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Triage acuity scales used in emergency rooms have a limited number of obstetrical modifiers. To understand patient flow and acuity in a tertiary care obstetrical triage unit, a five-category scale (5-Non-Urgent, 4-Less Urgent, 3-Urgent, 2-Emergent, 1-Resusitative) was developed with a comprehensive set of obstetrical modifiers. Objectives were:
1) To test the inter-rater reliability (IRR) of the Obstetrical Triage Acuity Scale (OTAS), and
2) To determine distribution of patient acuity and flow by OTAS level.
For IRR, 110 randomly selected charts were used to generate vignettes then built into an online test (Kappa - 0.8, SE - 0.05; n= 8 RN's). Eight triage nurses assigned acuity scores to each. At LHSC, there are approximately 11,300 yearly visits to triage. A retrospective analysis of 936 charts from January 2009 to December 2010 was done. Acuity, time of arrival, nursing assessments, health care provider assessment, discharge, and length of stay (LOS) were stratified by acuity.
The highest IRR was for the lowest acuity patients (OTAS 5) with substantial reliability (IRR 0.61-0.77, Kappa) for OTAS 1-4 (Table 1). Distribution by acuity was: OTAS 5=364 visits (39%), 4=272 (29%), 3=182 (19%), 2=103 (11%), 1=15 (2%). The mean LOS was: OTAS 5=118 minutes +/−SE 5.2, 4=109 +/−6.5, 3=107 +/−8.0, 2=164 +/−19.4, 1=140 +/−30.9. Drivers of LOS for OTAS 5 were time to primary nursing assessment (15 min), to health care provider assessment (73 min), and to discharge (118 min). Analysis was also done for OTAS 1-4.
1Inter-rater reliability measures
OTAS has substantial IRR for higher acuity and near perfect for non-urgent acuity. Implementation of OTAS allows for triaging of obstetrical patients by acuity, and improves patient flow. 68% of triage visits were of lower acuity (OTAS 4,5). LOS was similar across all OTAS levels. We are planning implementation of a fast track pathway for lower acuity patients to reduce their LOS and also improve time to assessment for more urgent patients.