In this issue of MCN, the important practice of obstetric (OB) triage is covered in a systematic review of the last 15 years of the literature by the acknowledged expert on this topic, Dr. Diane Angelini, and her colleague Dr. Elizabeth Howard. Dr. Angelini, a certified nurse-midwife (CNM), has produced extensive scholarly work about OB triage and has been instrumental in promoting best practices in OB triage at Women and Infants Hospital in Providence, Rhode Island. When we decided to open an OB triage unit at our hospital in 1999, we visited the unit at Women and Infants to make sure our plans were consistent with best practice. We learned so much and were grateful to her for generously sharing her expertise.

What becomes apparent quite quickly in reading the review by Angelini and Howard is the significant gaps in knowledge about this routine aspect of care. There has been very little research on OB triage even though it relates to all pregnant women who present to the hospital for care. More data are needed to generate rigorous evidence to guide this process.

Federal regulations apply to triage of pregnant women, including a timely medical screening exam by a qualified healthcare professional (often a labor and delivery nurse), determination of labor status, appropriate care, disposition, and/or transfer. The first important federal regulations that took effect in 1986 were part of The Consolidated Omnibus Budget Reconciliation Act of 1985 or COBRA and are known as the Emergency Medical Treatment and Active Labor Act (EMATLA). Over the years, gradually, patient safety principles have been integrated such as focusing on OB triage as a process rather than a location and noting that full assessment of the pregnant woman includes determination of fetal status.

Timeliness in assessment has been addressed by many hospitals by lowering the gestational age that women are seen in the labor and delivery area rather than the emergency department (ED). For example, a woman at 16 weeks who presents for care will likely have a much shorter time from presentation to being seen by someone who knows obstetrics if they are provided care in the OB unit rather than the ED. No one wants to wait in the ED for hours while sicker patients are appropriately triaged to be seen sooner. A pregnant woman's concerns about her baby or her pregnancy can be more quickly and more accurately resolved by OB caregivers. In our hospital, women at all gestational ages (unless there is obvious trauma or chest pain/respiratory issues that require ED care) are seen in the Maternity Welcome Center by a labor and birth nurse and CNM. A resident physician in training may also see the woman in certain situations depending on the month as the OB triage unit offers an opportunity for graduate medical education and mentorship by the CNMs. Patient satisfaction is enhanced by prompt evaluation by an OB care provider and timely and appropriate disposition.

Another key issue is timely disposition. It is important to develop a process whereby a decision is made in a reasonable time based on maternal-fetal status regarding whether to admit or discharge. Ensuring fetal well-being with a reactive nonstress test result is a safety and quality practice for women who are discharged at 32 weeks gestation or greater. Patient education regarding warning signs related to the presenting condition and when to call the provider or return to the hospital should be at an appropriate literacy level and followed by written instructions. Plans for timely and quality care can be hampered by inadequate staffing. Assessments can be delayed or overlooked, and patients can be kept needlessly waiting without a careful triage of their immediate needs. Delays in assessment and treatment can be the source of significant patient harm and associated professional liability.

I'm sure you will enjoy reading this systematic review. I hope it generates ideas for future nursing research because there are many limitations to the current literature on OB triage. This is a clinical area with a real need for quality improvement projects and research studies.