<div>Use of the Maternal Foetal Triage Index- Addressing the Third Delay in
Obstetrics: An Observational Study</div><div>Dr. Nirzarini M Vora, MBBS</div><div>Third Year Resident,</div><div>Department of Obstetrics and Gynaecology,</div><div>Medical College and SSG Hospital,</div><div>Baroda 390 001</div><div>Email: nirzarini@gmail.com</div><div>Phone: 08866869658</div><div>ORCiD ID: https://orcid.org/0000-0001-9692-0618</div><div>Dr. Nandita K Maitra,</div><div>MD, FRCOG</div><div>Additional Professor and Unit Head,</div><div>Department of Obstetrics and Gynaecology,</div><div>Medical College and SSG Hospital,</div><div>Baroda</div><div>Dr. Priyam B Pandya</div><div>MS</div><div>Senior Resident</div><div>Department of Obstetrics and Gynaecology,</div><div>Medical College and SSG Hospital,</div><div>Baroda</div><div>RUNNING TITLE: Evaluating MFTI Scale in Reducing Third Delay</div><div>ABSTRACT</div><div>OBJECTIVE: The Maternal Foetal Triage Index (MFTI), a five-tier scale
designed by Ruhl et al (2015) has been evaluated in this study for women
attending the triage area of a tertiary hospital, to examine the effect
on third delay and maternal and neonatal outcomes.</div><div>DESIGN: Prospective observational study</div><div>SETTING: The Labour and Delivery Unit of a tertiary care hospital</div><div>SAMPLE: A convenience sample of 1000 women</div><div>METHODS: Assessment included maternal history, baseline vital signs and
obstetric examination and categorised the woman as per the MFTI scale.
Evaluation of the MFTI score was assessed based on predefined maternal
and neonatal outcomes within 24h of attendance.</div><div>MAIN OUTCOME MEASURES: Flow of patients to triage, presenting
complaints, Duration of hospital stay, maternal and neonatal outcomes
within 24h of admission.</div><div>RESULTS: A priority wise distribution of subjects based on their
clinical diagnosis was found to be statistically significant for
anaemia, previous caesarean, postpartum haemorrhage, miscarriage and
hypertensive disorders. Sixty seven percent of the subjects belonged to
Priority 3-4 and the mean hospital stay duration varied from 8.26±7.68
days for Priority 1 to 3.82±2.74 days for Priority 4
((p&lt;0.0001). The average time spent in the triage room was
30±17minutes. A priority wise analysis of maternal and neonatal outcomes
based on OBICU and NICU admissions, mortality and stillbirths was found
to be significant.</div><div>CONCLUSION: The MFTI scale significantly reduced the third delay, which
is crucial in a high-volume, low resource setting. This also simplified
handover, improved documentation and decreased time to secondary
healthcare provider assessment.</div><div>FUNDING: None</div><div>KEY WORDS: obstetric triage, maternal mortality, third delay, acuity,
maternal fetal triage index</div><div>TWEETABLE ABSTRACT: Implementation of MFTI scale significantly reduces
third delay in high volume low resource settings: an observational study</div><div>INTRODUCTION:</div><div>Obstetric Triage is emerging as a specialized segment of care for both
outpatient and inpatient management of women in pregnancy. The word
“triage” is derived from a French word “trier’ and was originally
used for sorting mass casualties in the battlefield [1]. Obstetric
triage is more specialized than general and trauma triage, as it
involves assessing whether the
patient is in labour, the foetal well-being and risk stratification of
the pregnant woman. The role of obstetric triage and its impact on
adverse maternal outcomes remains unexplored in developing countries.</div><div>Women often have to wait for assessment and treatment after reaching the
health care facility. This delay within facilities is known as the
“third delay”. International guidelines recommend that assessment
should begin within 10 minutes of the patient reaching hospital [2].
Use of a validated tool to facilitate this initial assessment process
will improve the quality of care in high volume obstetric facilities.
Generally, obstetric triage volume will be about 20% to 50% higher
than total hospital birth volume with most women presenting for presumed
labour at term. however, women may also be seen for other complaints
like preterm labour, preterm premature rupture of membranes,
preeclampsia symptoms, decreased foetal movement, trauma, bleeding, or
any other medical condition related or unrelated to pregnancy.</div><div>Goodman et al in a study in Ghana found that an obstetric triage
improvement programme reduced the median patient waiting time from
facility arrival to first assessment by a midwife, from 40 min (15–100)
to 5 min (2–6) (p&lt;0.001) over the 5-year intervention
[3].</div><div>The Maternal Foetal Triage Index (MFTI) designed by Ruhl et al [4]
offers a standard method of assigning an acuity score to pregnant women
presenting to the hospital for care. It is thought to be the first OB
triage acuity tool validated for multidisciplinary use [5]. It uses
a five-level scale for categorizing acuity. The five tiers are:
“1-Stat” requires immediate lifesaving intervention for a woman or her
foetus; “2-Urgent” includes severe pain not related to contractions,
high-risk clinical condition, and/or the need for transfer to a higher
level of care; “3-Prompt” includes women at or over 34 weeks gestation
in active labour; “4-Non-Urgent” includes women at term gestation in
early labour; and “5-Scheduled or Requesting a Service” includes women
presenting for scheduled procedures or routine prenatal care.</div><div>This study was designed to evaluate the role of a dedicated triage tool
in pregnant women attending the Labour and delivery unit of a tertiary
level teaching hospital.</div><div>METHODS</div><div>This was a prospective observational study on a convenience sample of
1000 consecutively enrolled subjects coming to the Labour and Delivery
unit of the hospital, during the 24-hr emergency duty of the second
unit, which is every fifth day, not excluding weekdays, weekends or
public holidays. A separate room
in the labour and delivery unit was assigned as a triage room. This room
had two beds and a facility for emergency management and foetal
well-being assessment. Assessment according to the MFTI was conducted by
the first author, during the second year of her residency a (2019-2020)
when she was posted in the triage area. All patients were examined by a
single operator to ensure consistency.</div><div>There were no exclusion criteria.
Assessment included maternal
history, baseline vital signs, pulse oximetry, abdominal palpation and
auscultation of the foetal heart rate along with determination of active
vs latent phase of labour. Based on this assessment, the woman was
categorised as per the MFTI scale (Figure 1).</div><div>Depending upon the level of urgency/acuity as defined by the scale, the
woman was sent to the appropriate area. Women with higher level of
clinical urgency were taken immediately to ICU or operation theatre.
Women with lower levels of urgency were sent to the active labour room
or observation areas/wards.</div><div>OUTCOMES:</div><div>1. Number of women having triage assessment using the MFTI scale</div><div>2. Common presenting complaints</div><div>3. Flow of subjects from triage</div><div>4. Time to admission/discharge</div><div>5. Reliability and validity of the assigned category of urgency
following the initial triage assessment was undertaken by reviewing the
notes of women/babies who had predefined outcomes within 24 h of
attendance (these included maternal admission to High Dependency
Unit/Intensive Therapy Unit or death, category 1 Caesarean Section,
active neonatal resuscitation, Apgar &lt;7 at 5 min, routine
care, initial steps of resuscitation, requirement of bag and mask or bag
and tube ventilation, chest compressions or medication or neonatal
admission to Neonatal Intensive Care Unit or neonatal death).</div><div>STATISTICAL ANALYSIS: Descriptive
statistics was applied to analyse the data. Data was entered in an Excel
sheet. The Chi Square test was used for analysis of continuous
quantitative data and Anova test was applied for analysis of categorical
qualitative data. A p value of less than 0.05 was considered
significant.</div><div>FUNDING: None</div><div>RESULTS</div><div>The mean maternal age was 24.5 <i>+</i> 4.3 years, mean gestational age
was 35.6 <i>+</i> 6.1 weeks. Forty-four percent (44.1%) of the subjects
were primigravida and 55.9% were multigravidas. Fifty two percent
(52.1%) subjects were booked cases at the hospital, whereas 31.8% were
referred from other hospitals and only 16.2% presented as self-referred
cases. Labour pain (82.9%), leaking per vaginum (25.9%) and
hypertension (11.5%) were the most common presenting complaints for
subjects. The average time spent
in the triage room was 30±17minutes.</div><div>Table 1 shows that hypertensive disorders including preeclampsia and
eclampsia constituted 115 (11.5%) of the total subjects, preterm labour
constituted 270 (27%), anaemia 93(9.3%) and previous caesarean section
107(10.7%). Priority wise distribution of subjects with hypertensive
disorders, anaemia and previous caesarean section was highly
significant. Miscarriage and postpartum haemorrhage were the other
conditions that were assigned priority 1-2. The clinical diagnoses
assigned were not mutually exclusive, and they are not collectively
exhaustive.</div><div>Table 2 shows the distribution of subjects by MFTI scale and duration of
hospital stay. The duration of hospital stay
was 8.26±7.68 days for Priority 1,
7.02±7.26 days for Priority 2, 6.27±6.65 days for Priority 3 and
3.82±2.74 days for Priority 4. These observations were statistically
significant at p&lt;0. 0001.This is an effective indicator of
maternal morbidity.</div><div>Table 3 shows ICU and non-ICU admission according to priority by MFTI
scale. Seventy-six subjects were admitted to the obstetric ICU (OBICU),
which entails mechanical ventilation, blood transfusion, inotropic
support and higher antibiotics and led to additional maternal morbidity.
Nine hundred and twenty-four subjects were assigned non-ICU management.
Of the ninety-nine Priority 1 subjects requiring non-ICU management 37
(37.4%) required immediate admission to operation theatre and 62
(62.62%) were managed in the active labour as childbirth was imminent.
Of the 138 Priority 2 subjects assigned to a non OBICU management, 26
(18.8%) were managed in the operation theatre and the remaining were
admitted to the delivery unit for imminent birth. The observations were
statistically significant at a p value of 0.0001.</div><div>There were two maternal deaths in the Priority 1 group and 1 death in
priority 2. The causes were septic peritonitis, puerperal sepsis and
pulmonary embolism.</div><div>Table 4 shows the adverse perinatal outcomes associated with the acuity
scale. The number of NICU admissions and still births were significantly
more in Priority 1 and 2 as compared to Priority 3 and 4.</div><div>Table 5 shows the priority wise distribution of patients according to
booking status and referral status. It can be concluded that referred
patients were more likely to be of higher MFTI Priority,
Χ<sup>2</sup> (8, N=1000) = 92.168, P&lt;0.00001.</div><div>DISCUSSION</div><div>This prospective observational study aimed to evaluate the MFTI score on
a convenience sample of women attending the triage room of the labour
and delivery unit. In this study the Maternal Foetal Triage Index was
used as a systematic tool for assessment of these subjects.</div><div>MAIN FINDINGS</div><div>The average time spent in the triage room was 30±17minutes during the
study period, thus reducing the third delay in Obstetrics. The duration
of hospital stay was significantly higher at (8.26<i>+</i> 7.68) in
priority 1 subjects as compared to the lower priorities. Intrauterine
foetal demise, unless previously diagnosed, was categorised as Priority
1. Extreme prematurity of less than 34 weeks with detectable uterine
contractions or SROM or cervical dilatation/incompetence was categorised
as Priority 2.</div><div>Hypertensive disorders in pregnancy (115, 11.5%), preterm labour
(270,27%), anaemia (93,9.3%) and early pregnancy loss (46, 4.6%)
constituted the most common clinical conditions assigned to Priority
1-2. Previous Caesarean section was the most common clinical condition
assigned to Priority 3-4.</div><div>Ruhl et al (2015) have stated that the quality of patient care is
improved by the use of a standardised ED triage scale, according to the
American College of Emergency Physicians [4]. Forshaw et al (2016)
conducted an audit which concluded that instead of an informal triage at
the admissions desk, a systematic standardised flow diagram should be
used at the admissions desk and the presence of a midwife ensured there.
This reduced the time from entering the department to first assessment
from 192 min to 38 min. [6]. Goodman et al (2017) conducted a study
in Accra, Ghana where the third delay and time spent in triage was
analysed according to the time of day, day of week and the reason for
referral. The median wait time interval till assessment (the third
delay) was 40min (interquartile range 15-100min). The median time spent
in triage was significantly longer at night [55min (15-120)], than
the morning [35min (10-830] and evening [28min (12-51)] shifts
(p&lt;0.0004). There was no significant difference based on day
of week either in volume or waiting times (p=0.38). [7]</div><div>Brown et al (2019) conducted a study that demonstrated that nurses could
implement an acuity-based triage process where the number of roomed
triage subjects, number of subjects waiting to be triaged and the
overall unit census could be recorded in a timely manner. The time from
presentation to nurse assessment decreased by more than 50% with the
use of acuity based obstetric triage [8].</div><div>STRENGTHS AND LIMITATIONS</div><div>The MFTI scale was selected because it was applicable to subjects with
less than 20 weeks gestation and postpartum unlike other triage scales.
This study brings to light the importance of obstetric triage in
improving maternal and neonatal outcomes by reducing the third delay.
This is all the more significant since triage is not a widely discussed
topic in medical literature. Hence it was not possible to make robust
comparisons with other studies. Since there was no previous measurement
of third delay prior to this study, hence a parallel comparator arm is
not available. The study would have been more robust if it had been
possible to segregate the third delay as per the MFTI subcategory.
However, this could not be done. Once use of a systematic triage tool
becomes a standard of care across all facilities, audits could be
conducted to assess the efficacy.</div><div>INTERPRETATION</div><div>This study found that use of a systematic triage tool improved the time
spent by the woman after reaching the hospital. While this study used a
makeshift triage area with minimum facilities, a dedicated triage area
equipped with monitors, primary assessment and initial treatment should
be made available at the entrance of the labour and delivery area. A
systematic triage tool and triage assessment form should be used. Nurse
midwives could be trained specifically in OB triage.</div><div>CONCLUSION</div><div>Use of a systematic triage tool
such as the MFTI scale helped to reduce the time spent by the subject in
initial assessment, thus reducing the third delay. This is crucial in a
high volume, low resource emergency obstetric setting. Use of a formal
triage tool helped to make handover of subjects easier, improved
documentation and decreased the length of time to secondary healthcare
provider assessment for higher acuity subjects.</div><div>ACKNOWLEDGEMENTS</div><div>I would like to acknowledge the contributions of Dr Sahana SM and Dr
Vishakha Ahuja to the conduct of this study and the development of this
article.</div><div>CONFLICT OF INTEREST</div><div>None</div><div>CONTRIBUTION TO AUTHORSHIP</div><div>Dr Nirzarini Vora prepared the original draft, collected and prepared
the data and played a role in the analysis and interpretation of data.
Dr N K Maitra had a significant contribution to the conception and
design of the study, protocol formulation, analysis and interpretation
of data and preparing the final writeup. Dr Priyam Pandya also
contributed to data collection and preparation.</div><div>ETHICAL APPROVAL: The study protocol was approved by the Institutional
Ethics Committee Reference No. IECBHR/167-2020. Informed consent was
obtained from all individual participants in the study.</div><div>FUNDING: No funding was obtained</div><div>REFERENCES</div><div>1.Robertson-Steel I. Evolution of triage systems. Emerg Med J.
2006;23:154–155.</div><div><b>2.</b> Association of Women’s Health, Obstetric and Neo-natal
Nurses (AWHONN): Washington, DC. Women’s health perinatal nursing care
quality measures specifications 2013.</div><div><b>3.</b> Goodman DM, Srofenyoh EK, Ramaswamy R, Bryce F, Floyd L,
Olufolabi A et al. Addressing the third delay: implementing a novel
obstetric triage system in Ghana. BMJ Glob Health 2018;3: e000623.
doi:10.1136/ bmjgh-2017-000623</div><div><b>4.</b> Ruhl C, Scheich B, Onokpise B, Bingham D. Content validity
testing of the maternal fetal triage index. JOGNN 2015; 44(6), 701-709;
DOI:10.1111/1552-6909.12763</div><div>5. Association of Women’s Health, Obstetric, and Neonatal Nurses.
(2016). Maternal fetal triage index. Washington, DC.</div><div>6. Forshaw J, Raybould S, Lewis E, Muyingo M, Weeks A, Reed K et al.
Exploring the third delay: an audit evaluating obstetric triage</div><div>7. Goodman DM, Srofenyoh EK, Olufolabi AJ, Kim SM, Owen MD et al. BMC
Pregnancy and Childbirth. 2017:216 DOI 10.1186/s12884-017-1407-4</div><div>8. Brown S, Bellamy A, Naglieri R et al. Obstetric Triage Improvement
Process. JOGNN 2019;48 S86-94: 2019.</div><div>LIST OF TABLES</div><ol><li>Table 1: Distribution of subjects according to Priority and Final
Clinical Diagnosis</li><li>Table 2: Overall Distribution of Subjects by MFTI Scale</li><li>Table 3: ICU Admissions According to MFTI Scale</li><li>Table 4: NICU admissions and Stillbirths Based on Initial Assessment
of Acuity</li><li>Table 5: Booked/Referred/Emergency by MFTI Scale</li></ol><div>LIST OF FIGURES</div><div>FIGURE 1: The Maternal Fetal Triage Index. Ruhl et al.</div>