Maternity improvement resource

We had very clear feedback from our maternity workshop that providers and stakeholders want us to share more of the good practice we find on our inspections.

We analysed the inspection reports from the National maternity inspection programme and want to share the good practice we found in relation to triage. It is not exhaustive. But we hope that services can use the examples and get in touch with the trusts if they wish to learn more.

Quality improvement approach to improving communication and escalation

Portsmouth Hospitals NHS Trust - Queen Alexandra Hospital

The service had implemented a quality improvement project around patient safety and effective communication in triage, which was shared with staff and external stakeholders at a learning event. The service had developed a clear escalation guideline which included a maternity trigger list and a clear pathway for staff to follow during high acuity. This guideline was shared with their local maternity network system and the maternity and neonatal safety improvement programme. All the triage rooms had computer[s] on wheels for assessment and [were] equipped with cardiotocography (CTG) machines to help the timely assessment of fetal monitoring to ensure patient safety.

Strong awareness of maternity triage risks from the trust board and executive team

North Bristol NHS Trust – Southmead Hospital

The chief nurse had attended Birmingham Symptom-specific Obstetric Triage (BSOTS) training.

Effective use of electronic systems to ensure safety

South Tees Hospitals NHS Foundation Trust - The James Cook University Hospital

"In triage, records were routinely checked for safeguarding alerts, including on an internal database and on a national system of safeguarding alerts. Staff could see safeguarding concerns from other trusts for unscheduled out of area patients not known to this trust. Staff could contact the safeguarding team to update safeguarding information on the national system.

The service used a standardised prioritisation tool, which was included within the electronic patient records system (EPR).

This meant all staff had visibility of the number of times someone had called and could escalate their care appropriately. The use of electronic records meant telephone triage could be shared between sites. It also allowed the service to maintain oversight of repeat callers and deteriorations and adjust prioritisation.

Effective use of telephone triage

Milton Keynes University Hospital NHS Foundation Trust - Milton Keynes Hospital

The service had appropriate midwifery staffing in place to manage the maternity telephone triage. There was a designated midwife on each shift allocated to respond to and manage the triage telephone line.

This meant staff taking phone calls were appropriately trained and experienced.

Chelsea and Westminster Hospital NHS Foundation Trust - West Middlesex Hospital

Telephone triage was staffed by midwives working from home, so these staff were protected from being pulled into the numbers on labour ward.

Frimley Health NHS Foundation Trust - Frimley Park Hospital

Some organisations were working with local ambulance hubs and supporting others in their local areas to develop the same processes.

The service used a 24-hour telephone triage line for maternity queries and labour advice which was staffed by midwives within the local ambulance call-handling hub. This meant women had access to professional advice at any time of the day or night to ensure safe care. The service monitored call numbers and waiting times. Data showed a monthly average call rate of 2681 for both Frimley Park and Wexham Park hospitals between January and March 2023, and 73% of these calls were answered within 60 seconds. Data collected between January 2023 and May 2023 showed 15% of calls were abandoned by the caller and these were reviewed on a weekly basis. The service did not receive any complaints or safety concerns about the telephone line during this time.

Environment and equipment

Birmingham Women's and Children’s NHS Foundation Trust - Birmingham Women's Hospital

The service had a dedicated environment for maternity triage with space that allowed privacy and dignity for sharing confidential and/or poor outcomes.

Triage is open 24 hours a day with a dedicated phone line that is manned from 10am to 10pm. There were assessment rooms as well as rooms dedicated for women that needed to be seen urgently by a doctor. Triage was for women from 17 weeks of pregnancy up to 6 weeks postnatal who were experiencing any problems related to pregnancy or following birth. Women also attended for early labour assessments. Fetal assessments were offered for reduced fetal movements. Triage was situated next to labour ward so women could be transferred immediately if needed.

Wye Valley NHS Trust - The County Hospital

The service had identified a lack of space in the triage area as a risk and was in the process of moving triage to a new area with more space to facilitate safer assessment and patient flow…The service had identified that triage posed a potential risk to women due to the lack of space and current staffing model, and consequently triage had been included on the risk register.

George Eliot NHS Trust - George Eliot NHS Hospital

As part of a pilot, the service relocated its triage service, which was originally co-located with the maternity day assessment unit, to the delivery suite. This allowed for assessment rooms to be used when activity on the ward increased and also meant that triage was situated closer to the midwifery station. Staff working in both triage and the maternity day assessment told us the changes allowed them to provide a better service.

Staffing

We were encouraged to see leaders who were supportive and proactive in ensuring staff received the appropriate training to carry out their roles in triage, as well as providing opportunities to develop their skills further.

George Eliot NHS Foundation Trust - George Eliot Hospital

Leaders encouraged staff to take part in secondments and pilot projects to help all staff progress. For example, staff had been seconded to specialist midwife roles, and to manage the triage project.

The Dudley Group NHS Foundation Trust - Russells Hall Hospital

Leaders introduced training to help staff reach triage targets and aimed to achieve over 90% of women being seen within 15 minutes of arrival.

Further information

• Birmingham Symptom Specific Obstetric Triage System (BSOTS) (future.nhs.uk) Requires a FutureNHS account. Accounts are free and available for everyone working in health and care.
• Information about BSOTS (midtech.org.uk)
• When to contact maternity services? Sands and Tommy's Joint Policy Unit discussion paper (sands.org.uk)