OB Triage: The Responsibility of L&D or ER?

• The concept of OB triage can be confusing to staff and patients about where to go, and under what circumstances. 
• There are multiple ways patients can be referred to between L&D and the ER 
• Author, Hollie Dubroc, has some insight on how to improve the OB triage process.

Anyone who has worked in an emergency room, or a labor and delivery department can all relate to some confusion surrounding OB triage.  

To those who have not worked in either care area, the topic may seem very simple. A patient presents with a medical complaint to a facility, facility treats patient, and sends patient home when appropriate.  

Unfortunately, there is a completely tangled mess regarding OB triage that neither L&D nor ER can independently claim.

Arrival to OB Triage

To help build the overall picture, it is important to look at all the components that lead to this entanglement. 

Let us begin with an overview of where OB patients can potentially enter a facility with an initial concern:  

• Clinic sends patient over from concerns discovered during appointment 
• Clinic sends patients over from concerns presented over the phone 
• Ambulance brings patient with pregnancy complaints 
• Patient enters facility through front entrance and comes directly to labor and delivery with concerns 
• Patient enters facility though emergency department and is sent to labor and delivery 
• Patient calls labor and delivery and is instructed to come to labor and delivery

As you can see, multiple pathways exist to which pregnant patients may arrive at a labor and delivery unit for triage. Each entry has independent significance and cause, but the multiple pathways create the first reason leading to the complexity of OB triage.  

 OB Triage Staffing

Next, we will review some general staffing plans in each area to build perspective. Each facility will differ between one another due to census, staffing, and guidelines.

Emergency Room

A facility might even have dual or separate ownership of their emergency department creating separate regulating processes and billing components that govern the department, making it different from inpatient areas, such as labor and delivery.

Inside an ER department, there is typically a triage nurse, RNs, LPNs, technicians, and physicians.

L&D

Within labor and delivery, there are typically RNs and technicians. Depending on the facility there might be a physician or midwife present 24/7, but maybe only one on-call.  

An RN might not be specifically placed to take outpatients or the same RN could be handling labor patients, intrapartum patients, couplets, etc. 

Volume of labor and delivery patients can be extremely unpredictable with having none to having multiple triages in one hour.

The unpredictability makes it hard to accommodate for additional staff based off the need.

Evaluation in OB Triage

Each organization has individual policies regarding obstetric triage; these policies may range from open ended to straight forward.  

Many facilities simply indicate sending anything over 20 weeks to L&D regardless of the presenting complaint.  

A more straightforward policy may utilize an algorithm to determine which location to send the patient.  

Ultimately, several of these policies can have uncertainties, because patient signs and symptoms can have multiple grey areas until further assessments have been completed and interpreted.  

A prime example of a patient symptom that requires further investigation is a 27-week gestation patient with a headache.  Could this be a symptom of preeclampsia, head trauma, dehydration, or something else?

Potential Solutions for OB Triage

There are a few ways that facilities can streamline the triage process to cut down on confusion for both expectant mothers and staff.  

Few facilities may have a specific location for OB triage that is located within the ER, allowing for collaboration between the two areas. While this plan seems very logical, financially this can be difficult if your area has unpredictable volume.  

If an initial screening is clearly determined for a patient to remain in the ER, a tag team approach between the L&D nurse and ER nurse can be very beneficial. Similarly, this approach would be dependent on staffing and census to allow for this combination.  

Designating a single route of entry for all triage patients that is upheld 24/7, could increase patient safety and facility awareness of patients within its walls.  

Communication is going to be your ultimate key to success between ER and labor & delivery staff.  

Algorithms can be extremely useful to help determine optimal patient placement upon their arrival, to achieve the best care.

The Bottom Line

Independently, as a member of the healthcare team, it is always important to know your role. At all times, it is crucial to know your scope of practice, what equipment and supplies are available, and physician availability to you.

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