OBSTETRICAL TRIAGE: A COMMON AREA OF LITIGATION – HOW THE USE OF THE MATERNAL FETAL TRIAGE INDEX (MFTI) MITIGATES RISK
In this blog, I’ll be reviewing the common allegations specific to obstetrical triage. I’ll also review the incidence of obstetrical triage, the sources of recommendation specific to the use of standardized obstetrical triage acuity tools, and offer an introduction to the Maternal Fetal Triage Index (MFTI):
Common Allegations Specific to Obstetrical Triage:
- Failure to perform a medical screening exam
- Failure to perform a timely assessment of the fetus
- Delay in completing a medical screening exam
- Failure to have a policy delineating conditions that require a bedside evaluation by an obstetrical care provider prior to discharge following a medical screening exam by an obstetrical nurse
- Failure of the provider to perform a bedside evaluation for an obstetrical patient with a high risk medical or obstetrical condition
- Discharge of a patient without confirming fetal well-being
- Discharge of a pregnant woman who is unstable for discharge
- Failure to meet all aspects of the Emergency Medical Treatment and Labor Act (EMTALA) regulations in assessing, treating, and discharging a pregnant woman who presents for care
Incidence of Obstetrical Triage:
According to the American College of Obstetricians and Gynecologists, ACOG (2020), obstetrical triage exceeds the overall number of hospital births by 20–50%. Up to one third of evaluated obstetrical patients will not deliver. These obstetrical patients will be discharged home, or transferred to another unit following initial obstetrical evaluation. In addition to labor evaluations, obstetrical patients commonly present for (but not limited to) evaluation of preterm labor, preeclampsia, decreased fetal movement, preterm premature rupture of membranes, vaginal bleeding, and acute abdominal pain. Critical conditions such as motor vehicle collision injury, large placental abruption, or seizure, are less common, but require immediate triage, assessment, and management (ACOG, 2020).
Recommendations for Standardized Obstetrical Triage Acuity Tools:
ACOG recommends that women should be cared for according to triage acuity rather than by time of arrival. Historically, women have been evaluated on a first come, first serve basis when presenting to the labor and delivery unit (or, obstetrical triage unit). This method didn’t support timely identification of urgent or emergent obstetrical events (AWHONN).
Several obstetrical triage acuity tools have been developed to classify patients based on the urgency of the patient’s condition, often using a five-level system. These tools have increased the proportion of high-acuity patients being seen urgently. Several of these tools have been tested for content validity and interrater reliability and may be used to improve quality and efficiency of care and guide allocation of resources (JOGNN, 2015).
Many professional organizations recommend that hospital obstetrical units develop triage protocols based on local conditions, resources, but also informed by evidence-based decision making. ACOG recommends the validated algorithm, the Association of Women’s Health, Obstetric and Neonatal Nurses’ Maternal–Fetal Triage Index (MFTI).
The Maternal Fetal Triage Index (MFTI):
The Association of Women’s Health, Obstetric and Neonatal Nurses’ (AWHONN) implemented a Maternal Fetal Triage Index (MFTI) which serves as the first obstetrical acuity tool developed by a professional society for use across the United States.
The MFTI serves as an acuity tool (scale) that standardizes obstetrical triage and assists providers and nursing staff to prioritize urgency for provider evaluation and promotes effective multidisciplinary communication.
The MFTI evaluates maternal vital signs, fetal heart rate, presenting condition, status of labor, fetal movement, current obstetrical, medical and surgical history.
The ultimate goal of utilizing this tool is to improve patient safety and care. These improvements will assist in mitigating the common allegations associated with obstetrical triage medical malpractice cases. The elements of the MFTI prompts timely medical screening exams, with the inclusion of fetal assessment and evaluation of current history that supports risk stratification of the patient and fetus. Based on the risk assessment, the tool offers clinical guidance specific to follow up care.
Resources:
American College of Obstetricians and Gynecologists (ACOG) 2020. Hospital Based Triage of Obstetrical Patients, Committee Opinion, #667.
Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)
Ruhl C, Scheich B, Onokpise B, & Bingham D. 2015. Content Validity Testing of the Maternal Fetal Triage Index. J Obstet Gynecol Neonatal Nurs. 44(6):701-9. doi: 10.1111/1552-6909.12763.
P.S. Comment and Share: What is your experience in representing an obstetrical triage case? During case development, did you identify the use of an obstetrical triage acuity tool?