Birmingham Symptom-specific Obstetric Triage System (BSOTS)
The Birmingham Symptom-specific Obstetric Triage System (BSOTS) was developed to better assess and treat pregnant women who attend hospital with pregnancy related complications or concerns.
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There is no standardised system within maternity to treat pregnant women who attend with pregnancy related complications or concerns. Women are often seen in the order in which they arrive. The underlying good health of the maternity population may mask the severity of maternal illness, and no assessment of the condition of the unborn baby reinforces the need for a specific maternity system. CLAHRC WM and The Birmingham Women's and Children's Hospital (BWCH) started working with clinicians and public representatives in 2013 to develop a standardised assessment system (BSOTS). The system involves completion of a standard clinical triage assessment by a midwife within 15 minutes of the woman’s attendance which defines clinical urgency using a 4-category scale. This guides timing of subsequent assessment and immediate care (if required) using algorithms. Documentation is provided to support and standardise completion of the clinical tasks required, along with multidisciplinary training for clinical teams.
Maternity triage departments are the emergency portals for women to access maternity services with unexpected complications or concerns. In recent history, maternity triage departments have been established to see women away from delivery suites. However, unlike general Emergency departments, women are often seen in the order in which they arrive, rather than following an initial standardised triage assessment and clinical prioritisation. In addition, pregnant women are normally fit and healthy, which can mask how unwell they are using general triage tools, which also do not assess the condition of the unborn baby. Safety issues within maternity triage departments have been identified through the MBRRACE UK confidential enquiries, national HSIB maternity investigations and NHSR maternity reviews.
In the host organisation (BWCH); the issues with safety in maternity triage were identified by the medical and midwifery staff within the department before clinical incidents and outcomes confirmed the challenges for safe and effective care.
Triage is generally a high pressure and high risk area to work which can be stressful for both the midwifery and medical staff. Having a structured system in triage allows the staff to safely manage the workload and although the system does not reduce the number of women attending triage, it does enable the midwives to remain in control and have full knowledge of all women within the department.
Impact & Outcomes
Initial evaluation in 2013 at BWCH demonstrated that use of BSOTS increased the numbers of women seen by a midwife within 15 minutes of attendance from 39% to 54% [Relative risk (RR) 1.4 (1.2, 1.7 (95% confidence interval (CI)) and reduced the time to medical review for those who required it. Whilst this is not an absolute measure of safety, more timely assessment and intervention will reduce delays in essential care and improve safety for women and their babies.
BSOTS also showed excellent intra-rator reliability when tested, with an Intracluster Correlation Coefficient (ICC) of 0.961 (95% CI 0.91-0.99). There was no apparent difference between midwifery band level and amount of triage experience, showing that the BSOTS tools are reliable and consistent for use amongst varied midwifery staff