 Thank you everyone for coming along or for viewing our presentation after the event today from the YouTube channel. It's a great pleasure to be here. I wish to begin by acknowledging the Wurundjeru people of the Kulin Nations, which is the traditional owners of the land on which I am working today here in Australia. We pay our respects to the local people for allowing us to have our gathering on their land to their elders past, present and future. We thank the organisers of the Virtual International Day of the Midwife Conference in selecting our abstract to present today also. My name is Linda Sweet, and together with my colleague, Vadanko Vasilevsky, we will be presenting our evaluation of implementing the Birmingham Symptom Specific Triage System at Western Health in Melbourne, Australia. Our colleague Denise, who's also been integral to this process, was hoping to attend today, but she's actually on leave and is in the UK, and so it's three o'clock in the morning for her. She was hoping to hop on if she could get up, but I can't see her in the list at this point in time, but she may join us at some point as we go along. And if so, she'll be able to answer questions in the chat. So obstetric triage. So emergency department triage systems have been developed to ensure people are provided with appropriate care based on their clinical needs and to consider efficient use of resources. It is a process of prioritising the order in which people receive care on arrival to a healthcare service in consideration of their clinical presentation. Obstetric triage is usually undertaken by a midwife and involves identifying the woman's presenting problem and conducting physiological and vital signs assessments. The overall assessment is then used to determine the urgency of treatment required and prioritisation of care. Triage of pregnant women poses many challenges as the physiological changes associated with pregnancy do not match the general parameters of standard emergency department triage measures. For example, pregnant women have a higher resting heart rate, higher respiratory rate, lower blood pressure than women who are not pregnant. Another concern is that existing triage tools do not evaluate the condition of the unborn fetus. There is increasing recognition of the need to use a triage system that is specific to the physiological adaptations of pregnancy and the signs and symptoms of obstetric complications. For these reasons, the Birmingham Symptom Specific Obstetric Triage System, or as we call it, BESOTS, was developed by a team led by Professor Sarah Kenyon to standardise triage within maternity care settings to support the identification, prioritisation and care of women who present to health services with unaccompanied care. BESOTS is based on a traffic light system whereby by following assessment, the midwife determines a category of clinical urgency. Completion of a standard clinical triage is undertaken by a midwife ideally within 15 minutes of the woman's attendance. This includes taking brief maternal history, completion of baseline maternal observations such as temperature, pulse, respirations and blood pressure, assessment of pain levels using a numerical pain score scale, abdominal palpation and oscillation of the fetal heart rate if pregnant. This assessment is used to define a category of clinical urgency, which guides timing of subsequent assessment and immediate care by an obstetrician if required. Categories of clinical urgency are defined as red, requiring immediate further assessment and or treatment, orange, further assessment within 15 minutes, yellow, further assessment within one hour, or green, further assessment within four hours. The BESOTS provides standardised symptom specific algorithms for allocating of clinical priority and the immediate care and further investigation of the eight most common reasons for attendance. These include abdominal pain, antenatal bleeding, hypertension, suspected labour, ruptured membranes, reduced fetal movement or unwell other and postnatal concerns. Support triage of pregnant women has been increasingly recognised in Australia and around the world as an important factor contributing to adverse maternal and fetal outcomes. The prior process for managing of unplanned presentations at the service we work at, which is Western Health, was a treat in turn principle whereby women were generally reviewed in the order in which they present to the unit. This meant in some cases women were greeted by the ward clerk and directed to a waiting room and could have waited for significant periods of time before being assessed by a midwife. This presented significant clinical risk to the women and her fetus but also to the organisation including the failure to recognise clinical deterioration of a woman or fetus. Following the safe and successful move to a brand new maternity hospital and the establishment of a new model of care provided within the maternity assessment centre, the implementation of a maternity triage workflow has been instrumental in reducing the risk for women presenting with unplanned presentations. Initially a triage midwife role was implemented to ensure that women presenting with unplanned presentation were seen within 15 to 30 minutes of presentation to the department. A local analysis of this activity demonstrated that 81% of the women were being triaged within that timeframe with an average period of 21 minutes from presentation to triage. While the introduction of the triage midwife role increased the numbers of women with unplanned presentations being assessed within the target timeframe, more improvement was still required. Specifically there was a lack of standardised assessment, categorisation and prioritisation of women during this triage process. So the unit manager and senior staff went about looking at the different models of care to be able to address this problem. The BSOTS or the Birmingham Symptom Specific Obstetric Triage System was nominated as the preferred model for maternity triage here at Western Health. Implementation was guided by Professor Sarah Kenyon, supported by the educators and managers for the new model of care. Midwives who do the triage were provided education on the BSOTS and the model commenced in February 2021. This presentation will demonstrate the evaluation of the implementation of BSOTS. The aims of our study were to evaluate the effectiveness of BSOTS for women to have initial triage assessment within auditable standards which is 15 minutes, evaluate staff perceptions of the education for the implementation of BSOTS, evaluate staff perception regarding the impact of BSOTS on workflow, work satisfaction and quality of care, and determine women's satisfaction of their triage experience during the BSOTS implementation. So the study site is one of the largest maternity hospitals in Australia, now recording over 6,500 births per year. As you can see it's the lovely rainbow coloured building which is now on site next to Sunshine Hospital but it's called the Joan Kerner Women's and Children's Hospital. The maternity assessment centre within this service triages and manages on average 750 presentations of women, unplanned presentations of women per month which equates to an average of 25 unplanned presentations per day in addition to their planned presentations. So they are a very, very busy service. The study design used a multi methods approach with four distinct components to address each of the study aims. So the education process that the BSOTS requires for staff to undertake includes an evaluation survey which explores staff satisfaction, knowledge and confidence following their BSOTS education. We then went about undertaking a retrospective clinical data audit to examine women's presentations to the maternity assessment centre in the month of June 2021. We waited until June so that they had a four month period of time in which to get familiar with the BSOTS triage process and to have implemented it. And so that clinical audit data is looking about whether or not women receive the key within the auditable standards. We also undertook some focus groups to determine staff's experiences of the BSOTS implementation. And lastly, we did a survey evaluating women and staff satisfaction with the triage and care received in the maternity assessment centre during the BSOTS implementation. Quantitative data was analysed with descriptive statistics and non-parametric tests and the qualitative data was subjected to a thematic analysis following Braun and Clark's approach. So participants, in our training evaluation survey the participants were Medwifery staff who completed the BSOTS education pre-implementation. The retrospective clinical data audit was all women who presented to the maternity assessment centre during the month of June 2021. Focus groups were the Medwifery triage staff, so the midwives who performed triage, who engaged in the clinical care during the implementation. And the survey was women who received care in the maternity assessment centre between February and March 2022. So the results of the training evaluation, the BSOTS staff training evaluation survey was a paper based survey which came as a part of the BSOTS education package and was distributed to staff immediately following their education sessions. Training data was recorded on Excel spreadsheet by a research assistant. Data was summarised with descriptive statistics, so frequencies and percentages, and changes in pre- and post-education knowledge and confidence scores from the staff training surveys were analysed using Wilcoxon sign ranked tests. The qualitative survey data were analysed thematically, and you can see the data from the survey showed that knowledge and confidence significantly improved with a p-value of less than 0.001 following their BSOTS education. Both knowledge and confidence were rated at a median of five, which is the highest ranking on a like-it scale, following their BSOTS education, and the majority of participants rated the amount of information given during the education as appropriate, rated as three on the scale of one to five. Some rating the level of information provided as too much, however, none of the participants gave ratings to suggest there was too little or not enough, a rating of one or two. All of the participants reported that their questions had been answered during the education sessions. So qualitative data provided, following analysis, I should say, of the qualitative data, we developed four themes. The first was about quality survey data, sorry, quality education that supported learning and confidence. Staff provided a number of comments about the quality of the education, they valued the facilitator's approach, and reported that the sessions were interactive and promoted their learning for BSOTS implementation. As one staff member wrote, the facilitator was an excellent host, she made the sessions interactive, informative, and made it relatable to our hospital. The information was easy to understand and follow, and the facilitator made it very easy to understand how we would implement this in the maternity assessment centre. The second theme was about BSOTS providing a structured guide for streamlining women's care. Participants indicated that the BSOTS approach provided a structured guide to increase efficiency and ease of triage. As one participant indicated, I'm really excited that BSOTS is being implemented at the hospital, and the colour cards give an immediate visual overview of the department and need. They also noted that the approach would promote the consistency and flow of women's care. As another participant indicated, I think that BSOTS will work well and make triaging easier and more streamlined, consistent care. The third theme was the anticipated difficulties in adapting to the new systems and managing the flow of presentations. A key anticipated challenge to implementing BSOTS was ensuring that all staff adapted to the new system, especially in the context of increasing numbers of women presenting to the hospital. This was something that had been noted because it was a brand new hospital, and this was all happening during COVID as well. There was a significant increase in the number of presentations to the maternity assessment centre. Staff noted that a lack of time and willingness of other staff to modify their practice would potentially be a difficulty. They were concerned about everyone knowing and implementing the correct policies, and that the culture of doing what we have always done may be problematic. Participants also indicated the difficulty for the triage midwife to take phone calls from women at the same time as managing the women presenting in person. A few staff identified the need for a second triage midwife to answer the phone on busy shifts, and as one wrote, triage needs a second midwife to answer the phone and to round on the women who are in the waiting room. The participants also anticipated impacts on the flow of women's care as they identified delays in women being seen on time due to the volume of presentations. The fourth theme was about needing core staff and resources, which of course is not directly related to BSOTs, but this was something that the staff acknowledged in relation to BSOT's implementation. They identified the need of having core staff in the maternity assessment centre who were aware of the BSOT system to ensure effective triage of women. One participant wrote on the importance of highlighting BSOTs to clinical staff so that women have a clear understanding of priority, wait times, and what can be done in clinic or at a GP clinic rather than having to come to MAC. Another suggested the need for leaflets or banners to help women understand how they are prioritised and how long they should expect to wait. Participants repeatedly noted that the need for a senior doctor to always be present in the waiting, sorry, in the MAC, in the setting to support the flow of women for the timely medical review, as well as requiring more spaces for triage in women. As one participant said, this system will only work if there are more registrars, RMOs and midwives and rooms available to see women within expected timeframe. I'll now hand over to Vadanka to present the audit outcomes. Thanks for that, Linda, and thank you for inviting me along to present at this great event. So now I'm going to speak on the clinical audit data that was conducted using data from 688 women. However, we had to exclude 28 women from the analysis because they had important data missing from the analysis that we wanted to examine. So if you look at this table, this shows where the women presented from to the maternity assessment centre or MAC as it's known at the hospital. So the majority presented from home, followed by antenatal care and the emergency department or via ambulance. So here we can see the reason for the presentation and if you see on the left column there, we had data from 637 on this component. So missing data on a number of components was an issue and a limitation in this audit. However, we still have quite good numbers. But as you can see in this table, the majority of women were presenting to the centre for decreased fetal movement, labour assessment. So they were showing signs of labour, abdominal or back pain or spontaneous rupture of membranes. So this looks at the overall wait time for triage assessment. And the clinicians that were involved in our study did a quick internal audit in November 2020. So that was just before they implemented BSOTs. And they found that the average wait time for women to be assessed was 96 minutes. So this was within the context of peak COVID where there was reduced staffing and reduced resources. So there were quite long delays in women being assessed. And following BSOTs implementation as a result of this analysis, we found that the triage time reduced significantly to 22 minutes. So it shows that the BSOTs approach has really helped to reduce the delays in women being at least initially being assessed by somebody. So you can see here that over for half of the women are being triaged within 15 minutes. And the majority are being triaged within 30 minutes as shown by the table there. So this table looks at how long women waited from the time they entered the service to the time that they were seen by a triage midwife. So ordinarily women would not be given a BSOTs colour when they enter the service. It's not until they actually are triaged. But we were interested to see how long women were waiting for in relation to the colour they were later allocated to. So you can see that women who were allocated green, which is the lowest risk category, the majority of them were being seen within that 30 minute period and same for yellow. But if you look at the orange and red categories, which are the higher risk categories, a large proportion of those were being seen within the 15 minute timeframe, which suggests that the urgency of their situations was quickly acknowledged and they were triaged quickly as well. So the following table looks at the time to ongoing care for women. So once they'd been triaged, the next stage was for them to receive either medical or further midwifery care. And there are a number of auditable standards on which these categories are measured. And the first standard for all women who are allocated green category, the auditable standard is that 75% of women are seen within 240 minutes or 4 hours. And if you could look at the table there, about 99% of women were seen within that 4 hour period. But what's even better is for most of them, they were being seen within an hour, despite their low risk category. For women in yellow category, the auditable standard is that 75% are seen within a 60 minute period. And again, we achieved well above the standard there, with 86% of women being seen within that 60 minute timeframe. For women who are allocated orange, the auditable standard is that 75% are seen within 15 minutes. According to our data, only 57% were seen within this timeframe, which shows that there is a room for improvement there. And women allocated to the red category, the auditable standard is that all women allocated to red are seen within a 5 minute period. And there were very low numbers of women allocated to this category, but again, there's room for improvement with only 50% there. However, what I will say is after we analyse the data, there were a number of women who did not have a besots category and five of those were deemed to be red. And the reason why they weren't given a category is because they bypass triage and went straight to care. So if we added those women, the proportion of women being seen within 5 minutes would increase to about 80%. Again, it wasn't all of them, but much better outcomes as opposed to what we initially thought when we reviewed the clinical notes of the women more closely. So this data reflects data we collected from focus groups after the besots implementation had occurred. So these focus groups were conducted with nine midwifery staff who were within the triage role at the service. And the analysis of the data came up with four themes and that included quality of education. Besots provides a good guide. It promotes women-centred care and barriers to implementing besots. And I will go through these things a bit more closely now. So theme one relates to the quality of education and participants were really satisfied with the education and resources provided in preparation for besots implementation. There was some acknowledgement, however, that there would potentially be a value of a supernumerary triage midwife to help new staff in the role. So that would be an additional midwife in the triage role to support any new staff members who might not be familiar with the triage environment. So one of the staff members said, I felt like the training was pretty good, like the online stuff. And then we did a thing with the facilitator where we did some mock scenarios and putting people in groups. And for me, I actually hadn't done triage in Mac before or the maternity assessment centre, but I started doing it after doing the besots training. So it was probably helpful for me and it gave me clarity of like, okay, this is a system I can work on and this is how I do triage. Besots provides a good guide is the second theme. And all the participants suggested that the besots process and the algorithm provided an accurate and efficient way to conduct the triage of women. So it helped them to identify women who required further assessment and plan their care. And it was also particularly informative for junior staff who were new to the triage role. So this staff member said, I think it defines the roles a little bit more clearly. So you don't end up doing more than you should be doing as a triage midwife and taking up time, but you should be spending actually triaging and making the flow of care better. So you've done your besots algorithm, you've done what you can do in triage, spent your 10 minutes with the woman, you've categorized, you've handed over, and that's the end of your care. If you've got another five people waiting in the waiting room, you move on to the next one. So those strict boundaries around the role was really helpful to the staff and made them conduct the role more efficiently. So participants also suggested that the besots allowed them to make better clinical decisions and it helped them to justify the care for women. So if they were needed to speak to a medical doctor who needed to prioritize the care of a woman, they had a good kind of background to demonstrate to that staff member why this woman should be seen more quickly. They also suggested that the besots helped them to pick up issues a lot more faster that they might not necessarily have picked up had they not had the algorithms and the steps in place that the besots provides. So this staff member said, I was triaging a woman, first baby, normal pregnancy, just absolutely normal. She came in because she thought she was in labour. I was talking to her and I noticed her feet looked a little bit swollen. No issues with the baby, examined her, did her blood pressure and it was through the roof. It was so high. And then I was like, oh, that's weird. Let me recheck it again. I rechecked it four times and it was high. And so from her being what would have been over the phone conversation and initially green, she ended up being orange. To me, it just goes to show you that this woman had normal pregnancy and like she was, I think, right at the end of her pregnancy and she ended up with preeclampsia. It might have taken someone else longer to sort of establish what needs to be done. And this was a very experienced midwife and even she said it was really valuable having that structured approach to identify issues a lot sooner in women. And the third theme relates to the promotion of woman-centred care. So the staff suggested that the BSOTs allowed them to actually manage women's expectations and let them know when they should or when they hope to be seen by a further healthcare professional. So for example, this staff member said, I think sometimes it gives them a realistic expectation of what an emergency department has got to do with their care. So like I find it, if someone, if I've tried to triage someone and they agree and then sometimes I'll say, so the good news is we've categorized you as green. So we're going to care for you and we're going to do these things. But at the moment, we're not super concerned. It's up expectations where they understand that there might be a long wait to be seen and so they're less likely to get quickly frustrated. So I think that's good for them. And the final theme relates to the barriers of implementing BSOTs and some of these were highlighted in the pre-implementation education surveys where staff were concerned that the implementation would be impacted by how many staff members actually are aware of the process and actually buy into the process and avoid doing what they've always done. So one of the key issues was a lack of knowledge and education in the BSOTs and that was particularly relevant to the medical doctors not understanding what the BSOTs involves and what the different colors of prioritization of women means. The staff also spoke about the additional documentation required of BSOTs being a burden, especially as a lot of the information they put on the BSOTs forms had to also go on other hospital systems. So they felt that there was a lot of duplication of work that was unnecessary and lack of resources and staffing, which was especially relevant to the issues associated with the pandemic and difficulties in maintaining staff during that time. So one staff member said about the lack of awareness amongst other staff that there the doctors still going to the midwife in charge and saying, oh, who's next? Who's next? But I think they need to recognize, hey, actually this one's already prioritized. Like you don't recognize the colors at all. I think if you do a survey on them, which is the doctors right now and ask them about the colors, they'd probably be like, oh, not really sure what's green and what's like yellow. Like I don't think they actually understand the colors. So we also conducted a women's satisfaction survey to look at how women felt about the triage process during the implementation and the survey included 38 women. We've got the demographic information there. The majority were under 38 years of age. Most were born in Australia, followed by India, New Zealand and other countries and those stats are very reflective of the cultural groups that come to the service. We had a good mix of highest education level as identified there. The majority of women were within above 25 weeks gestation and most of them were receiving hospital-based midwifery care at the time. So these are the satisfaction ratings of the women. The majority were satisfied with the time to triage, the verbal information they received at triage, the time to treatment, the time spent in treatment and how well with dignity and respect they were treated. And overall the majority were quite satisfied with the triage process and the care that they received. There were a small number of women who identified that they were unsatisfied. However, when speaking to these women they did acknowledge that the reasons for this lack of satisfaction was associated with the poor staffing that they'd observed as a result of the pandemic and they understood that had that situation not been apparent the type of care they received might have been of better quality. So in conclusion we found that the BSOTS provides a structured framework for triaging women and staff really valued this particularly junior staff. The time to care was improved. However, there is some room for improvement particularly for women in high risk categories so the orange and red categories and again we believe that a lot of these delays were a result of the pandemic or poor recording in our data. It supports clinical decision making and the development of staff and the BSOTS helps to manage women's expectations for care so it really provides a good framework for communicating with women and letting them know how long they should expect to wait to be treated and it also makes them feel good because they receive that initial assessment. So overall we recommend that the education of BSOTS is improved amongst all clinical staff so that they are aware of the system and so that it becomes well embedded in how the service works and ensure that all resources are available to support the implementation and having dedicated staff to champion the BSOTS approach and translate the documentation onto online systems to avoid duplication which is going to occur already. I've heard next year all of these information will be translated to the online system to avoid that issue. So I'll thank you for your time and I'm happy to answer any questions if there's anyone there with Linda. Okay, thank you very much Linda and Fidanka for very, very important research and I think because we have some trouble in connection the first so we have very limited participants in our session but maybe we have still time to have some discussion maybe I have I cannot see the question in the chat box so maybe we can discuss about important point here that I notice from the presentation BSOTS can promote women's centre care so maybe you can explain a little bit more about that. Is that to me or to Linda? To me? It's up to Linda please. Yeah so it really promotes women's centre care because as I said during the presentation the BSOTS it gives the midwife a structure about it gives her an idea of how long this woman should expect to wait for her care how how urgent her care is so this helps to manage women's expectations so they can say look you've been allocated the green colour which means you're a low risk category however that means because you're low risk category you're going to wait much longer for your care and women seem to appreciate that because they know that okay I'm low risk so that makes me feel good because there's nothing you know urgently wrong with my baby but at the same time I know that I will be seen but I'll need to wait a bit longer for that and then someone who is noted a higher risk category the midwife will say okay we need to really make sure that we move on to you quickly so you receive some urgent care because we're a little bit concerned and again that helps to assure the woman that she's going to be looked after within a timely manner I think having the assessment I think having the triage assessment done within those auditable timeframes is what helps encourage that woman-centred care so every woman's being seen in an appropriate time frame and understanding the process that's going to go ahead moving forward to her care and because that they've now got two triage midwives at the busy times of the day so they have a triage midwife there 24-7 but they have a second triage midwife during the day to answer the phone calls and things so that the triage midwife that's doing the hands-on is not being taken away from that role all the time so they're really focusing on ensuring the women are being treated appropriately rather than just as we said earlier the first come first serve and therefore that's not woman-centred because it's not addressing their individual needs okay Linda there is some problem in the connection okay thank you very much for the answer and our session today so maybe I think the time is over and thank you very much again and I hope a lot of hospital will can adopted your research I think it's