Triage in NHS Obstetrics
• 12:36 Maternity Triage Communication and Concerns
• 30:02 Supporting TheObsPod Accessibility

Transcript

Florence: 0:00

Hello, my name's Florence. Welcome to the OBSpod. I'm an NHS obstetrician hoping to share some thoughts and experiences about my working life. Perhaps you enjoy Call the Midwife. Maybe birth fascinates you, or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth. Perhaps you work in maternity and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case and, for that matter, anyone else that's interested, the OBS pod is for you. Episode 178, maternity Triage.

Florence: 1:00

I thought it was about time that I did an episode on triage. What do I mean by triage? Well, I looked up the Oxford Dictionary definition and, strangely enough, the first definition it gives is about sorting wool. That actually triage was sorting out different qualities of wool in the 18th century. However, later on, seemingly around the time of the First World War in the early 20th century, it became a medical term for deciding which casualties needed the most urgent treatment and, in actual fact, used a subverb in terms of triaging out or leaving those for whom medical treatment was actually not likely to be successful and focusing on those where life could be saved. So it has a battlefield connotation, but most people are probably more familiar with the idea of triage. When they turn up in A&E in an emergency situation you see a nurse, usually fairly swiftly after you've arrived, and they do some basic observations so pulse, blood pressure, ask what you feel might be wrong with you, what are your symptoms, and then from that decide the urgency with which you need to be seen. In A&E departments in the UK the Manchester triage system is used, which was introduced in the late 90s and is a five-point system that helps staff decide the urgency with which patients should be treated. Therefore, for nearly 30 years there's been something in place in the NHS in terms of triaging acutely unwell people, but interestingly not in maternity. Not, that is, until the middle of the last decade when the team in Birmingham developed BSOTS, standing for Birmingham Symptom Specific Obstetric Triage System, bsots.

Florence: 3:47

So the idea is that a woman turns up at the maternity service, now arriving in a triage area, and is rapidly seen by a midwife who does those basic observations pulse, blood, blood pressure, oxygen levels, baby's heartbeat and finds out what symptoms the woman is experiencing and triages according to urgency how quickly the woman needs to be seen by midwifery or medical staff for further treatment or tests. The idea of introduction was to make sure that those women who needed urgent attention would get it quickly, and the system categorises women into red, needing immediate medical attention, amber, needing immediate attention in the next 15 minutes, and yellow and finally green. And green is ideally seen within four hours. Similar to the normal A&E waiting time is ideally seen within four hours. Similar to the normal A&E waiting time. Well, I say normal A&E waiting time, but that's rather gone out of the window recently with the pressure the NHS has been under. So the idea of the BSOTs is that you should have rapid assessment of those women and babies that need it, because in obstetrics, as I've said in previous episodes, everything is extremely time critical. If you have concerns about a woman's well-being or a baby's well-being, every minute counts. So women categorized as red need immediate attention, calling the team and transferred to the labour ward or theatre. And women that are amber also need urgent senior review by a middle grade obstetrician or consultant, whereas those that are yellow or green, whilst it's annoying to have to wait, we're not putting their safety at risk by doing so.

Florence: 6:12

You might ask why we couldn't use the Manchester triage system that's been in use since the 90s in normal A&E, and that's because maternity has some very specific different parameters, because your physiology changes in pregnancy. So what we consider normal blood pressure, pulse and even some blood tests are actually abnormal for pregnancy. They're different. We have different reference ranges for many things and therefore you can't just apply the same sort of triage system because you may not pick up the women that are unwell. The triage system has to be the triage system has to be maternity specific, and the success of the BSOTS Birmingham system meant that they found that the numbers of women assessed within 15 minutes of arrival in a maternity department went from around 38% to 58%, and the aim is for women to be assessed by a midwife with those basic initial assessments within 5 or 10 minutes of arrival, which has got to be good. Since the introduction of this system in Birmingham and numerous other organisations adopting the BSOTS system, it has become adopted as a national recommendation. The Royal College wrote a paper in December 2023 recommending implementation of this type of system across the board, and for my own maternity unit, this was a quality priority for last year.

Florence: 8:20

It sounds very straightforward and easy to implement, but actually one not only needs the right space in which to triage and see women, but also the right staff. If you look at the numbers of women seen in triage in maternity units, it's generally published that you might see three times the number of women that are actually having their babies at the hospital in any month, because women may attend with worries about their baby's movements or they may attend on numerous occasions during their pregnancy. So triage can be immensely busy. So to give you a feel of activity, last month in our maternity unit we saw almost a thousand women and the triage team can see up to 50 women on our busiest day. This is activity from a turn to unit that has around 5,000 births a year and therefore this implementation of a sensible system for prioritising the order in which women are seen is very important.

Florence: 9:53

Published data suggests that around 15 to 20 percent of women attending a maternity triage will be amber, so we'll need that required senior review within 15 minutes of arrival, either because there's something wrong on their maternal observations so, for example, raised blood pressure or rapid pulse or respiratory rate or because of concerns about fetal heart monitoring. And if you look at the numbers of women that score red on the triage system, the numbers are tiny, maybe two or three a month. So in this way it helps us not only prioritize time wise the women that really need rapid input, but also the seniority of doctor that they may see. So we have excellent junior members of staff who are gp trainees and they have excellent core skills in recognising when someone is unwell but they don't have the specialist knowledge and expertise of maternity care, certainly when they start with us. So they can safely see the women that are yellow or green and have a longer timeframe in which to be seen and then discuss with a senior colleague. And we can hone our attention in terms of more senior staff to the red and amber women who may need that very timely intervention to prevent them or their baby becoming very seriously unwell very rapidly. And it's much clearer now as a consultant on call if someone rings from triage or comes around from triage and says they have a woman scoring red or amber, I know I need to immediately release someone to go and assess the situation and see what needs to be done if I can't go myself.

Florence: 12:36

One of the key pieces of published feedback from the BSOTS implementation and BSOTS studies are that staff found it easier to communicate with one another about the urgency using the colour coding system how quickly women needed to be seen and what their concerns were. So how does a woman turn up at triage? So, coming back to our unit stats, around 78% of women self-refer. We also have extremely strict criteria about which pregnant women can and cannot be seen in the main A&E department. Pregnant women have different symptoms sometimes and different physiological parameters which are not necessarily well understood by our emergency medicine colleagues, and therefore a small number of women come to triage via A&E, having been directed on as maternity is a more appropriate place for them to be seen because of the obstetric expertise.

Florence: 14:04

There has been a lot of suggestion of telephone helplines and indeed in the Royal College of Obstetricians and Gynaecologists paper that I mentioned and I will put in the show notes, there is also advice about dedicated 24-hour telephone helpline, staffed by a midwife in a quiet place doing nothing else, who can give her full attention to women and give advice on the phone, and that is generally how we invite people into the maternity unit. We encourage them to phone the helpline to discuss with a midwife what the issue is and then we can direct them as appropriate as to whether they need to come in urgently to triage or whether actually they could wait for an appointment. This makes it slightly easier for us because we can give some advice over the phone and we've also got some idea of who we're expecting to walk through the door. For example, sometimes if a woman rings up who thinks she might be in pre-term labour, the team will give us in the neonatal unit the heads up before she's even entered the building. Some women will, of course, just appear, turn up of their own accord. Obviously, we have an open door and we very much encourage women to attend if they have any worries. Some women will be sent in by the community midwives and some women may possibly be sent in by their GP.

Florence: 15:43

And that brings me to the other aspect of triage. Everything I've described up to now might seem great, totally standard, very good safety, and why wouldn't you want to do it? But there is a flip side to this whole triage issue in that we're breaking up that relationship both with the general practitioner, the GPs, and also potentially the community midwives or midwifery teams, because the first port of call is starting to be the hospital, the hospital maternity system and triage. And there is some value in that, in that the hospital is open 24-7, it's always staffed. There's always people there and if you've got a complication or problem you don't want to be sitting around waiting for an appointment.

Florence: 16:48

But it definitely breaks up the continuity. Traditionally women, if they had more minor complications in pregnancy, would contact their midwife or their midwifery team and the midwife might phone them back, maybe arrange a visit or fit them into clinic to have an appointment. And because you've got that continuity and they know that woman and that woman knows that midwife, you then have the ability to know what is a bit different for that woman and how that woman normally is, what her medical and obstetric history is, and that might give you some pointers. Whereas if a woman is phoning a helpline or coming into triage, chances are she's never met the staff before. They don't know her. She doesn't know them. And yes, we do now have digital notes and they can look on the system and see what her appointments say and what the history is and the interactions she's had with the maternity service.

Florence: 17:56

But it's not the same. It's not relationship-based care, which has been very much the basis of lots of maternity care in the past. Equally, gps certainly in my local area are completely now excluded from maternity care. It's very rare that when a woman has a difficulty in pregnancy, she contacts her GP. When a pregnant woman booked her maternity care, one of the first things that the midwife would do at that first assessment is decide what type of care the woman was going to receive, and one of the options was what was called shared care, which was shared care with the GP. So the woman would see the midwife for a number of appointments and the GP for a number of appointments. However, this seems to have completely disappeared. We don't have that shared care arrangement with our local GPs anymore. It's not their fault. They're completely overloaded and my understanding is it's also to do with the way the GP contract works. I believe that they don't have those appointments included in their contract anymore, but it can mean that the GP is completely out of the conversation of the care of that woman for a period of time, which is not ideal if the GP is someone who's very familiar with that woman ideal if the GP is someone who's very familiar with that woman.

Florence: 19:43

Gps may have lots of useful information about the women on their books, about their chronic health conditions, if they have them, and whilst that won't always be important and of use, I do feel that the emphasis on women self-referring to maternity services and being cared for by midwives and obstetricians has really taken away from that that the family doctor had with that woman and we're medicalising and bringing everything into hospital. So I was interested also when I was exploring this topic to have a little look at what women think of the BSOTS system, and there are a few small reports published, including one from a hospital in Australia that implemented BSOTS. That said women found it acceptable. They had better communication about their likely waiting times and they were more satisfied with that. But I know from some women that they find it a very busy area. They can be waiting for some time. They see a different team of midwives or doctors each time they come and it isn't necessarily a great experience.

Florence: 21:30

You might ask why we couldn't use the Manchester triage system that's been in use since the 90s in normal A&E and that's because maternity has some very specific different parameters, because your physiology changes in pregnancy. So what we consider normal blood pressure, pulse and even some blood tests are actually abnormal for pregnancy. They're different. We have different reference ranges for many things. There are also important symptoms that in pregnancy may be very significant that in the general population might be completely innocuous and therefore you can't just apply the same sort of triage system because you may not pick up the women that are unwell. This is why the triage system has to be maternity specific.

Florence: 22:50

The other benefit for us in having implemented BSOTS is that we can very clearly audit how we're doing in terms of meeting targets. Are we seeing and assessing those women in a timely way and, if not, what were the barriers to that? What were the blocks? And there's a very clear escalation process in BSOTS. If a woman is waiting longer than she should be how you escalate to the consultant on call. So, unlike previously, we've got a clear expectation of time frames in which women might see, rather than an open-ended situation. And the CQC National Review of Maternity Services published in September 24 highlighted maternity triage as a really important first step for women with an emergency concern during their pregnancy or the immediate postnatal period the first six weeks and was a safety concern in around a third of CQC maternity inspections overall, although they did acknowledge that the RCOG paper and guidance had come out after some of the inspections they'd had. So hopefully maternity triage will be an area of rapid improvement in the immediate future, do I think it's a good system. It definitely has some safety benefits.

Florence: 24:39

It can end up feeling a bit disjointed and I think we need to be careful about which women are being seen in triage and which women actually could wait for an appointment with their midwifery team or obstetric team or GP. I think some of the particularly green women. Do they really need to come to hospital? Probably not, but there are so many things that worry women in pregnancy. You know you really want to be there for those women that are worried 24-7. And that's definitely how we improve safety for women and babies. But does it all need to come to the hospital? No, could we safely direct some of it elsewhere? Maybe Could we do a better job of women seeing their midwives and GPs.

Florence: 25:51

For some of the less urgent stuff, probably, but it's very challenging because even something as simple as a urinary tract infection, if left untreated, can make a woman unwell, can risk the chance of preterm labour. So it's very challenging not to sweep everything up into triage and just try and make that as safe as one possibly can. So what's my zesty bit, I think, for a woman, know that maternity helplines and triage are there to be used. You may have a bit of a wait if something isn't urgent. But if you're ever unsure about a symptom or problem you're having in pregnancy, it is always better to ring your maternity service and find out. If you can easily get hold of your midwife and it doesn't seem like an urgent thing to you, then great. But at the end of the day, that 24-hour number is your port of call.

Florence: 27:10

For anything you're worried about there's an expert who can talk to about. There's an expert who can talk to. Never sit at home and worry. We'd always rather you came and we saw you and everything was fine and you went away happy and reassured. If you're a member of staff, then maybe you're very used to this sort of triage, maybe you're not, but bear in mind that there's a reason why it's been recommended. There's good grounds for making sure that women are seen in the right order and those with more urgency take priority and however tempting it is when someone's been waiting a long time or a longer time, to bump them forwards and and try and be kind to them, actually it's really important that we stick to that clinical prioritisation and only come to the women that are non-urgent when all those are have been seen. So it can be a bit frustrating when triage is busy and you've got less, perhaps, doctor capacity to review people. But just keep like with any structured tool, it's there for a reason and if you stick to that red, amber, yellow, green you're not going to go wrong. You're going to be safe on your busiest, busiest day. Thanks for listening.

Florence: 29:04

I very much hope you found this episode of the OBS pod interesting. If you have, it'd be fantastic if you could subscribe, rate and review on whatever platform you find your podcasts, as well as recommending the OBS pod to anyone you think might find it interesting. There's also tons of episodes to explore in my back catalogue from clinical topics, my career and journey as an obstetrician and life in the NHS more generally. I'd like to assure women I care for that I take confidentiality very seriously and take great care not to use any patient identifiable information unless I have expressly asked the permission of the person involved on that rare occasion when it's been absolutely necessary.

Florence: 30:02

If you found this episode interesting and want to explore the subject a little more deeply, don't forget to take a look at the programme notes where I've attached some links. If you want to get in touch to suggest topics for future episodes. You can find me at TheObsPod, on Twitter and Instagram, and you can email me theobspod at gmailcom. Finally, it's very important to me to keep the OpsPod free and accessible to as many people as possible, but it does cost me a very small amount to keep it going and keep it live on the internet. So if you've enjoyed my episodes and, by chance, you do have a tiny bit to spare, you can now contribute to keep the podcast going and keep it free via my link to buy me a coffee. Don't feel under any obligation, but if you'd like to contribute, you now can. Thank you for listening.