EBP final

Chapter I


At a large university medical center on a level III Labor and Delivery Triage unit in New York City patients are experiencing long wait times. Patients are suffering a delay in care, treatment, and transfer due to excessive waits. Causing patients to become increasingly agitated, leave without being seen (LWBS), leave against medical advice (AMA) and overall patient dissatisfaction.


Studies show that Emergency Department crowding and efficient throughput is a global problem associated with increased patient mortality and decreased quality of care.  Authors noted that mortality rates in crowded EDs were moderately higher than those that were not crowded (Carter et al., 2014; Southern et al., 2012; Garland et al., 2013). In a retrospective, cross-sectional analysis of data from the Nationwide Inpatient Sample (NIS) between January 1. 2002- December 31, 2011, in which more than 7 million hospitalization stays were reviewed.  It was found that 338,000 hospitalizations were discharged against medical advice (DAMA) each year, with a 1.9% average increase over the decade (Spooner et al., 2017).  DAMA patients are more likely to leave with inadequate care, increasing their risk for hospital readmission, morbidity, and mortality (Carter et al., 2014; Southern et al., 2012; Garland et al., 2013).  These patients tend to return to the ED within two days and have approximately twice the risk of 30-day mortality and significant readmission (Southern et al., 2013). Spooner et al. noted that although research on DAMA amongst the obstetric patient is scant, their analysis found about 2.7% (9,138) of DAMA patients a year are from obstetrics.

Patients that leave without being seen (LWBS) are at lower risk of hospital admission and show no greater risk of mortality, but are at higher risk of returning to an ED within two days (Southern et al., 2013; Tropea et al., 2012).  It is inferred that patients that LWBS are typically patients that aren't seriously ill thus showing insignificant mortality rates (Tropea et al., 2012).

However the financial implications of LWBS needs to be taken into consideration.  While it is difficult to calculate cost for services not rendered, studies have shown that there's a potential of lost charges due to diversion, LWBS and DAMA resulting in a loss of over $20 million (Sayah et al., 2014; Seamus et al., 2014).  

In the article Financial Impact of Emergency Department Crowding by Foley et al. the authors showed that the hospitals overcharged over $1,500 for 6,205 patients with over $9 million in excess charges in 2007 due to increased Length of Stay (LOS).  After deducting the usual reimbursement, it showed that the hospitals loss almost $4 million.  Also, in the near future Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) will be used to calculate reimbursement (Murphy et al., 2014).  Since the assessment for reimbursement will be based on patients review, it can only behoove the hospital to implement patient satisfaction from the onset of care.

Labor and delivery triage is a multidisciplinary, multivariable, complex specialty within the hospital. It is commensurate with any emergency department, with similar chief complaints as well as an unpredictable census, accompanied by the multiple complaints that accompany pregnancy. 


The purpose of this project is to decrease Labor and Delivery triage wait time in L&D.


P- Pregnant Females in an inpatient L&D unit

I – Use of an Advance Practice Nurse in the triage area

C – Current use of interns

O – Decrease triage wait time by 10%

T – Six months

Burning Clinical Question

Will utilizing an Advance Practice Nurse in the triage area on a labor and delivery unit in an acute care facility decrease patient wait time by 10% in six months?

Chapter II

The purpose of this evidence-based practice project is to decrease lengthy triage wait time and length of stays on the labor and delivery unit.

Literature Search and Yield

            Electronic databases were used to acquire articles that would support an evidence-based practice change.  The databases used were Cumulative Index of Nursing and Allied Health Literature (CINAHL) Plus with full text, Cochrane, PubMed and Google Scholar.

The Keywords used were Labor & Delivery Triage yielding 22 articles, Labor & Delivery throughput yielding 257 articles, Labor & Delivery Triage Wait Time yielding 1093 articles. Further review of the abstracts showed that the information didn't correlate to the imitative of this project. So I searched using the keywords Emergency Department Triage yielding 7,040 articles, Emergency Department throughput yielding 10,200 articles, Emergency Department wait times yielding 16,600 articles.


Modifications were made to the search to purge results. For the articles to be included, they needed to be peer viewed, scholarly articles, between 2012 and 2017 written in English. Further review via abstracts yielded seventeen articles. After critical appraisals, two were deemed inadequate. The ten articles chosen were the most recent, that utilized an APN or designated lead person. Articles excluded were those older than five years, non-peer reviewed, and those that didn't include ERB approval.

Literature Review Protocols and Hierarchy of evidence

Articles were reviewed using quantitative and qualitative tools from the 2017 NURS 7701 syllabus to determine the quality and strength of the evidence.  For systematic reviews and cohort studies, the 2013 Critical Appraisal Skills Program (CASP) were utilized to determine quality and strength. Hierarchy of evidence was determined using Melnyk & Fineout-Overholt's tool (2011).

Review of Literature

The premise of this Evidence-Based Project stems from the state of Obstetric Triage care.  The article  "Obstetric Triage: A Systematic review of the past fifteen years: 1998-2013 by Diane Angelini and Elisabeth Howard serves as a firm foundation. The article was published in The American Journal of Maternal/Child Nursing in 2014, a peer-reviewed journal.

The evident purpose of this systematic review is to depict critical categories which influenced obstetric triage from 1998-2013.  Thirty-three sources were deemed appropriate after an extensive search of the electronic databases PubMed, CINHAL, Ovid and Cochrane Library Reviews and inclusion/exclusion criteria were met (Angelini and Howard, 2014).

The literature follows a logical sequence; seven key categories were defined from the review.  Each category was discussed at length.  In Category 1, Legal Issues and Impact of EMTALA the Emergency Medical Treatment and Active Labor Act (EMTALA) was passed by the US Congress in 1986. The law's initial intent was to ensure patient access to emergency medical care and to prevent the practice of patient dumping, without consideration of medical condition or stability before the transfer (Zibulewsky, 2001). With EMTALA patients must be seen and assessed by a healthcare provider promptly. The review notes that liability for the guidelines and standards set forth by EMTALA are often mentioned throughout the literature reviews.

Category 2 continues with the Liability Pitfalls in regards to EMTALA as an area of concern.  Category 3 Risk Stratification focuses on the use of Acuity tools to aid in prioritizing patients according to urgency.  Several studies mention the use of Tools to assess Acuity. Many tools exist for the Emergency Department(ED) triage. However acuity tools specifically for OB triage are lacking.  The first OB triage acuity tool was developed in 2011 by Paisley et al. (Angelini and Howard, 2014). 

Category 3 and 4 Clinical Decision Aids could have been combined; they both discussed the use of tools, protocols, and guidelines for care. Which are paramount for the rapid and accurate completion of assessments which are essential for throughput.  Category 5 Utilization, patient flow, and satisfaction reviewed patient perspective on wait time and satisfaction.  Category 6 consisted of literature that incorporated advanced education and use of Advanced Practice Nurses in the OB triage. Category 7 literature dealt with common non-obstetric issues routinely seen/managed in OB triage.

Overall the review was clear and precise. Methods used were appropriate. The findings show a need for further research.  Limitations noted were the lack of available literature specifically about Obstetric Triage.  Authors recommended:

  • An updated survey of obstetric triage functionality, especially in Level III perinatal center with a large volume of births. 
  • Further research on the impact of overflow on outcomes and cost-effectiveness in OB triage.
  • Determination of the ideal length of stay (LOS).
  • Determination of the correct provider mix in the OB triage area and the cost and clinical outcomes of their use (Angelini and Howard, 2014).

Wait Times

            To avoid patient dissatisfaction leading to patients LWBS or AMA both which can lead to adverse outcomes (Garland et al., 2013; Southern et al., 2012; Spooner et al., 2017).  It is imperative that care is provided promptly. Patients discharged AMA, are at a higher risk for both morbidity and mortality, and there are definite correlations between patient satisfaction experience, wait times and perception of care (Bleustein et al., 2014).  Also, the Studer Group published an analysis showing that malpractice risk is four times greater in emergency departments with an average wait greater than 60 minutes, compared to EDs with an average wait of less than 30 minutes.

            In the level II quantitative study done by Bleustein et al., (2014) 11,352 Press Ganey questionnaires were analyzed to assess the correlation between wait times and patient satisfaction.  Not only in regards to the provider but also the perception of his/her ability to provide quality of care.  In their review of the literature, they found that there were three key factors associated with patient satisfaction.  Which were provider-patient interaction, patient-specific characteristics and perceived waiting times. Patients that waited longer than 20 minutes gave lower scores (Bleustein et al., 2014). No gaps in literature were mentioned.  Press Ganey HCAHPS which is a well-established tool was used for this study. Surveys were sent to all patients visiting the ED over one year, roughly 49,000 with a return of about 23%. Statistical analysis was done using univariate and multivariate association tests and statistical modeling techniques, which were appropriate for this study.  The results were clearly summarized both narratively and with tables and graphs.  Chi-Square tests were used to imply a direct correlation between wait time and patient satisfaction ratings.

 Noted limitations include the inability to distinguish between the actual quality of care and actual time spent with the physician.  Also, whether the acuity of the patients biased their responses.  Suggested implications for practice include the need to not only provide quality efficient care but to also take into consideration minimizing wait times. 

The article Minimizing ED Waiting Times and Improving Patient Flow and Experience of Care by Sayah, Rogers, Kingsley-Rocker & Lobon, (2014), is a level II quantitative research design. It reviews the outcome of re-engineering the entire ED at Cambridge Hospital in Massachusetts.  Statistical and computational techniques were used to analyze and present results. The authors succinctly identify the purpose and the problem statement, "a system-wide process improvement project aimed at optimizing the ED patient experience by expediting throughput and flow" (Sayah et al., 2014).

.           The ED at the Cambridge hospital was faced with long patient wait and turnaround time necessitating the study to identify changes made and their impact on quality of care. Sayah et al identified the importance of the study as providing an avenue and evidence on the quality of care and the impact of the interventions at the hospital.  However, they do not articulate or list any research questions for the study.

There isn't a proper review of literature; neither do they offer a comparison of studies identifying gaps. A slight mention of a literature review is mentioned briefly in the introduction; however, it lacks a synthesis to bring out the research gaps.  Data collection and analysis methods are clearly identified and described. Electronic medical records were used for data collection, timestamps were used to estimate patient wait time, and alert flags were used to determine which patients LWBS. The T-test was used to compare the means of the before January 2005 and after April 2008 data. There is no mention of any factors that threatened the internal and external validity of the research. The research also does not identify and or use any theoretical frameworks or concepts.

All patients visiting the emergency department were included in the study approximately 30,000 patients. IRB approval was received. The unit was divided allowing a split flow based on acuity. Relaxation of rigid specialized designation areas allowed for more bed availability.  The Emergency Severity Index (ESI) triage tool was utilized to assess acuity. Mini registration shortened the intake process by decreasing the number of questions asked; full registration took place at the bedside.

It's a well-known fact that some of the ED overcrowding correlates with the length of stay (LOS) and boarding of admitted patients. Therefore there was also a focus on facilitating movement of admitted patients. One intervention included sending stable patients with written reports directly to units bypassing verbal report (Sayah et al., 2014).

The presented data measured parameters which were relevant to the research questions such as the amount of ambulance diversion hours, Press Ganey scores, and length of wait time. The figures and tables that depicted the results were well presented.  The authors incorporated previous studies into the description of the results, comparing the results to past research interventions. Relevant graphs coalesced the findings and linked them to the study aims. Study limitations included generalization due to the level and type of ED in which the study took place. The authors do not discuss the implications of the study to practice nor do they identify any recommendations for future studies.

Final results showed a notable positive impact.  Diversions went from 148hr to 0, PG scores rose from 12% to 59%, LOS decreased from a mean of 204 minutes to 132minutes, LWBS decreased from 4.1% to 0.9%. The significance is shown by the billable hours acquired due to the decrease in diversions and LWBS and a significant increase in PG scores. 

This study shows great promise for practice change; it clearly illuminates that inefficient throughput and delays in care negatively impacts patient satisfaction and outcomes (Sayah et al., 2014).

Acuity Tools / Split Flow

            Acuity tools are used to assess and prioritize patients according to their specific needs.  It is commonly used with reliability in Emergency Departments throughout North America.  Various acuity tools exist for use in the ED, it's not until 2011 is such tool developed for Obstetrics. The ability to quickly assess and treat patients has been known to reduce LOS and increase patient satisfaction scores (Smithson et al., 2013)

In 2013, Smithson, D., Twohey, R., Rice, T., Watts, N., Fernandes, C. and Gratton, R. published Implementing an Obstetric Triage Acuity Scale: interrater reliability and patient flow analysis in the American Journal of Obstetrics and Gynecology.  It's based on the hypothesis that by using an acuity tool in OB triage such as those used with positive results in the ED will garner the same results for the OB population.  The study aimed to test the reliability and validity of said tool as well as assess the distribution of the acuity and patient flow (Smithson et al., 2013). 

The study spanned one year and had a clear objective and methodology.  All triage visits during the time frame were used resulting in approximately 11,300 patients. The OTAS is a comprehensive five color-coded acuity scale.  Eight nurses were trained to use the OTAS, and it allowed for quick assessment and disposition of patients. Results showed that OTAS has a high degree of reliability, a significant decrease in LOS by an average of 36 minutes.  Probable limitations include the fact that due to the nature of OTAS 1 it's believed that those patients bypassed triage and were directly admitted to the unit. Also, the study was "paper-based" and limited to human error for assignment of time.  Even with limitation, this study is of valuable use for rapid assessment and disposition patients.

In 2016,   Bish, P., McCormick, M., and Otegbeye, published Ready-JET-Go: Split Flow Accelerates ED Throughput in the Journal of Emergency Nursing. The authors did not yield any peer-reviewed articles detailing the planning/ implementation of the split flow design and sought to fill that void.  In an inner-city hospital in New Jersey, they saw an average of 48,000 patients and found it challenging to stay within the Centers for Medicare and Medicaid Services(CMS) metrics. This study was implemented with hopes of increasing patient flow and decreasing LOS by splitting the ED into areas determined by acuity levels using ESI.  In the JET area, a team consisting of Medical Doctor, Registered Nurse, and Patient Care Tech rounded as a team; this method increased communication and orders were able to be done immediately. The methods were clearly stated.  They were able to identify peak volumes and added additional seating.  Overall the findings were positive.  JET patients examinations were completed in 30 minutes, with median Arrival-Departure time reduction by 43 %, an 80-minute decrease. Press Ganey scores increased 10-30% in various areas.  The results were clear and included tables. No limitations were identified.  This study shows that utilizing acuity tools have a positive impact on practice.

In the article entitled "Does an emergency department (ED) flow coordinator improve patient throughput" published in the peer-reviewed Journal of Emergency Nursing in 2014. By Seamus O. Murphy, Bradley E. Barth, Elizabeth F. Carlton, Molley Gleason and Chad M. Cannon, the problem was clearly defined, with increased emergency department volume as the cause of overcrowding, and reduction of patient throughput. The purpose of the study was to investigate the effects of introducing an emergency flow coordinator on patient throughput. However, a decrease in lost potential charges was also noted.

The significance is shown when researchers note that there are potential lost charges due to diversion, LWBS and AMA discharges resulting in a potential loss of over $20 million. Also, while HCAHPS don't apply to the ED, it can only behoove the hospital to implement patient satisfaction from the onset of care (Murphy et al.,2014).

The independent and dependent variables were clearly defined. There was a logical sequence in reviewing the literature on ED overcrowding and solutions in addressing this challenge.  A significant gap in the literature pertaining to the use of ED flow coordinators to address the issues that plague the ED supports the necessity of the present study. 

No theoretical framework was used for the study. The hypothesis was not stated precisely, in a way that can be tested. The methodology is clearly stated and includes reviewing data, analyzing it with descriptive statistics before and after the study. Methods of data collections are sufficiently described. No internal or external threats to the validity of the study are mentioned (Murphy et al., 2014).

The use of ESI and split flow were the clear methods and procedures used. Data collection methods were clearly defined but didn't indicate the exact instruments used for data collection.  Therefore the reliability and validity of the data instrument cannot be guaranteed.  The rights of the human subjects were protected because the study was approved by the local institutional review board (Murphy et al., 2014).

According to the results, there was a notable improvement in hours spent in ED, reducing overcrowding. The results of the study are also presented in tables, illustrating that by implementing a flow coordinator, they were able to facilitate the movement of patients through the emergency department.

Limitations noted were the external validity. Also, the financial formula is based on an assumption of returns and doesn't account for reimbursement rates and the ability to collect payment. The results indicate that by implementing a flow coordinator, the ability to facilitate the movement of patients through the emergency department is highly probable.

Advance Practice Nurse

In 2013 Julie Paul, Robin Jordan, Susan Duty and Janet Engstrom published the study "Improving Satisfaction with Care and Reducing Length of stay in an Obstetric Triage Unit Using a Nurse Midwife Managed Model of Care in the Journal of Midwifery and Women's Health.

          The clear purpose of the study was to determine whether an obstetrical triage managed by a certified nurse midwife would increase patient satisfaction and decrease the length of stay (Paul et al., 2013). The hypothesis is clearly stated. The significance of the study is noted because shortly determination of reimbursement from 3rd party payers will be dependent upon patient satisfaction. (Paul et al., 2013). It also has the potential to be utilized on similar units. The literature follows a logical sequence and consists of several peer-viewed academic journals with congregant results of other studies. One gap noted was the possibility that any qualified, dedicated provider staffed in the triage could yield similar results.

        In a level III Hospital based obstetric triage 272 women volunteered to participate in the study. IRB and administrative approval were obtained. Data was collected using an established, validated questionnaire. Quantitative data were analyzed using SPSS version 20 (Chicago). Chi-square was used for categorical data, And Fisher exact test was used to compare that dichotomous data. Four tables presented thorough insight into the results.     A noted limitation was the fact that only one CNM was used during the study, which may have had led to less relevant results. Further investigation is needed to highlight the cost-effectiveness of utilizing an Advance Practice Nurse for this position. Also, to verify if the use of other Advance Practice Nurses, such as a Nurse Practitioner would yield similar results.  Final results indicate the use of a CNM to manage OB Triage increased patient satisfaction as well as decreased wait time.

Published in 2017 The design and implementation of an obstetric triage system for unscheduled pregnancy-related attendances: a mixed methods evaluation written by Kenyon, S., Hewison, A., Dann, S., Easterbrook, J., Hamilton-Giachritsis, C., Beckmann, A. and Johns, N., in BMC Pregnancy and Childbirth. It's a mixed method level II study that takes place in a maternity ward in the United Kindom.  Authors hypothesized that a delay/ failure to recognize and treat maternity patients promptly and adequately lead to adverse outcomes.  The Birmingham Symptom-Specific Obstetric Triage System (BTOS) using a four-color acuity scale was developed and implemented.  A structured audit investigating whether implementation of BTOS would impact patient care was performed.  A review of the literature showed a need for such a tool.  Clear, concise methodology and objectives were expressed.  An audit of 994 notes was reviewed additionally questionnaires were given to the providers. The sample size was adequate and chosen at random, confirmation of statistical significance was shown using verified methods.  IRB approval was obtained for questionnaires and focus groups and was deemed not necessary for chart audits.  Results were presented clearly with accompanying tables for visual inspection.    Data missing from charts, such as times of contact, is a noted limitation. Also that it was performed on only one maternity unit. Regardless of limitations, the study showed the BTOS has excellent inter-operator reliability. The acuity tool with split flow improved the organization of the triage department (Kenyon et al., 2017).

In Australia the study by Dinh, M., Walker, A., Parameswaran, A. and Enright, N. ,Evaluating the quality of care delivered by an emergency department fast track unit with both nurse practitioners and doctors publishing in 2012 in the Australasian Emergency Nursing Journal, did an observational study using a convenience sample of adults with a two-fold aim. One was to assess the overall quality of care by the fast track unit, secondly evaluating MD vs. NP care in the ED.  Dinh et al. hypothesized that patients that received care from an NP may have higher patient satisfaction.  A total of 320 participants from an inner city district level hospital, were enrolled in a 1-year process. Inclusion/exclusion and randomization criteria were appropriate.  Data collection was clear and concise, IRB approval was obtained. Results reported were clearly outlined accompanied by tables and graphs to illuminate the results further.  The outcome of the study showed shorter waiting time in the NP group, and patient satisfaction scores were significantly higher. Both groups showed a comparable quality of care, overall health outcomes and adverse event rates were similar (Dinh et al., 2012).

Some limitations include the fact that only one NP was employed at the time. Therefore, the study did not take place on the NPs days off. Also, only low-risk patients were seen in the fast track, thus limiting the types of patients seen. Patients that LWBS didn't complete the surveys. Even with these limitations, the results of the study show great significance for practice.

In 2015 Jennings, N., Clifford, S., Fox, A., O'Connell, J. and Gardner, G. Performed a level I systematic review to assess the impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department it was published in the International Journal of Nursing Studies, a peer-reviewed journal.  A thorough search of four electronic databases with clearly defined keywords yielded 1013 articles. After inclusion/exclusion criteria were met, 84 articles remained for critical appraisal.  Johanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument was used to assess quality yielding 14 articles for review.  Results were summarized accompanied by graphs and a synthesis table. Need for this study was clearly demonstrated because previous reviews were 5-7 years old. Also, there is limited evidence evaluating the impact of cost, quality of care, wait times and patient satisfaction regarding the use of NPs in the ED. Limitations include the sparse literature available on this topic, especially in reference to costs.  The results showed that an NP in the ED has a positive impact on patient satisfaction and a decrease in wait times. Costs and overall quality of care provided by of ED NPs were shown to be equal to that of other health professionals (Jennings et al., 2015). Authors express a need for additional research.

Synthesis of Evidence

The evidence shows that patient throughput in the triage area is a problem for quality care, risk management, patient safety and satisfaction (Angelini and Howard, 2014; Bluestein et al., 2014).   An increase in patient throughput in triage will improve all of these problems. The evidence presented shows that fast-tracking (based on acuity) and the use of acuity tools decrease wait times, lower length of stay, improve patient flow, and contribute to patient satisfaction (Bish et al., 2016; Bleustein et al.,2014; Dinh et al., 2012; Murphy et al., 2014; Paul et al., 2013; Sayah et al., 2014 & Smithson et al., 2013) . Additionally, by having a dedicated provider in triage has been attributed to increased patient satisfaction, improved throughput and decreased wait times   (Dinh et al., 2012; Jennings et al.,2014; Kenyon et al., 2017; Murphy et al., 2014; Paul et al., 2013 & Sayah et al., 2014).  Decrease in wait time can have financial improvements by decreasing LWBS and DAMA thereby reducing potential loss charges and possible malpractice claims (Angelini and Howard, 2014; Murphy et al., 2014; Sayah et al., 2014; Southern et al., 2012 & Tropea et al., 2012).

The information available for Labor and delivery triage is limited. However, there are many studies based on the ED. Since the ED triage and the L&D triage are similar, it can be hypothesized that standards created for ED triage can prove useful in improving Labor and Delivery Triage.


On the basis of a review of literature, a recommendation can be made for the addition of an NP to fulfill the provider role in triage and to add an acuity tool to the triage process. The addition of both an NP and acuity tool has shown positive results in patient care, such as decreased LOS, LWBS, and DAMA. While increasing throughput and patient satisfaction.


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