L&D Triage Orientation Triage derived from French verb
trier: To separate, sort, select Lori Van Zoeren BS, RN Ferris
State University
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Objectives Identify skills and qualifications necessary for LD
Triage Success Describe EMTALA and how it applies to the LD triage
role Practice scoring patients for Medical Exam Screen and identify
patients who require immediate provider evaluation Discuss supplies
needed to assist providers in triage evaluation Assess and
accurately interpret real life scenarios through case studies
Evaluate the effectiveness of the orientation program
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ED triage skills for success ENA, 2009 Diverse knowledge base
Strong interpersonal skills Independent Effectively communicate
Strong critical thinking Ability to perform a brief, focused
interview and physical assessment Ability to make quick accurate
decisions Multi-tasker under stress Ability to provide on-going
education Ability to work collaboratively Delegation ability
Adaptability to fluctuations in workflow Understanding of the
cultural diversity of not just patient but family
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L&D Triage Nurse Qualifications Successful L&D unit
orientation At least two years of labor and delivery experience At
least one year of labor and delivery experience at Bronson
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Emergency Triage VS OB Triage
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Prioritizing Case Study Patient presents with complaint of
passing a plum sized clot at 37 weeks. Baby is active and there are
no other risk factors communicated initially. Patient presents with
complaint of a MVA two days ago and just wanted to make sure baby
was alright. She is 28 weeks gestation and no other risk factors
noted initially. Patient presents to triage at 18 weeks with
complaint of lower back pain and cramping for 4 hours which has
gotten progressively worse over the last hour. Patient states she
is scared as she has lost a baby at 20 weeks due to incompetent
cervix.
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What is EMTALA ? Austin, 2011 Emergency Medical Treatment and
Active Labor Act Medical Exam Screen 250 foot rule Capability &
Capacity
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EMTALA Violation Example Austin, 2011 Patient was evaluated and
deemed in active labor at a hospital that did not deliver babies.
Patient was allowed to be transported in friends car to the
delivering hospital. The patient was delivered a few minutes after
arrival and both mom and baby were fine. The hospital paid $40,000
dollars in civil monetary penalties for allegations that they
failed to provide appropriate medical exam screening and
stabilizing treatment as well as not providing appropriate transfer
vehicle.
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Initial Documentation EMR requirements include the triage
portion of the triage/admission tab in the EPIC chart Medical exam
screen within 20 minutes Complex physical assessment PTA
medications (prior to admission) Labor flow sheet with fetal
monitor tracing interpretation and any interventions if indicated
Consent for treatment signed upon arrival Allergies documented
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Medical Exam Screen Policy Screening within 20 minutes of
arrival and again prior to discharge Patients scoring 10 or greater
must be seen by a provider in a timely fashion Emergency Medical
Condition Acute pain vs. regular contractions 10 minute fetal heart
rate monitor
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Medical Exam Screen Scoring Patient presents to LD triage. SVE
reveals: 2cm, 70% effaced, and -2 station. Membranes intact.
Contractions are every 4 min, lasting 30-40 seconds, palpate mild,
regular, no urge to push. Vital signs are: Temp 98.8, BP is 138/88,
Resp 20. There is no edema of extremities but facial edema is
present. Is having normal bloody show and FHT stable and reactive.
Baby is vertex.
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Medical Exam Screen Scoring Patient presents to triage who is
38 weeks gestation with bright red bleeding like her normal
periods. SVE deferred due to bleeding initially. She is having an
occasional contraction, no urge to push, VS are stable, no edema.
FHR is normal and reactive. Baby was vertex by Leopold's.
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Medical Exam Screen Scoring Patient presents to triage with
complaint of abdominal pain that rates a 10 on the pain scale. She
is writhing around in the bed to the point it is difficult to
palpate for contractions. SVE reveals cervix that is 0 cm, 40%
effaced, and 0 station. She states no leaking of fluid or bleeding,
she is holding her breath like she is bearing down. BP stable,
pulse is 110, Temp 100. No edema. FHR 110 with moderate variability
and accelerations. Baby is vertex.
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Re-evaluation guidelines Pre-eclampsia-B/P every 15 if
elevated, FHR every hour Labor evaluation- FHR every hour, VS every
4 hours Preterm labor- FHR every hour, VS every 4 hours Any
abnormalities would indicate increased surveillance
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Med exam screen: Not always Austin, 2011 Non-emergency
situations such as: Patients admitted directly into the hospital,
bypassing triage. Betamethasone Injections or NSTs
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Success in L & D Triage Resources readily available Know
your parameters Do you always have the backing to place orders? OB
section/More to follow Order to do an SVE Do not be fooled
Communication & Situation Background Assessment Recommendation
(SBAR)
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Chain of Command Charge Nurse Unit Coordinator Manager Director
CNO PAUL BERKOWITZ, MD (OB/GYN) CAMELIA MERATI, MD (Hospitalist)
STEVEN POLLENS, MD (Family Practice) JOHN SIKORA, DO
(Anesthesia)
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Stryker Gynnie Carts
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Know the supplies needed to assist providers in specimen
collection
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Amnisure Review policy if not familiar Explain procedure
(insert 2-3 inches into vagina and leave for 60 seconds) Insert
swab into solvent and rotate swab for 60 seconds Properly label
specimen and collect in Epic for the lab requisition Tube to lab as
a stat and call 6440 to notify an Amnisure is coming for
evaluation
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Amnisure Collection Inaccurate results can occur in the
presence of: Meconium, antifungal creams, lubricating jelly, baby
oil, Replens, expired solution, gross presence of blood, digital
exams prior to swabbing, sample is collected greater than 12 hours
after ruptured membranes
Underlying Pathology Devarajan & Chandraharan, 2011 Area of
PainOrgans to considerPossible causes Left HypochondrialSpleen,
pancreas, colonSplenic infarc, colitis EpigastricStomach, pancreas,
aorta, heart Gastritis, pancr, aortic dissection/mayocarditis/MI
Right HypochondrialLiver, Kidney, hepatic flex colon, gall bladder
Liver issues, Fatty Liver of preg, HELLP, Pre-eclamp Right
LumbarKidney, ascending colonPyleo, renal calc, IBS UmbilicalTrans
colon, appendix, uterus Appy, gastro, pancreatitis, abruption,
uterine rupture Left LumbarKidney, descending colonPyelo, renal
calc, IBS Left IliacSigmoid, Lt tube/ovaryIBS, Ectopic, tube
abscess or rupture, ovarian torsion Right IliacAppendix, rt
tube/ovaryAppy, diverticulistis, above Supra-pubicBladder,
UterusCystitis,abrup, Scar rupt
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Which of the following is not associated with abruptio
placenta? Cocaine Heroin HTN Smoking Advanced Maternal Age Women
under 20 years of age Abdominal trauma Alcohol Use Male fetus
Chorioamnionitis
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Triage Imminent Delivery The infant warmer is in triage in the
corner by the blanket warmer. Supplies are covered but is stocked
with needed emergency supplies to deliver a baby in the triage
area.
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Discharge Process
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Social Work Resources Coverage Cab passes Phone cards Child
Life Domestic violence
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Drug Seeking Behavior Never chart that a patient is drug
seeking Describe patients perception of her pain Document
assessment of patients observable symptoms BE OBJECTIVE! MAPS
report
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Case Study 1 41 year old G2 P1 30 week pregnant patient
presents via ambulance to L&D triage. She was shopping and
collapsed. She has no known medical conditions. She had an oral
airway but spit out in route to hospital. Her VS are HR of 130, BP
190/110, Temp 97.3, Oxygen sat 93%, Glascow Coma scale 10/15.
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Case Study 2 25 y/o G2 P1 presents to triage with painless
vaginal bleeding at 24 weeks. She had a previous cesarean section
delivery. VS BP 130/78, Pulse 92, Resp 20, Temp 98.4.
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Case Study 3 Patient is 40 weeks gestation and presents to
L&D triage in active labor. Fetal heart tones are 145. After
asking if any bleeding or leakage of fluid you perform a SVE.
Cervix is dilated 5 cm, 100% effaced, and -3 station. Patient
rolled to left side and spontaneous ruptured membranes occurred.
Fetal heart tones were then noted and verified at 70 bpm as
patients pulse is 96.
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Case Study 4 Pt is a 20 year-old G3-P1 pregnant patient who
complains of vaginal discharge which is especially prominent after
intercourse. She states that it has a fishy odor. There is no
bleeding and no regular contractions. VS are stable. She does
complain of left lower quadrant pain that is constant.
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Case Study 5 Call from the ER received with report to expect an
ambulance bringing in a G3, P2 patient who is 32 weeks pregnant
involved in a multivehicle pile up. Patient is alert and oriented,
her VS are stable, fetal heart tones are 150 with positive fetal
movement.
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Case Study 6 A 31 year-old G4 P3 patient with twin gestation at
36 weeks presents to triage. When placed on cart she spontaneously
ruptures membranes and there is a moderate amount of bleeding
noted. Twin A now has fetal tachycardia and a sinusoidal heart rate
pattern.
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Vasa Previa
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Case Study 7 Patient presents to L&D Triage with complaints
of dizziness, headache, difficulty concentrating, pounding heart,
tingling of the mouth, and feeling irritable. She is sweaty and
pale.
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In Summary
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References Austin, S. (2011, June). What does EMTALA mean for
you? Nursing, 41(6), 55-59.
http://dx.doi.org/10.1097/01.NURSE.0000398175.36147.bc
http://dx.doi.org/10.1097/01.NURSE.0000398175.36147.bc Bronson
Methodist Hospital website.(2014). https://inside.bronsonhg.org/
Devarajan, S., & Chandraharan, E. (2011). Abdominal pain in
pregnancy: A rational approach to management. Obstetrics,
Gynaecology, and Reproductive Medicine, 21(7), 198-206.
http://dx.doi.org/10.1016/j.ogrm.2011.04.001 Emergency Nurses
Association. (2011). Triage qualifications. Retrieved from
http://www.ena.org/SiteCollectionDocuments/Position%20Stat
ements/TriageQualifications.pdf
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Project Goals and Objectives Goal: To develop an orientation
program for labor and delivery triage nurses at Bronson Methodist
Hospital in Kalamazoo, MI Objectives: 1.1 Identify recommended LD
triage nurse competencies required to care for the obstetrical
patient population. 1.2 Provide an educational program for nurses
who work in LD triage on skills needed for competency that are
unique to triaging obstetrical patients. 1.3 Evaluate the
effectiveness of the orientation program for staff. 1.4 Preceptor
evaluation of the attainment of the proposed goals of the scholarly
project. 1.4 Self- evaluation of the attainment of the proposed
goals of the scholarly project. 1.5 Revise orientation program
based on evaluation results.
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Personal & Professional Accountability Adherence to NLN
Nurse Educator Competencies Performed a comprehensive literature
search Assimilated knowledge from lit review Applied new knowledge
to the triage orientation program Followed project plan utilizing
time management skills
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Project Outcomes Increased knowledge of EMTALA and the legal
ramifications Increased knowledge of the differences between ER
triage and LD triage BMH standards discussions for triage
competency Collaboration discussions with area hospitals Hands on
activities provided new knowledge of assisting providers with
obtaining cultures
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Project Evaluation Do you have a better understanding of
EMTALA? Was the PPT beneficial to learning about LD triage role?
Did the PPT provide new knowledge? Do you feel the importance of
the Medical Exam Screen was thoroughly explained? Do you believe
you can correctly prioritize patients listed in case studies? Do
you believe the objectives of the LD orientation and competency
validation program were met?