Background
Severe hypertension remains one of the leading preventable causes of maternal mortality in the United States. Timeliness to response to severe hypertension in pregnancy is a crucial quality indicator tracked by state and national organizations. We hypothesized that the implementation of the Maternal-Fetal Triage Index, a validated acuity tool, would improve care performance in women with severe hypertension in an urban, inner-city hospital setting.
Objective
This study aimed to assess the impact of the Maternal-Fetal Triage Index on the management of women presenting with severe preeclampsia diagnosed by severe hypertension as measured by time to provider assessment, administration of magnesium sulfate, and immediate administration of acute antihypertensives.
Study Design
This was a prospective, observational study of pregnant women presenting to the labor and delivery triage unit with severe preeclampsia diagnosed by severe hypertension giving birth at a large urban inner-city academic facility before (epoch 1: January 1, 2019, to December 31, 2019) and after (epoch 2: March 1, 2021, to September 31, 2021) the implementation of the Maternal-Fetal Triage Index. Baseline outcomes of time to assessment, time to magnesium sulfate prophylaxis, and time to antihypertensive medication administration before the implementation of the Maternal-Fetal Triage Index were assessed. The Maternal-Fetal Triage Index tool was implemented on March 1, 2021, following standardized education in 2020 for all triage nurses, unit technicians, healthcare unit coordinators, and healthcare providers. Time to assessment, administration of magnesium sulfate prophylaxis, and time to antihypertensive administration after the implementation of the Maternal-Fetal Triage Index were compared with measures before the implementation of the Maternal-Fetal Triage Index. Statistical analysis included Wilcoxon rank-sum test with P <.05 considered significant when comparing epoch 1 with epoch 2.
Results
A total of 370 patients were admitted with severe hypertension in 2019 before the use of the Maternal-Fetal Triage Index, and 254 patients were admitted with severe hypertension in 2021 after the implementation of the Maternal-Fetal Triage Index. There was no difference between epochs across baseline characteristics, including age, race and ethnicity, parity, and body mass index. After the Maternal-Fetal Triage Index was implemented, the time to provider assessment was significantly improved, from a median time of 44 minutes (interquartile range, 0–65) in epoch 1 to 17 minutes (interquartile range, 0–39) in epoch 2 ( P <.001). Furthermore, the time from arrival to magnesium sulfate prophylaxis was significantly faster with a median time of 161 minutes (interquartile range, 109–256) in epoch 1 vs 127 minutes (interquartile range, 85–258) in epoch 2 ( P =.001). Moreover, there was a decrease in the time from arrival to antihypertensive medication administration for severe blood pressures after the implementation of the Maternal-Fetal Triage Index (101 minutes [interquartile range, 61–177] vs 66 minutes [interquartile range, 35–203]; P <.001).
Conclusion
The implementation of the Maternal-Fetal Triage Index at a large urban inner-city hospital was associated with improved timeliness of assessment and treatment of women with severe hypertension. The Maternal-Fetal Triage Index is a viable tool to improve the efficiency in triage units, specifically in the management of severe hypertension.
Introduction
Labor and delivery triage units serve an important role in identifying and stabilizing obstetrical patients needing emergent care. As triage volumes routinely exceed total birth volumes by 20% to 50%, timely triage of presenting patients is crucial to the safe and effective care of the entire unit. Assessment tools have been commonplace in obstetrics, but there is not currently an accepted national standard. The Maternal-Fetal Triage Index (MFTI), developed by the Association of Women’s Health, Obstetric and Neonatal Nurses in 2014 and endorsed by the American College of Obstetricians and Gynecologists (ACOG) in 2016, is one such tool. , , The MFTI tool was developed specifically for obstetrical patients presenting to triage based on specific patient presentations to prioritize patient acuity based on vital signs and symptoms. It is made up of a 5-level scoring system with a score of 1 as the highest priority and a score of 5 as the lowest priority as outlined in Figure 1 . It can be easily implemented into the electronic medical record. Unlike other earlier triage tools, the MFTI has been evaluated in the literature for content validity and interrater reliability. However, clinical outcome data are limited. , Specifically, the global assessment of MFTI has not been shown to decrease performance time in the care of all women in triage.
Why was this study conducted?
This study was conducted to assess the impact of the Maternal-Fetal Triage Index (MFTI) on time to assessment and time to intervention in patients with severe hypertension in pregnancy.
Key findings
Time from arrival to assessment, prophylaxis with magnesium sulfate, and administration of antihypertensives improved with the implementation of the MFTI in patients with severe hypertension in pregnancy.
What does this add to what is known?
The MFTI can improve efficiency in the assessment and management of patients with severe hypertension in pregnancy in an urban, inner-city hospital setting.
Severe hypertension is 1 common triage presentation that is associated with increased morbidity and mortality if timely treatment is not initiated. Response time to severe hypertension is a quality metric tracked by state and national organizations to improve maternal outcomes. The R3 report released by The Joint Commission in 2019 identified recognition and timely response to severe hypertension or preeclampsia as 1 of its 13 elements of performance, as a preventable cause of maternal morbidity and mortality. This shares similar goals and principles with state-based initiatives and bundles, such as those produced by Alliance for Innovation on Maternal Health (AIM) and the California Maternal Quality Care Collaborative, to identify and treat severe hypertension and implement protocols to influence such change. ,
We hypothesized that the implementation of the MFTI would improve the timeliness of care, specifically when looking at severe hypertension, categorized as stat or priority 1 ( Table 1 ). This study aimed to explore the time interval for the evaluation and management of women with severe hypertension before and after the implementation of the MFTI. This was accomplished by (1) analysis of performance time from arrival to assessment, (2) arrival to magnesium sulfate (MgSO 4 ) prophylaxis, and (3) arrival to administration of antihypertensive medications. In addition, we examined the impact of the MFTI on maternal and fetal clinical outcomes and investigated the effect of race, if any, on the strength of association between epoch and outcome.
| Does the woman or fetus have stat or priority 1 vital signs? | Maternal heart rate of <40 or >130 bpm Apneic: Sp02 of <93% Systolic BP of ≥160 mm Hg Diastolic BP of ≥110 or <60 mm Hg or palpable No FHR by Doppler (unless previously diagnosed demise) FHR of <110 bpm for >60 s |
| Does the woman or fetus require immediate lifesaving intervention? | Cardiac compromise Severe respiratory distress Seizing Hemorrhaging Acute mental status change or unresponsive Signs of placental abruption Signs of uterine rupture Prolapsed cord |
| Is birth imminent? | Fetal parts at the perineum Active maternal bearing down efforts |
Materials and Methods
This was a prospective, observational study conducted at Parkland Hospital’s obstetrical triage unit. Parkland Hospital is a county-supported, urban, academic center, serving the medically indigent women of Dallas County. Women at >20 weeks of gestation who present to the hospital with any complaint are evaluated in the labor and delivery triage, which is contiguous with the labor and delivery unit. This triage unit is managed by advanced practice providers (APPs) using standardized written protocols for assessments and admission with physician oversight. This model has proven to be efficacious and has been endorsed by the ACOG. , ,
Our study population included all patients who presented to the triage unit at ≥24 weeks of gestation admitted with a diagnosis of preeclampsia with severe features by severe hypertension diagnosed in the Parkland women’s health clinic or on presentation to the triage unit. Severe hypertension was defined as a verified systolic blood pressure (BP) of ≥160 mm Hg or diastolic BP of ≥110 mm Hg by nursing staff. Patients were excluded if they were not admitted for delivery at the time of presentation. Our standard triage protocol for elevated BPs is as follows: BPs are recorded by automated machines either in the triage unit or in the associated women’s health clinic and then manually validated by nurses, APPs, or physicians. For patients with verified severe range BPs (≥160/110 mm Hg), MgSO 4 prophylaxis is initiated. Moreover, patients are treated with intravenous (IV) hydralazine, labetalol, or immediate-release nifedipine when IV access is not available per ACOG guidelines with a target goal of treatment within 60 minutes. This target time metric is also endorsed by state-based organizations, including Texas AIM, for meeting maternal quality of care guidelines and The Joint Commission. , Patients who have severe range BPs recorded by nursing staff on multiple occasions but not validated by physician or APP do not receive IV antihypertensives but do meet the criteria for preeclampsia with severe features by severe range BPs and are given MgSO 4 prophylaxis.
The first period, epoch 1, included patients admitted from January 1, 2019, to December 31, 2019, and was before the implementation of the MFTI. The second period, epoch 2, included patients admitted from March 1, 2021, to September 30, 2021, after the implementation of the MFTI following standardized education in 2020 for all nurses, technicians, healthcare unit coordinators, and healthcare providers. With the implementation of the MFTI, the assessment of patients was prioritized on the basis of vital signs and symptoms at presentation. Nursing staff assigned a number based on the MFTI acuity scale of 1 to 5 based on the criteria outlined in Figure 1 prompting a response from the healthcare providers.
Data were generated from a computerized obstetrical database for all women delivering at Parkland Hospital and medical record review by research personnel of all women meeting the inclusion criteria. The primary outcome for this study was time interval for the evaluation and management of women with severe hypertension before and after the implementation of the MFTI as shown by (1) time from arrival to assessment, (2) time from arrival to MgSO 4 prophylaxis, and (3) time from arrival to the administration of antihypertensive medications. Other neonatal and maternal outcomes and the effect of race on the association and outcome were assessed and compared between the 2 epochs.
The projected sample size was calculated using the following rationale. Using pilot data from 2019, it is discerned that the standard deviation of the triage admission to labor and delivery admission time was 20 minutes. As these data are compressed to short times, the data of the pilot were supportive of the use of a 2-sided Student t test. To discern a mean difference of 5 minutes, 253 patients were needed in each arm for 80% power. Statistical analysis was performed using SAS (version 9.3; SAS Institute, Cary, NC). Univariable analysis was performed using the Student t test, chi-square test, and Wilcoxon rank-sum test. To investigate whether the effect is different across races, a logarithmic transformation was imposed on the 4 outcomes to transform them to statistical normality (Gaussian) to apply analysis of variance for the comparisons rather than use the rank methods. The results were considered significant if P <.05. This study was exempt by The University of Texas Southwestern Medical Center Institutional Review Board.
Results
A total of 370 patients were admitted with severe hypertension in epoch 1, and 254 patients were admitted with severe hypertension in epoch 2. There was no difference between epochs across baseline characteristics, including age, race and ethnicity, parity, and body mass index ( Table 2 ). Total volume per month between epochs was not significantly different with a median volume of 1532 (interquartile range [IQR], 1426–687) in epoch 1 vs 1477 (IQR, 1318–1563) in epoch 2 ( P =.15). Moreover, unit staffing remained the same during the study periods. After the MFTI was implemented, the time to provider assessment was significantly improved, from a median time of 44 minutes (IQR, 0–65) in epoch 1 to 17 minutes (IQR, 0–39) in epoch 2 ( P <.001). The time from arrival to MgSO 4 prophylaxis was also significantly faster with a median time of 160 minutes (IQR, 109–256) in epoch 1 vs 127 minutes (IQR, 85–258) in epoch 2 ( P =.001) ( Figure 2 ). There was also a decrease in the time from arrival to antihypertensive medication administration for severe BPs after the implementation of the MFTI. In epoch 1, 320 patients were treated with antihypertensive medications based on the criteria for treatment, and 226 patients were treated with antihypertensive medications in epoch 2. There was a significant decrease in the time from arrival to treatment with antihypertensives with 101 minutes (IQR, 61–177) in epoch 1 vs 66 minutes (35–203) in epoch 2 ( P <.001) ( Table 3 ).
