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Rashidi F, Simbar M, Safari S, Kiani Z. The design of an Obstetric Telephone Triage Guideline (OTTG): a mixed method study. BMC Womens Health 2024; 24:246. [PMID: 38637803 PMCID: PMC11025151 DOI: 10.1186/s12905-024-03076-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 04/04/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Clarifying the dimensions and characteristics of obstetric telephone triage is important in improving the quality of services in the health system because researchers can evaluate the effectiveness of treatment, care and diagnostic measures in the form of obstetric telephone triage by developing a guideline. Therefore, this study aimed to design an Obstetric Telephone Triage Guideline (OTTG) using a mixed-method study. METHODS The present study was carried out using an exploratory sequential mixed method study in two qualitative and quantitative phases. An inductive-deductive approach was also used to determine the concept of obstetric telephone triage. In this respect, a qualitative study and a literature review were used in the inductive and deductive stages, respectively. Moreover, the validity of the developed guideline was confirmed based on experts' opinions and results of the AGREE II tool. RESULTS The guideline included the items for evaluating the severity of obstetric symptoms at five levels including "critical", "urgent", "less urgent", "no urgent", and "recommendations". The validity of the guideline was approved at 96%, 95%, 97%, 95%, 93%, and 100% for six dimensions of AGREE II including scope and purpose, stakeholder involvement, the rigor of development, clarity of presentation, applicability, and editorial independence, respectively. CONCLUSION The OTTG is a clinically comprehensive, easy-to-use, practical, and valid tool. This guideline is a standardized tool for evaluating the severity of symptoms and determining the urgency for obstetrics triage services. By using this integrated and uniform guideline, personal biases can be avoided, leading to improved performance and ensuring that patients are not overlooked. Additionally, the use of OTTG promotes independent decision-making and reduces errors in triage decision-making.
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Affiliation(s)
- Farzaneh Rashidi
- Midwifery and Reproductive Health Research Center, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoumeh Simbar
- Midwifery and Reproductive Health Research Center, Department of Midwifery and Reproductive Health, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Saeed Safari
- Department of Emergency Medicine, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Kiani
- Midwifery and Reproductive Health Research Center, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Ramaswamy R, Bogdewic S, Williams CR, Deganus S, Bonzi GA, Boakye J, Koranteng E, Mensah R, Amanor A, Bryce F, Owen MD. Implementation matters: assessing the effectiveness and sustainment of an obstetric triage program at a high-volume facility in Ghana. Implement Sci Commun 2023; 4:138. [PMID: 37968768 PMCID: PMC10647175 DOI: 10.1186/s43058-023-00527-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 11/03/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Maternal mortality remains stubbornly high in Ghana. Current national efforts are focused on improving the quality of care offered in health facilities. Obstetric triage is one intervention that has been proposed to improve the timeliness and appropriateness of care, two key elements of quality. In this study, we describe and evaluate a theory-based implementation approach to introduce obstetric triage into Tema General Hospital, a high-volume maternity hospital in Greater Accra, that blends concepts from implementation science and quality improvement. This implementation project was a first attempt to scale this intervention into a new facility, following initial development in the Greater Accra Regional Hospital (formerly Ridge Hospital) in Accra. METHODS This was a retrospective mixed-methods evaluation of two stages of implementation: active implementation and sustainment. We triangulated monitoring data captured during active implementation with clinical outcome data (timeliness of first assessment, accuracy of diagnosis, and appropriateness of care plan) from direct observation or patient obstetric triage assessment forms at baseline, at the completion of the active implementation stage, and following a 12-month "washout" period with no contact between hospital staff and the purveyor organization. Finally, we assessed embeddedness of the new triage procedures using the NoMad, a quantitative assessment of constructs from normalization process theory (NPT). RESULTS Patient waiting time decreased substantially during the study. At baseline, the median arrival-to-assessment waiting time was 70.5 min (IQR: 30.0-443.0 min). Waiting time decreased to 6.0 min (IQR: 3.0-15.0 min) following active implementation and to 5.0 min (IQR: 2.0-10.0 min) during the sustainment period. Accuracy of diagnosis was high at the end of active implementation (75.7% correct) and improved during the sustainment period (to 77.9%). The appropriateness of care plans also improved during the sustainment period (from 66.0 to 78.9%). Per NoMad data, hospital staff generally perceive obstetric triage to be well integrated into the facility. CONCLUSIONS This theory-based implementation approach proved to be successful in introducing a novel obstetric triage concept to a busy high-volume hospital, despite resource constraints and a short implementation window. Results proved long-lasting, suggesting this approach has high potential for engendering sustainability in other facilities as well. Our approach will be useful to other initiatives that aim to utilize program data to create and test implementation theories.
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Affiliation(s)
- Rohit Ramaswamy
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Stephanie Bogdewic
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Caitllin R Williams
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sylvia Deganus
- Tema General Hospital, Ghana Health Service, Tema, Ghana
| | | | - Joana Boakye
- Tema General Hospital, Ghana Health Service, Tema, Ghana
| | | | | | - Alice Amanor
- Tema General Hospital, Ghana Health Service, Tema, Ghana
| | | | - Medge D Owen
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
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Reynolds CW, Horton M, Lee H, Harmon WM, Sieka J, Lockhart N, Lori JR. Acceptability of a Whatsapp Triage, Referral, and Transfer System for Obstetric Patients in Rural Liberia. Ann Glob Health 2023; 89:34. [PMID: 37273491 PMCID: PMC10237243 DOI: 10.5334/aogh.4030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 04/29/2023] [Indexed: 06/06/2023] Open
Abstract
Background Maternal mortality continues to disproportionately affect low- and middle-income countries, including Liberia. Though the relationship between obstetric triage systems and improved maternal outcomes is well documented, standardized triage protocols are lacking in rural Liberia. Mobile health interventions are a promising method to triage obstetric patients. Objectives This study explores the acceptability of a WhatsApp Triage, Referral, and Transfer (WAT-RT) system among Liberian midwives and community health assistants. Methods Individual interviews and focus group discussions were conducted among midwives (n = 18) and community health assistants (n = 112). Interviews were designed to understand the current referral system in rural Liberia, how a WAT-RT System can address referral limitations, and the acceptability of the WAT-RT System. Data were audio recorded, transcribed, and translated into English. Data analysis was conducted via NVivo12 with independent and cooperative techniques among multiple researchers. Findings The current referral system is not standardized with limitations including a lack of triage protocols, transportation difficulties, and inconsistent communication of patient information, which could be addressed by a WAT-RT System. The acceptability for the WAT-RT System was high. Facilitators to implementation included utilizing a pre-existing communication and referral infrastructure, access and competency surrounding mobile phones, and increased opportunities for training and inter-provider collaboration. Barriers included disproportionate phone access between midwives and community health assistants, network reliability, and a lack of data standards. Recommendations for successful implementation included centralizing phone financing and standardizing triage protocols. Conclusions The WAT-RT System demonstrated high acceptability among frontline health care providers in rural Liberia. Barriers to program success could be reasonably addressed with simple interventions and planning. Multiple benefits included addressing care delays for obstetric patients, promoting bidirectional provider communication, and increasing the quality of obstetric triage. Future studies should focus on piloting the WAT-RT System among this population and recruiting other key stakeholders to determine intervention feasibility.
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Affiliation(s)
| | - Madison Horton
- Columbia University School of Nursing, New York City, NY, US
| | - HaEun Lee
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI, US
| | | | | | - Nancy Lockhart
- University of Michigan School of Nursing, Ann Arbor, MI, US
| | - Jody R. Lori
- University of Michigan School of Nursing, Ann Arbor, MI, US
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Yazdimoghaddam H, Sadrzadeh SM, Karimi FZ. The obstetric and gynecological service providers' and recipients' perception and experience of the quality of obstetric triage services during the COVID-19 pandemic in Iran. BMC Pregnancy Childbirth 2023; 23:133. [PMID: 36859268 PMCID: PMC9975866 DOI: 10.1186/s12884-023-05351-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 01/05/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Enhancing the quality of obstetric triage services requires a clear perception of the current situations and problems, this issue gained more importance during the COVID-19 pandemic. The purpose of this study was to explore the obstetric and gynecological service providers' and recipients' perception and experience of the quality of obstetric triage services during the COVID-19 pandemic. METHODS This research was a qualitative study carried out using conventional content analysis. Participants were selected through purposive sampling, and data collection was conducted using in-depth semi-structured interviews. Data were analyzed using MAXQDA software and conventional content analysis. Validity of the data was approved based on four criteria: credibility, dependability, conformability and transferability. RESULTS Five themes emerged through analysis: "unpreparedness to deal with the COVID-19 resulting in disorganized triage", "threat to the physical and mental health of personnel during the COVID-19 pandemic", "degradation of the quality of services due to improper triage structure during the COVID-19 pandemic", "communicating with patients which is neglected during the COVID-19 pandemic" and finally "accountability required to improve the provision of services during the COVID-19 pandemic. CONCLUSION Obstetrics and gynecology service providers and recipients faced formidable challenges in the triage department during this pandemic caused by the complex and ambiguous nature of the Coronavirus. Identifying the problems, barriers and challenges in providing services to patients in this situation especially in triage, can lead to an improvement in the outcome of services.
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Affiliation(s)
- Hamideh Yazdimoghaddam
- grid.412328.e0000 0004 0610 7204Department of Operating Room, Faculty of Paramedics, Leishmaniasis Research Center, Sabzevar University of Medical Sciences, Sabzevar, Iran
| | - Sayyed Majid Sadrzadeh
- grid.411583.a0000 0001 2198 6209Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Zahra Karimi
- Reproductive Health, Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran. .,Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran.
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Housseine N, Rijken MJ, Weller K, Nassor NH, Gbenga K, Dodd C, Debray T, Meguid T, Franx A, Grobbee DE, Browne JL. Development of a clinical prediction model for perinatal deaths in low resource settings. EClinicalMedicine 2022; 44:101288. [PMID: 35252826 PMCID: PMC8888338 DOI: 10.1016/j.eclinm.2022.101288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 12/19/2021] [Accepted: 01/17/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Most pregnancy-related deaths in low and middle income countries occur around the time of birth and are avoidable with timely care. This study aimed to develop a prognostic model to identify women at risk of intrapartum-related perinatal deaths in low-resourced settings, by (1) external validation of an existing prediction model, and subsequently (2) development of a novel model. METHODS A prospective cohort study was conducted among pregnant women who presented consecutively for delivery at the maternity unit of Zanzibar's tertiary hospital, Mnazi Mmoja Hospital, the Republic of Tanzania between October 2017 and May 2018. Candidate predictors of perinatal deaths included maternal and foetal characteristics obtained from routine history and physical examination at the time of admission to the labour ward. The outcomes were intrapartum stillbirths and neonatal death before hospital discharge. An existing stillbirth prediction model with six predictors from Nigeria was applied to the Zanzibar cohort to assess its discrimination and calibration performance. Subsequently, a new prediction model was developed using multivariable logistic regression. Model performance was evaluated through internal validation and corrected for overfitting using bootstrapping methods. FINDINGS 5747 mother-baby pairs were analysed. The existing model showed poor discrimination performance (c-statistic 0·57). The new model included 15 clinical predictors and showed promising discriminative and calibration performance after internal validation (optimism adjusted c-statistic of 0·78, optimism adjusted calibration slope =0·94). INTERPRETATION The new model consisted of predictors easily obtained through history-taking and physical examination at the time of admission to the labour ward. It had good performance in predicting risk of perinatal death in women admitted in labour wards. Therefore, it has the potential to assist skilled birth attendance to triage women for appropriate management during labour. Before routine implementation, external validation and usefulness should be determined in future studies. FUNDING The study received funding from Laerdal Foundation, Otto Kranendonk Fund and UMC Global Health Fellowship. TD acknowledges financial support from the Netherlands Organisation for Health Research and Development (grant 91617050).
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Affiliation(s)
- Natasha Housseine
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, The Netherlands
- Division of Woman and Baby, University Medical Centre Utrecht, The Netherlands
- Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania
- Corresponding author: Natasha Housseine, Julius Center for Health Sciences and Primary Care, UMC Utrecht, Postal address: Huispost nr 1. STR 6.131, P.O. Box 85500, 3508 GA Utrecht, The Netherlands, Telephone number: +255 745 338950.
| | - Marcus J Rijken
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, The Netherlands
- Division of Woman and Baby, University Medical Centre Utrecht, The Netherlands
| | - Katinka Weller
- Department of Obstetrics and Gynaecology, Erasmus MC University Medical Centre Rotterdam, The Netherlands
| | | | - Kayode Gbenga
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, The Netherlands
| | - Caitlin Dodd
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, The Netherlands
| | - Thomas Debray
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, The Netherlands
| | - Tarek Meguid
- Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania
- School of Health and Medical Sciences, State University of Zanzibar
- Village Health Works, Kigutu, Burundi
| | - Arie Franx
- Department of Obstetrics and Gynaecology, Erasmus MC University Medical Centre Rotterdam, The Netherlands
| | - Diederick E Grobbee
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, The Netherlands
| | - Joyce L Browne
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, The Netherlands
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McCarthy MF, Pollock WE, McDonald SJ. Implementation of an obstetric triage decision aid into a maternity assessment unit and emergency department. Women Birth 2021; 35:e275-e285. [PMID: 34183275 DOI: 10.1016/j.wombi.2021.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 06/03/2021] [Accepted: 06/07/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND The obstetric triage decision aid (OTDA) consists of 10 common pregnancy complaints with key signs and symptoms generating a triage score based on targeted questioning responses. It was developed to provide a standardised approach for obstetric triage conducted by midwives and emergency nurses as neither professional group are expert in the triage of pregnant and postpartum women. AIM To evaluate implementation of the OTDA into an emergency department (ED) and maternity assessment unit (MAU). METHODS The OTDA was introduced to the ED and MAU of a hospital in Australia. A range of implementation strategies were utilised and assessed by pre and post staff survey, and a three-month post-audit of unscheduled maternity presentations. The primary outcome was adoption rate of the OTDA. Secondary outcomes were staff confidence and waiting times. Analyses were undertaken using SPSS (v24). Paired analysis was conducted on staff surveys. RESULTS There were a total of 2829 unscheduled presentations: ED (n=708) and MAU (n=2121), 88.1% were triaged using the OTDA, used more in the MAU than the ED (93.2% vs 72.7%; p<.001). In the MAU, women seen within 15min of arrival improved significantly from 42.0% to 78.0%. There was improvement in the self-rated confidence (p=.002) and competence (p=.004) by nurses and midwives to conduct obstetric triage. CONCLUSION The introduction of the OTDA required different approaches to change practice. There were improvements in staff self-rated confidence and competence, a reduction in clinical risk associated with under-triage in the ED and improved prioritisation of care in the MAU.
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Affiliation(s)
- Mary F McCarthy
- Mercy Hospital for Women, 163 Studley Rd, Heidelberg, VIC, 3084, Australia; Werribee Mercy Hospital, 300-310 Princes Hwy, Werribee, VIC, 3030, Australia.
| | - Wendy E Pollock
- Northumbria University, Benton, Newcastle-upon-Tyne, NE7 7XA, UK; La Trobe University School of Nursing and Midwifery, Bundoora, VIC, 3086, Australia. https://twitter.com/@Matcritcare
| | - Susan J McDonald
- Mercy Hospital for Women, 163 Studley Rd, Heidelberg, VIC, 3084, Australia; Werribee Mercy Hospital, 300-310 Princes Hwy, Werribee, VIC, 3030, Australia; La Trobe University School of Nursing and Midwifery, Bundoora, VIC, 3086, Australia
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Moudi A, Iravani M, Najafian M, Zareiyan A, Forouzan A, Mirghafourvand M. Factors influencing the implementation of obstetric triage: a qualitative study. Midwifery 2020; 92:102878. [PMID: 33161173 DOI: 10.1016/j.midw.2020.102878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 09/28/2020] [Accepted: 10/23/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify factors influencing the OB triage implementation in Iran DESIGN: Qualitative study of conventional content analysis SETTING: A teaching tertiary referral hospital in Ahvaz, Khuzestan, Iran PARTICIPANTS: 37 professional midwives, nurses, gynecologists, and specialists of emergency medicine, and 6 patients MEASUREMENTS AND FINDINGS: Semi-structured interviews were conducted individually and face-to-face. Interviews were audio recorded, transcribed, and analyzed using conventional content analysis. Four overarching categories and nine themes emerged from the content analysis of the interviews and observations. Overarching categories were the guideline, individual, cultural and social context, and organization. The development and structure were themes of the guideline. Knowledge, attitudes, and behaviors were related to the category of individuals. The cultural and social context included cultural and social changes. Implementation and monitoring strategies and executive infrastructure were organizational themes. Participants had differences and similarities in understanding influencing factors. CONCLUSION The guideline, individual, cultural and social context, and organization were key factors influencing the OB triage implementation in Iran. Some variety was detected between the different occupational groups' perceptions of influencing factors. Providing human resources and training and empowerment of them was the most significant factor influencing, which was acknowledged by almost all participants in all occupational groups. IMPLICATION FOR PRACTICE Identifying the influencing factors from the perspective of all stakeholders can improve the process of OB triage implementation by eliminating barriers and enhancing facilitators.
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Affiliation(s)
- Asieh Moudi
- PhD in Midwifery, Midwifery Department, Birjand University of Medical Sciences, Birjand, Iran.
| | - Mina Iravani
- PhD in Reproductive Health, Assistant Professor in Midwifery Department, Reproductive Health Promotion Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Mahin Najafian
- Associate Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, School of Medicine, Fertility Infertility and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Armin Zareiyan
- Public Health Nursing Department, Nursing Faculty Aja University of Medical Sciences, Tehran, Iran.
| | - Arash Forouzan
- Department of Emergency Medicine, Imam Khomeini General Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Mojgan Mirghafourvand
- Social Determinants of Health Research Center, Tabriz University of Medical sciences, Tabriz, Iran
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Moudi A, Iravani M, Najafian M, Zareiyan A, Forouzan A, Mirghafourvand M. Exploring the concept and structure of obstetric triage: a qualitative content analysis. BMC Emerg Med 2020; 20:74. [PMID: 32933481 PMCID: PMC7493847 DOI: 10.1186/s12873-020-00369-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/10/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Obstetric triage is a new idea, so the design and implementation of it requires identification of its concept and structure. The aim of this qualitative study was to explore the concept and structure of the obstetric triage in Iran. METHODS The purposive sampling was done and it continued until reaching the theoretical saturation. Thirty-seven semi-structured interviews were conducted individually and face-to-face. Interviews were audio recorded, transcribed, and analyzed using conventional content analysis. RESULTS Two themes, 8 main categories, and 16 subcategories emerged from the content analysis of the interviews and observations. The themes were the concept and structure of obstetric triage. The concept of obstetric triage consisted of three categories of nature, process, and philosophy of obstetric triage. The structure of obstetric triage included five categories of assessment criteria, emergency grading, determining the appropriate location for patient guidance, initiation of diagnostic and therapeutic measures, and timeframe for initial assessment and reassessment. CONCLUSION Findings highlighted that obstetric triage is a process with a dual and dynamic nature. This process involves clinical decision making to prioritize the pregnant mother and her fetus based on the severity and acuity of the disease in order to allocate medical resources and care for providing appropriate treatment at the right time and place to the right patient. The results of this study could be used for the design and implementation of the obstetric triage system.
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Affiliation(s)
- Asieh Moudi
- Midwifery Department, Birjand University of Medical Sciences, Birjand, Iran
| | - Mina Iravani
- Midwifery Department, Reproductive Health Promotion Research Center, Nursing and Midwifery School, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Mahin Najafian
- Department of Obstetrics and Gynecology, School of Medicine, Fertility Infertility and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Armin Zareiyan
- Public Health Nursing Department, Nursing Faculty Aja University of Medical Sciences, Tehran, Iran
| | - Arash Forouzan
- Department of Emergency Medicine, Imam Khomeini General Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mojgan Mirghafourvand
- Midwifery Department, Social Determinants of Health Research Center, Tabriz University of Medical sciences, Tabriz, Iran
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Moudi A, Iravani M, Najafian M, Zareiyan A, Forouzan A, Mirghafourvand M. The development and validation of an obstetric triage acuity index: a mixed-method study. J Matern Fetal Neonatal Med 2020; 35:1719-1729. [PMID: 32495659 DOI: 10.1080/14767058.2020.1768239] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: There is uncertainty about the applicability of developed country triage scales in the developing population.Objective: To develop and validate an obstetric triage scale in Iran.Methods: This exploratory sequential mixed-method study was conducted on experienced gynecologists, emergency medicine, midwives, and nurses as evaluators, and pregnant or parturient women as sample. Development of obstetric triage acuity index was done using qualitative study and literature review. Thirty-two evaluators in two rounds evaluated the clinical impact score, content validity ratio, and content validity index. The tool performance was compared with a standard reference in 415 women. The association of urgency levels with hospitalization, resource utilization, and emergency department length of stay were assessed in 599 women. Five midwives independently double-triaged 234 convenience women to estimate inter-rater reliability.Results: Out of 191 items in the initial draft, 9 (4.7%) items in the face validity, 33 (18.1%) in the first, and 5 (3.2%) in the second content validity round were removed because not meeting the expected thresholds. Nine items added based on evaluators' suggestions. Finally, total items had a kappa above 0.74, and S-CVI/Ave, S-CVI/UA were 0.99 and 0.86, respectively. There was a significant correlation between the two tools (r = 0.661, p < 0). Level 1 mothers had a higher chance of using ≥ 2 resources (OR = 16.4, 95% CI = 2.06-129.98) and hospitalization (OR = 18.0, 95% CI = 3.96-81.51) compared to the level 5, after adjusting for gestational age/postpartum, and referral method. Sensitivity, specificity, and accuracy of the scale in predicting hospitalization were 74.8% (95% CI = 69.73-79.49), 80.8% (95% CI = 73.60-86.74), and 76.7% (72.67-80.48), respectively. The over and under-triage rates were 6.1% and 17.1%, respectively. The absolute agreement inter-raters was 86.8%, and the linear weighted kappa was 0.86 (95% CI = 0.81-0.91).Conclusion: The designed OB triage scale showed good validity and reliability in the tertiary teaching hospital. Studying this tool at lower levels, non-educational, and public hospitals are recommended for external validity testing.
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Affiliation(s)
- Asieh Moudi
- Midwifery Department, Reproductive Health Promotion Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mina Iravani
- Midwifery Department, Reproductive Health Promotion Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mahin Najafian
- Department of Obstetrics and Gynecology, School of Medicine, Fertility Infertility and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Armin Zareiyan
- Public Health Nursing Department, Nursing Faculty, Aja University of Medical Sciences, Tehran, Iran
| | - Arash Forouzan
- Department of Emergency Medicine, School of Medicine, Imam Khomeini General Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mojgan Mirghafourvand
- Department of Midwifery, Social Determinants of Health Research Center, Tabriz University of Medical sciences, Tabriz, Iran
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Williams CR, Bogdewic S, Owen MD, Srofenyoh EK, Ramaswamy R. A protocol for evaluating a multi-level implementation theory to scale-up obstetric triage in referral hospitals in Ghana. Implement Sci 2020; 15:31. [PMID: 32398109 PMCID: PMC7218616 DOI: 10.1186/s13012-020-00992-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/16/2020] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Ghana significantly reduced maternal and newborn mortality between 1990 and 2015, largely through efforts focused on improving access to care. Yet achieving further progress requires improving the quality and timeliness of care. Beginning in 2013, Ghana Health Service and Kybele, a US-based non-governmental organization, developed an innovative obstetric triage system to help midwives assess, diagnosis, and determine appropriate care plans more quickly and accurately. In 2019, efforts began to scale this successful intervention into six additional hospitals. This protocol describes the theory-based implementation approach guiding scale-up and presents the proposed mixed-methods evaluation plan. METHODS An implementation theory was developed to describe how complementary implementation strategies would be bundled into a multi-level implementation approach. Drawing on the Interactive Systems Framework and Evidenced Based System for Implementation Support, the proposed implementation approach is designed to help individual facilities develop implementation capacity and also build a learning network across facilities to support the implementation of evidence-based interventions. A convergent design mixed methods approach will be used to evaluate implementation with relevant data drawn from tailored assessments, routinely collected process and quality monitoring data, textual analysis of relevant documents and WhatsApp group messages, and key informant interviews. Implementation outcomes of interest are acceptability, adoption, and sustainability. DISCUSSION The past decade has seen a rapid growth in the development of frameworks, models, and theories of implementation, yet there remains little guidance on how to use these to operationalize implementation practice. This study proposes one method for using implementation theory, paired with other kinds of mid-level and program theory, to guide the replication and evaluation of a clinical intervention in a complex, real-world setting. The results of this study should help to provide evidence of how implementation theory can be used to help close the "know-do" gap. Every woman and every newborn deserves a safe and positive birth experience. Yet in many parts of the world, this goal is often more aspiration than reality. In 2006, Kybele, a US-based non-governmental organization, began working with the Ghanaian government to improve the quality of obstetric and newborn care in a large hospital in Greater Accra. One successful program was the development of a triage system that would help midwives rapidly assess pregnant women to determine who needed what kind of care and develop risk-based care plans. The program was then replicated in another large hospital in the Greater Accra region, where a systematic theory to inform triage implementation was developed. This paper describes the extension of this approach to scale-up the triage program implementation in six additional hospitals. The scale-up is guided by a multi-level theory that extends the facility level theory to include cross-facility learning networks and oversight by the health system. We explain the process of theory development to implement interventions and demonstrate how these require the combination of local contextual knowledge with evidence from the implementation science literature. We also describe our approach for evaluating the theory to assess its effectiveness in achieving key implementation outcomes. This paper provides an example of how to use implementation theories to guide the development and evaluation of complex programs in real-world settings.
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Affiliation(s)
- Caitlin R Williams
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stephanie Bogdewic
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Medge D Owen
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Kybele, Inc., Lewisville, North Carolina, USA
| | | | - Rohit Ramaswamy
- Public Health Leadership and Maternal and Child Health, UNC/RTI Consortium for Implementation Science, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
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Goodman DM, Srofenyoh EK, Olufolabi AJ, Kim SM, Owen MD. The third delay: understanding waiting time for obstetric referrals at a large regional hospital in Ghana. BMC Pregnancy Childbirth 2017; 17:216. [PMID: 28693518 PMCID: PMC5504760 DOI: 10.1186/s12884-017-1407-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 07/03/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delay in receiving care significantly contributes to maternal morbidity and mortality. Much has been studied about reducing delays prior to arrival to referral facilities, but the delays incurred upon arrival to the hospital have not been described in many low- and middle-income countries. METHODS We report on the obstetric referral process at Ridge Regional Hospital, Accra, Ghana, the largest referral hospital in the Ghana Health System. This study uses data from a prospectively-collected cohort of 1082 women presenting with pregnancy complications over a 10-week period. To characterize which factors lead to delays in receiving care, we analyzed wait times based on reason for referral, time and day of arrival, and concurrent volume of patients in the triage area. RESULTS The findings show that 108 facilities refer patients to Ridge Regional Hospital, and 52 facilities account for 90.5% of all transfers. The most common reason for referral was fetal-pelvic size disproportion (24.3%) followed by hypertensive disorders of pregnancy (9.8%) and prior uterine scar (9.1%). The median arrival-to-evaluation (wait) time was 40 min (IQR 15-100); 206 (22%) of women were evaluated within 10 min of arrival. Factors associated with longer wait times include presenting during the night shift, being in latent labour, and having a non-time-sensitive risk factor. The median time to be evaluated was 32 min (12-80) for women with hypertensive disorders of pregnancy and 37 min (10-66) for women with obstetric hemorrhage. In addition, the wait time for women in the second stage of labour was 30 min (12-79). CONCLUSIONS Reducing delay upon arrival is imperative to improve the care at high-volume comprehensive emergency obstetric centers. Although women with time-sensitive risk factors such as hypertension, bleeding, fever, and second stage of labour were seen more quickly than the baseline population, all groups failed to be evaluated within the international standard of 10 min. This study emphasizes the need to improve hospital systems so that space and personnel are available to access high-risk pregnancy transfers rapidly.
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Affiliation(s)
- David M Goodman
- Department of Obstetrics & Gynecology, Duke University Medical Center, Box 3084, Durham, NC, 27710, USA
| | | | - Adeyemi J Olufolabi
- Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC, 27710, USA
| | - Sung Min Kim
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Medge D Owen
- Department of Anesthesiology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157-1009, USA.
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