The design of an Obstetric Telephone Triage Guideline (OTTG): a mixed method study

This was an exploratory sequential mixed method study in two qualitative and quantitative phases to develop and validity assessments of the guideline an inductive-deductive approach was performed to explain the concept of obstetric telephone triage. In this respect, a qualitative study and a literature review were carried out to extract the codes and convert them to the items of the OTTG. After item generation and developing the first draft of OTTG, its validity was assessed by the experts using Appraisal of Guidelines for Research and Evaluation II (AGREE II). Figure 1 shows the procedure of the study for OTTG development and validation.

The details for the procedure of the study are as follows:

The participants were 21 obstetric triage personnel and the key informants, including emergency medicine specialists, clients, gynecologists, and reproductive health specialists. The average work experience of obstetric triage personnel was 13.6 years (work experience of 3 to 28 years).

Based on the results of the qualitative phase, 124 primary codes and 35 integrated codes were extracted through the semi-structured interviews.

According to the participants’ opinion, the most significant factors influencing the use of obstetric telephone triage services were in two main categories: common complaints (27 codes) and communication (8 codes).

The common complaints category includes items such as abdominal pain, hemorrhage, hypertension, postpartum concerns, membrane rupture, suspicion of labor onset, illness/other, and decreased fetal movements. The communication category includes items such as last menstrual period, age, gestational age, number of pregnancies and parity, and obstetric and medical history. These items were included in the obstetric telephone triage guidelines. The extracted items from the qualitative interviews are listed in Table 1.

Ten items were also extracted from the review of the searched articles. In the deductive approach, otherwise, the items related to obstetric telephone triage, which were not identified in the qualitative phase, were then added to the main items. These additional items include headache with aura, headache without aura [36], severe and continuous pain after 24 weeks of gestation [28], lack of fetal movements before 20 weeks [28], lack of fetal movements between 20 and 24 weeks, pain and gestational age between 24 and 37 weeks [28], confirmed uterine pregnancy by ultrasound or unconfirmed pregnancy by ultrasound between 5 and 16 weeks [37] and mild vaginal bleeding [38, 39], dyspnea lasting less than 24 h and mild diarrhea before 16 weeks [28, 40].

Finally, the items extracted from the qualitative study (using an inductive approach) were integrated with the items extracted from the literature review (using a deductive approach) results and initial draft of the obstetric telephone triage guideline was created.

Figure 2 the components of obstetric telephone triage guidelines.

The guideline was then reviewed by experts, who prioritized the recommendations into five levels: critical, urgent, less urgent, no urgent, and recommendation. The critical level included life-saving measures for both the mother and fetus, while the other levels consisted of hospital referral within one hour, four hours, and 24 h, as well as the need for a consultation (Fig. 3).

The obstetric telephone triage guidelines included multiple levels and evaluation criteria for both the mother and fetus and were once again provided to experts for validation.

Table 2 shows the validity and quality of the developed guideline based on the AGREE II tool (Table 2). According to the experts’s opinion, the score obtained in all domains of the AGREE II tool was above 60%, so the designed guideline has a content validity.

The final validation of the guideline was carried out based on the opinions of experts in terms of applicability (93%), scientific (90%), and importance (100%).

The present study introduces an understandable, applicable, and valid guideline for obstetric telephone triage. This guideline is the first obstetric telephone triage guideline designed in Iran, which is based on the modified Emergency Severity Index (ESI) obstetric triage [41]. This guideline helps to perform obstetric telephone triage based on cause, the severity of symptoms, and treatment for pregnant women in 5 levels including Critical (life-saving measures for mother or fetus), Urgent (visit the hospital within an hour), Less Urgent (Refer to the hospital within four hours), No urgent (refer to the hospital within twenty-four hours) and Recommendations (need to consult) [41]. In a study conducted in the United States of America to develop a telephone triage of candidiasis diagnosis, Hoffstetter et al. (2012) showed that it is difficult to diagnose candidiasis using symptoms and self-report through telephone triage as well as telephone treatment in symptomatic women. However, a telephone symptom guide for the diagnosis of candidiasis increased the accuracy of treatment by telephone triage [42]. While obstetric telephone triage guidelines are intended to guide triage personnel, they should not reduce their decision-making ability or professional responsibility and should be consistent with the patient’s professional insights and preferences.

Based on a survey, providing friendly advice in telephone triage leads to mothers’ reassurance and prevention of premature delivery for childbirth [43]. In a study, Huibers et al. reported that the majority of calls responded to by triage personnel were non-urgent [44]. In a study, pregnant women often make several calls for pregnancy and childbirth counseling. Triage personnel often provide different responses that are not documented, which leads to safety problems for the caller. Therefore, it is important to develop an evidence-based process for telephone triage [45]. In a study by Wahlberg et al., triage personnel reported callers’ anger, loud voice, and disrespectful behavior. In addition, they barely listened to the triage personnel’s guidance and were ultimately dissatisfied with the call. An inaccurate understanding of the situation or exaggeration of the event disrupts triage personnel’s judgment and causes loss of information [46]. Obstetric telephone triage is a complex multifaceted process affected by different internal and external factors [27]. Having a unified national guideline on telephone triage can reduce weaknesses in management and planning.

The results of the present study showed the validity of 93%, 90%, and 100%, respecting the guideline’s applicability, scientific, and importance, respectively. In a study by Engeltjes et al., an obstetric telephone triage guideline was designed based on the Rotterdam Obstetric Triage System (ROTS) in the Netherlands. The guideline included the examination of emergency obstetric symptoms at five levels. Their results showed that 91.9% of the experts considered the tool to be complete, accurate, and user-friendly, and 98.4% of them expressed that the tool was ready to be used [28]. The results of the studies showed that the validity of The Maternal Fetal Triage Index (MFTI), the Perinatal Emergency Team Response Assessment (PETRA), and the Swiss Emergency Triage Scale (SETS), all three obstetric triage systems, were 72.9%, 80%, and 78.4%, respectively [6, 8, 47].

The validation was performed using different methods for triage guidelines. The results showed that external validity is one of the most valid methods [15]. In maternal care, developing valid obstetric triage guidelines is critical [48, 49], and that also requires training packages [50]. There is limited evidence on the implementation and evaluation of such a system [51]. A successful triage unit follows a consistent policy. All instructions should be for the management of all clients for various reasons. If providers fail to follow the guidelines or standards, difficulties in fulfilling responsibilities and risks for clients may occur [52]. The guidelines allow all triage personnel to quickly evaluate and provide services to clients. Coordinated use of protocols, guidelines, and team training are effective ways to improve the quality of the services. In all cases, the use of guidelines and timely evaluation enables team action and coordination to ensure appropriate results [53].

One of the major limitations of the present study was the lack of access to obstetric telephone triage guidelines of different countries with various healthcare systems in the world. Another limitation of the present study was the lack of consideration of the patient’s voice and cultural factors.