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Acuity Assessment in Obstetrical Triage

Article  in  Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC · February 2016
DOI: 10.1016/j.jogc.2015.12.010

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Acuity Assessment in Obstetrical Triage
Robert J. Gratton, MD,1,2 Neila Bazaracai, BMSc,1 Ian Cameron, BMSc,1
Nancy Watts, RN, MN, PNC(C),3 Colleen Brayman, RN, BScN,4 Gregg Hancock, MD,5
Rachel Twohey, MET,2 Suhair AlShanteer, MD, MBBS, MScHIS,2 Jennifer E. Ryder, MHS,1
Kathryn Wodrich, BScN,2 Emily Williams, BScN,2 Amélie Guay, RN, MSc,6
Melanie Basso, RN, MSN, PNC(C),7 David S. Smithson, MD8
1
Department of Obstetrics & Gynaecology, Schulich School of Medicine & Dentistry, University of Western Ontario, London ON
2
London Health Sciences Centre, London ON
3
Mount Sinai Hospital, Toronto ON
4
Canadian Triage and Acuity Scale National Working Group, Interior Health Authority, Kelowna BC
5
Stratford General Hospital, Stratford ON
6
McGill University Health Centre, Glen Site, Montreal QC
7
BC Women’s Hospital and Health Centre, Vancouver BC
8
Division of Reproductive Medicine, Department of Obstetrics & Gynecology, University of Ottawa, Ottawa ON
Abstract
Objective: A five-category Obstetrical Triage Acuity Scale (OTAS)
was developed with a comprehensive set of obstetrical
determinants. The purposes of this study were: (1) to compare the
inter-rater reliability (IRR) in tertiary and community hospital
settings and measure the intra-rater reliability (ITR) of OTAS; (2)
to establish the validity of OTAS; and (3) to present the first
revision of OTAS from the National Obstetrical Triage Working
Group.
Methods: To assess IRR, obstetrical triage nurses were randomly
selected from London Health Sciences Centre (LHSC) (n ¼ 8),
Stratford General Hospital (n ¼ 11), and Chatham General
Hospital (n¼ 7) to assign acuity levels to clinical scenarios
based on actual patient visits. At LHSC, a group of nurses
were retested at nine months to measure ITR. To assess
validity, OTAS acuity level was correlated with measures of
resource utilization.
Results: OTAS has significant and comparable IRR in a tertiary care
hospital and in two community hospitals. Repeat assessment in a
cohort of nurses demonstrated significant ITR. Acuity level
correlated significantly with performance of routine and second
order laboratory investigations, point of care ultrasound, nursing
work load, and health care provider attendance. A National
Obstetrical Triage Working Group was formed and guided the
first revision. Four acuity modifiers were added based on
hemodynamics, respiratory distress, cervical dilatation, and fetal
well-being.
Key Words: Obstetrical triage, reliability, validity
Competing interests: None declared.
Received on August 17, 2015
Accepted on October 9, 2015
http://dx.doi.org/10.1016/j.jogc.2015.12.010
OBSTETRICS
Conclusion: OTAS is the first obstetrical triage scale with
established reliability and validity. OTAS enables standardized
assessments of acuity within and across institutions. Further, it
facilitates assessment of patient care and flow based on
acuity.
Résumé
Objectif : Une échelle d’acuité du triage en obstétrique (EATO) selon
cinq catégories a été conçue au moyen d’un ensemble exhaustif
de déterminants obstétricaux. Cette étude avait les objectifs
suivants : (1) comparer la fiabilité inter-évaluateurs (FIE) dans
des milieux hospitaliers tertiaires et communautaires, et mesurer
la fiabilité intra-évaluateur (FIT) en ce qui concerne l’EATO; (2)
établir la validité de l’EATO; et (3) présenter la première révision
de l’EATO issue du groupe de travail national sur le triage en
obstétrique.
Méthodes : Pour évaluer la FIE, des infirmières affectées au triage
en obstétrique ont été sélectionnées au hasard au sein du
London Health Sciences Centre (LHSC) (n ¼ 8), du Stratford
General Hospital (n ¼ 11) et du Chatham General Hospital
(n ¼ 7), et nous leur avons demandé d’attribuer des degrés
d’acuité à des scénarios cliniques fondés sur de réelles
consultations de patientes. Au LHSC, un groupe d’infirmières
ont été testées à nouveau neuf mois plus tard aux fins de la
mesure de la FIT. Pour évaluer la validité de l’EATO, le degré
d’acuité de celle-ci a été mis en corrélation avec des mesures
d’utilisation des ressources.
Résultats : L’EATO compte une FIE significative et comparable au
sein d’un hôpital de soins tertiaires et des deux hôpitaux
communautaires. La tenue d’une deuxième évaluation au sein
d’une cohorte d’infirmières nous a permis de constater une FIT
significative. Le degré d’acuité présentait une corrélation
significative avec la tenue systématique et de deuxième ordre
de tests de laboratoire et d’une échographie au point
d’intervention, ainsi qu’avec la charge de travail des services
infirmiers et la présence du fournisseur de soins. Un groupe de
travail national sur le triage en obstétrique a été formé et a
orienté la première révision de l’EATO. Quatre modificateurs de
FEBRUARY JOGC FÉVRIER 2016 l 125
OBSTETRICS

l’acuité (fondés sur l’hémodynamique, la détresse respiratoire,
la dilatation cervicale et le bien-être fœtal) ont été ajoutés.
Conclusion : L’EATO est la première échelle de triage en obstétrique à
compter une fiabilité et une validité établies. Elle permet la tenue
d’évaluations standardisées de l’acuité au sein d’un même
établissement et d’un établissement à l’autre. De surcroît, elle
facilite l’évaluation des soins offerts aux patientes et celle de leur
cheminement, en fonction de l’acuité.
Copyright ª 2016 The Society of Obstetricians and Gynaecologists of
Canada/La Société des obstétriciens et gynécologues du Canada.
Published by Elsevier Inc. All rights reserved.
J Obstet Gynaecol Can 2016;38(2):125-133
INTRODUCTION
and implemented the Obstetrical Triage Acuity Scale, a
five-category (1-resusitative, 2-emergent, 3-urgent, 4-less
urgent, 5-nonurgent) triage acuity scale with a complete
set of obstetrical determinants.
In our initial study we demonstrated that OTAS had
excellent inter-rater reliability in a tertiary care centre.2,3,8 In
addition, OTAS acuity level correlated with rates of hospital
admission. The purposes of this study were: (1) to compare
the IRR in tertiary and community hospital settings and
measure the intra-rater reliability of OTAS, (2) to establish
the validity by correlating acuity with a number of measures
of resource utilization, and (3) to present the first revision of
OTAS based on consensus input from the National
Obstetrical Triage Working Group.

T riage is the process of sorting patients into those who

need evaluation and treatment urgently and those who
can safely wait. Triage acuity scales such as the Canadian
METHODS

Three obstetrical triage units in Southwestern Ontario were

Triage Acuity Scale,1e3 the Emergency Severity Index,4
involved in assessing the IRR and ITR of the newly devel-
and the Manchester Triage System5 have been widely
oped OTAS triage scale. LHSC is a tertiary care centre with
implemented in emergency departments to address access
approximately 11500 triage visits yearly (approximately
to care, wait times, and resource allocation.1,5 These acuity
5800 births/year). This obstetrical triage unit provides
scales have been extensively studied to establish their
urgent and emergency care for pregnant women beyond 20
reliability and validity for a wide spectrum of patient pre-
weeks’ gestation. Patients come for care from the local area,
sentations.4e7 In reviewing these scales, there is limited
and tertiary referrals come from the southwest region of
application to obstetrical triage because the acuity de-
Ontario. The standardized assessment of acuity using
terminants do not reflect the diversity of obstetrical pre-
OTAS was implemented on April 1, 2012. The imple-
sentations or the specialized triage needs of obstetrical
mentation was guided by staff education, written practice
patients. In CTAS, triage is based on the patient’s pre-
cases, and a group of triage nurses designated as “OTAS
senting complaint (complaint-oriented triage), but there are
champions.” Compliance in assigning acuity was over 90%.8
only seven high-acuity obstetrical presentations.3 Similarly,
The community hospitals, Stratford General Hospital with
the ESI,4 used in the United States, and the Manchester
3600 triage visits per year (approximately 1200 births/year)
Triage System5 from the United Kingdom also were found
and Chatham General Hospital with 1300 triage visits per
to have a limited number of obstetrical determinants.
year (approximately 913 births/year), implemented OTAS
Based on this review of existing scales, the need for a more
in their obstetrical triage units on January 1, 2014, and
specialized obstetrical triage scale was identified. At
November 1, 2014, respectively.
London Health Sciences Centre, the authors developed
To assess reliability, obstetrical triage nurses were randomly
selected six to eight weeks after implementation at each
ABBREVIATIONS
obstetrical triage unit (LHSC, SGH, and CGH) to partici-
pate in the evaluation of OTAS. These nurses used the
CAPWHN Canadian Association of Perinatal and Women’s
Health Nurses OTAS tool to assign triage levels to written clinical scenarios
CGH Chatham General Hospital
that were based on actual patient visits. These scenarios
CTAS Canadian Triage Acuity Scale
were created from patient visits during randomly selected
four-hour time blocks (two per day) from June 1, 2011, to
ESI Emergency Severity Index
January 31, 2012, at LHSC. The short vignettes contained
IRR inter-rater reliability
the initial set of patient medical information that would be
ITR intra-rater reliability
available to an obstetrical triage nurse, and the acuity level
LHSC London Health Sciences Centre was determined. The acuity assignment was entered into an
MEOWS Modified Early Obstetric Warning System online questionnaire using Survey Monkey. The IRR was
OTAS Obstetrical Triage Acuity Scale measured using the direct correlation coefficient and Fleiss’s
SGC Stratford General Hospital Kappa correlation to account for multiple raters, multiple

126 l FEBRUARY JOGC FÉVRIER 2016


categories, and similar classification by chance alone. A
calculated sample size of 110 scenarios was based on a
confidence interval of 95% and eight raters.9 The IRR at
LHSC was compared with that at SGH and CGH using
attribute agreement analysis. At LHSC two years after
implementation, a second group of nurses completed the
assessment of acuity; the same nurses repeated the assess-
ment nine months later, and the ITR was determined by the
test-retest reliability.
In our previous study,8 we reported the rates of admission to
the antenatal unit and birthing unit after a retrospective
assignment of an OTAS level. In this study, the relationship
between OTAS level and measures of resource utilization at
LHSC was examined prospectively. We reviewed 489
randomly selected charts from between January 1 and
December 31, 2013, and three representative measures of
laboratory and investigative resources were assessed. From
the chart review, the frequency of routine laboratory in-
vestigations (complete blood count, blood group and type);
second order laboratory investigations (serum aspartate
transaminase, alanine transaminase, creatinine, international
normalized ratio partial thromboplastin time, and fetal
fibronectin); and of the use of point of care ultrasound was
determined. To further establish the validity, OTAS level
was correlated with two measures of care provider work-
load. First, the triage nurses documented an assessment of
the time and complexity of the triage care required. The
criteria for an intensive assessment/observation were (1)
maternal vital signs every 15 minutes or more, (2) initiation
and maintenance of an intravenous line and/or adminis-
tration of intramuscular medications, (3) drawing of blood
for investigation, and (4) continuous fetal heart rate
assessment. This metric captured the most complex care
provided and was correlated with high, intermediate, and
low OTAS acuity. Second, depending on the reason for the
triage visit, the physician or midwife (health care provider)
may receive a report from the triage nurses and physically
attend to the women in triage, or they may develop a
management plan and communicate this by telephone to the
Table 1. Inter-rater reliability following implementation at three hospitals
LHSC (n ¼ 8)8
Site Direct Correlation Fleiss’s Kappa Direct Correlation
OTAS 1 0.88 0.77 1.00
OTAS 2 0.84 0.73 0.81
OTAS 3 0.75 0.61 0.68
OTAS 4 0.75 0.65 0.74
OTAS 5 0.83 0.87 0.86
OVERALL 0.79 0.71 0.78
Acuity Assessment in Obstetrical Triage
triage nurse without physically attending the patient in triage.
Attendance of the health care provider in triage was corre-
lated with acuity. Chi-square analysis was used to determine
the significance of the association between high acuity
(OTAS 1,2), intermediate acuity (OTAS 3), and lower acuity
(OTAS 4,5) and the metrics of resource utilization.
Fisher exact test was used to assess the relationship
between intensive observation/assessment and acuity. The
Cochran-Armitage test was used to test for trends in the
proportions across the levels of acuity.
An Obstetrical Triage Symposium was held on June 7, 2013,
and obstetrical care providers and administrators from
community hospitals were invited to attend. The LHSC
triage group conducted site visits and produced an
“Implementation Tool Kit.” Following implementation of
the OTAS at LHSC and the Obstetrical Triage Symposium,
a webinar was hosted by the Canadian Association of
Perinatal and Women’s Health Nurses on December 2,
2013. From among the participants, a National Obstetrical
Triage Working Group was formed. Monthly teleconfer-
ences were held and a face-to-face meeting was held at the
CAPWHN meeting on October 23, 2014. Broad input was
sought, and suggested amendments were reviewed and
discussed to make revisions to the OTAS tool.
Ethics approval for the study was provided by the Western
University Research Ethics Board.
RESULTS
The IRR was calculated using both the direct correlation
coefficient and the Fleiss’s Kappa correlation. The initial
IRR at implementation at the three hospitals is shown in
Table 1. There was no significant difference in the overall
IRR in the tertiary (LHSC: direct correlation 0.79, Fleiss’s
Kappa 0.71)8 and community hospitals (SGH: 0.78, 0.70;
CGH: 0.77, 0.69). In all hospitals the overall IRR was
“substantial” (Fleiss’s Kappa 0.61 to 0.80).10 The overall
IRR for all 33 nurses (LHSC: 8 in 2012, 7 in 2014; SGH:
SGH (n ¼ 11) CGH (n ¼ 7)
Fleiss’s Kappa Direct Correlation Fleiss’s Kappa
0.64 0.86 0.81
0.68 0.85 0.69
0.61 0.71 0.55
0.66 0.66 0.61
0.83 0.90 0.88
0.70 0.77 0.69
FEBRUARY JOGC FÉVRIER 2016 l 127
OBSTETRICS
11; CGH: 7) who assigned acuity to the 110 clinical vi-
gnettes was 0.77 (Fleiss’s Kappa 0.69).
Seven nurses completed the acuity assessment and their
individual results were compared with a repeat assessment
nine months later. There was no significant difference in
the IRR between initial assessment (direct correlation 0.74,
Fleiss’s Kappa 0.65) and assessment nine months later
(0.75, 0.66). The ITR for each of the seven nurses was
assessed by determining the test-retest reliability, and the
correlation was high (Pearson correlation coefficient 0.80).
Figure 1. Correlation between higher acuity levels and
routine laboratory investigations (A), second order
laboratory investigations (B), and the performance of point
of care ultrasound (C)
128 l FEBRUARY JOGC FÉVRIER 2016
At LHSC there was a significant relationship between
acuity and routine laboratory investigations (c2 ¼ 31.6,
P < 0.001) with a decrease in investigations from high
acuity (OTAS 1,2) to intermediate acuity (OTAS 3) and
low acuity (OTAS 4,5) (Cochran-Armitage trend test:
P < 0.001) (Figure 1A). There also was a significant rela-
tionship between acuity and second order investigations
(c2 ¼ 13.2, P ¼ 0.001) with a decrease in investigations
from high acuity (OTAS 1,2) and intermediate acuity
(OTAS 3) to low acuity (OTAS 4,5) (P ¼ 0.007)
(Figure 1B). There was a significant relationship between
acuity and point of care ultrasound (c2 ¼ 12.2, P ¼ 0.002)
with a decrease in investigations from high acuity (OTAS
1,2) to intermediate acuity (OTAS 3) and low acuity
(OTAS 4,5) (P < 0.001) (Figure 1C).
There also was a significant relationship between acuity and
intensive observation/assessment (Fisher’s exact test, P ¼
0.002) with a decrease from high acuity (OTAS 1,2) to
intermediate acuity (OTAS 3) and low acuity (OTAS 4,5)
(P < 0.001) (Figure 2A) and a significant relationship be-
tween acuity and health care provider attendance (c2 ¼
26.9, P < 0.001) with a decrease from high acuity (OTAS
1,2) to intermediate acuity (OTAS 3) and low acuity
(OTAS 4,5) (P < 0.001) (Figure 2B).
Figure 2. Correlation between the nursing work load
assignment of “intensive observation/assessment” (A)
and health care provider attendance and acuity (B)
 Acuity Assessment in Obstetrical Triage
Figure 3. National Triage Working Group revised OTAS tool
FEBRUARY JOGC FÉVRIER 2016 l 129
OBSTETRICS
Figure 4. OTAS acuity modifiers
After the CAPWHN meeting in October 2014, input was
sought for amendments to the OTAS tool, and the CTAS
National Working Group provided input to ensure align-
ment in overlapping presenting complaints (e.g., the cate-
gory “respiratory complaints” is in both OTAS and CTAS).
The colour coding for acuity levels was revised in keeping
with the modifications made in CTAS.11 The complaint list
from the original OTAS tool was further organized into
categories to include pain, abdominal trauma, and signs of
infection (Figure 3). Substance use and mental health
complaints also were added. The final modification was the
addition of four acuity modifiers (hemodynamic stability,
respiratory distress, fetal well-being, and cervical dilatation)
(Figure 4). The use of acuity modifiers is consistent with the
CTAS tool. Modifiers are used to support or increase the
acuity level from that which would be assigned based on the
complaint alone. Because vital signs are an important
parameter in determining acuity, the CTAS modifiers of
hemodynamic stability and respiratory distress were added
to OTAS. The descriptive criteria for the modifiers
(i.e., shock; hemodynamic compromise; and mild, moder-
ate, and severe respiratory distress) were added from
CTAS3,11 (Table 2, Figure 4). In addition, vital sign
parameters specific to pregnancy were added to OTAS. The
vital sign parameters (Figure 4) were taken from the
Maternal Early Warning Criteria11,12 and the Modified
130 l FEBRUARY JOGC FÉVRIER 2016
Early Obstetric Warning System.13 Either the descriptive
modifier (shock) or the specific vital signs (systolic blood
pressure < 90 mm Hg, heart rate > 120 beats/minute)
may be used to increase the acuity. Two modifiers unique
to pregnancy assessment were added. Assessment of
cervical dilatation and fetal well-being (atypical/abnormal
fetal heart rate, meconium staining of the amniotic fluid)
also may be used to support or increase the acuity level
(see Figure 4).
DISCUSSION
Obstetrical triage units face many of the same problems as
emergency departments, with overcrowding, prolonged wait
times, and limited resources. The development of several
triage acuity scales in emergency departments has led to
standardization of care and better use of resources when
determining which patients must be assessed urgently and
which can safely wait.1-5 Even though obstetrical triage units
have been widely implemented over the last 10 to 15 years,
they have been largely used as pre-labour assessment
areas.14 More recently, changes in practice have led to
pregnant women with a wide spectrum of urgent and non-
urgent complaints being assessed in obstetrical triage units.
Triage acuity scales, such as CTAS1e3 (widely implemented
in Canadian emergency departments), the ESI4 (United
 Acuity Assessment in Obstetrical Triage

Table 2. Signs of hemodynamic instability and respiratory distress3

Definitions and Information
Hemodynamic stability Shock: Evidence of severe end-organ hypoperfusion: marked pallor, cool skin, diaphoresis, weak or thready
pulse, hypotension, postural syncope, significant tachycardia or bradycardia, ineffective ventilation or
oxygenation, decreased level of consciousness
Hemodynamic compromise: Evidence of borderline perfusion, pale, history of diaphoresis, unexplained
tachycardia, postural hypotension (by history), or suspected hypotension (lower-than-normal blood pressure or
expected blood pressure for a given patient)
Vital signs at the upper and lower ends of normal as they relate to the presenting complaint, especially if they
differ from the usual values for the specific patient
Respiratory distress Severe: Cyanosis, lethargic or confused, fatigue from increased work of breathing, oxygen saturation < 95%
Moderate: Increased work of breathing, significant or worsening stridor
Mild: Dyspnea, tachypnea, shortness of breath with exertion

States), and the Manchester Scale5 (United Kingdom), have
a limited number of obstetrical determinants. Paisley et al.15
published a descriptive study of the implementation of the
Florida Hospital Obstetric Triage Acuity Tool in four hos-
pitals; however, no performance measures of the scale were
reported. Angelini and Howard stated that a valid and
reliable obstetric triage tool “is needed to promote timely
and appropriate care for the pregnant woman and her
fetus.”16
OTAS was developed based on the five-category CTAS
tool. It includes a comprehensive set of obstetrical pre-
senting complaints organized by categories of signs and
symptoms. Within each category, the criteria for acuity
levels 1 to 5 were developed by an expert review panel
comprising LHSC physicians and nurses (see Figure 3).
The suggested response times from CTAS (time to initial
assessment, time to health care practitioner attendance)
for each of the five acuity levels were added to the OTAS
tool.
In our initial study, we showed that OTAS had significant
IRR in a tertiary care centre (8 nurses tested), and acuity
correlated with hospital admission.8 In this study, we
extended the initial findings by presenting a thorough study
of reliability and validity of the OTAS triage scale. This is
the first study to compare the IRR between tertiary and
community hospitals and to measure the ITR of an
obstetrical acuity scale. A total of 33 nurses from both
tertiary care and community hospitals completed the
assignment of acuity. The IRR was substantial in both
tertiary care and community hospitals, and OTAS per-
formed equally well in both tertiary care and community
settings. The ITR also was significant. In studies of acuity
scales, acuity is often correlated with measures of resource
utilization.7,17 The OTAS acuity level correlated well with
the performance of routine laboratory investigations. With
increasing acuity level, there was an increase in the
performance of tests to measure renal and hepatic function
and coagulation profiles and in the assessment of the risk
of preterm labour (using fetal fibronectin). High and in-
termediate acuity was correlated with increased point of
care ultrasound assessment. OTAS also correlated with
nursing work load (intensive observation/assessment) and
attendance of the primary health care provider. In sum-
mary, OTAS shows significant reliability, both inter-rater
and intra-rater, and performs similarly in tertiary care
and community hospital settings. OTAS correlates with a
number of measures of resource utilization and hospital
admission rates.8 Based on these findings, we believe that
OTAS is the first standardized obstetrical acuity scale with
established reliability and validity.
A National Obstetrical Triage Working Group was formed
to facilitate regional and national implementation, establish
national research priorities, and guide the continued
refinement of OTAS to meet the needs of obstetrical triage
units across the country. Similar to the CTAS National
Working Group, which has implemented several revisions
to make the triage process more standardized and objec-
tive,2,3,18 the members of this group sought national input
to revise the scale. All changes were made by consensus to
preserve the standardized assessment of acuity. This
commitment to using a common and standardized version
of the OTAS enables comparative studies of patient care
and flow among participating institutions. The CTAS
National Working Group co-chair also helped significantly
in guiding the first revision, which was finalized in January
2015 (see Figures 3 and 4). Colour coding, wording, and
organizational changes were made to align the format with
the most recent version of the CTAS tool.
CTAS has developed many modifiers that are used to
enhance the accuracy of the acuity assignment beyond that
based solely on the patient’s primary complaint. Hemo-
dynamic stability and respiratory distress are two of the

FEBRUARY JOGC FÉVRIER 2016 l 131

OBSTETRICS
CTAS modifiers that are applicable across many pre-
sentations and allow the initial acuity level to be supported
or increased. The National Obstetrical Triage Working
Group agreed that the assessment of the vital signs would
similarly improve the accuracy of acuity assessment in the
obstetrical patients. These two modifiers, along with cer-
vical dilatation and fetal well-being, were added to meet the
needs of the obstetrical triage population.
The descriptive criteria for the hemodynamic stability and
respiratory distress modifiers used in CTAS (see Table 2)
were used, but it was agreed that specific pregnancy pa-
rameters also should be included. The Maternal Early
Warning Criteria were developed to “facilitate timely
recognition, diagnosis and treatment” for women devel-
oping critical illness in pregnancy.12 A second tool, the
MEOWS, also was identified as a bedside screening tool to
predict maternal mortality.13 The abnormal vital sign
parameters for the OTAS modifiers were adapted from
both of these tools and were incorporated into the
hemodynamic stability and respiratory distress modifiers to
increase the ability to accurately assess acuity (see Table 2).
The fetal well-being modifier includes criteria for abnormal
auscultation only (fetal heart rate <110 or >160) and for
continuous fetal heart rate monitoring. The modifier does
not suggest that a routine monitor strip should be completed
in triage. The indication for auscultation or a monitoring
strip should follow the Fetal Health Surveillance Guidelines
for cardiotocography on admission.19 A course for OTAS
instructors and care providers has been developed to guide
implementation and the use of the modifiers.
The OTAS tool is limited by the suggested response times
for primary and health care provider assessment. As in
CTAS, these times are ideal objectives based on expert
panel consensus and are not established care standards.
These suggested time frames based on acuity have been
carried over from CTAS and were established with a pa-
tient focus (what most of us would want for family
members or ourselves) and the need for timely interven-
tion to improve outcome.3,11,18 We recognize that there
may be multiple demands placed on care providers’ time
and that there are wide variations in patient care demands.
The “ideal time frames” cannot always be successfully
achieved without unlimited resources.
A limitation of this study is that the measurement of
reliability is based on written vignettes and not real-
time triage assessments. Even though real-time assess-
ment of OTAS level by two nurses may be possible,
this methodology in multiple centres with the required
increase in sample size renders this approach unfeasi-
ble. Previous studies comparing written vignettes and
132 l FEBRUARY JOGC FÉVRIER 2016
real-time assessments have shown good agreement in
measuring reliability.20 Finally, OTAS was designed for
acuity assessment in pregnant women at 20 weeks’
gestation or more. Some obstetrical triage units also
provide care for postpartum patients and patients with
some pregnancy complications at less than 20 weeks. To
facilitate the use of OTAS in these triage units, a post-
partum module and a “12 to 20 week” module have been
developed and can be added to the OTAS tool.
CONCLUSION
OTAS was developed with a comprehensive set of
obstetrical and maternal health determinants. We have
demonstrated that OTAS has significant and comparable
IRR in a tertiary care and two community hospitals. In
addition, repeat assessment in a cohort of nurses showed
significant ITR. Acuity level OTAS 1 to 5 correlated
significantly with measures of resource utilization,
including the performance of routine and second order
laboratory investigations and point of care ultrasound.
OTAS acuity also correlated with measurement of nursing
work load and attendance of health care provider. A Na-
tional Obstetrical Triage Working Group guided the first
revision of OTAS. Four acuity modifiers were added to
enhance the accuracy of the acuity assessment. Standard-
ized assessment of acuity with OTAS prioritizes patient
care and enables assessment of resource requirements and
quality of care based on acuity. We believe that OTAS has
potential for wide application in obstetrical triage units and
emergency departments that provide urgent care for
pregnant women.
ACKNOWLEDGEMENTS
Financial support for the study was provided by the
Academic Medical Organization of Southwestern Ontario’s
Innovation Fund.
We thank Michelle Harding, Deborah Wiseman, Erin
Musgrave, Nancy White, Jill Cousins, Dr. Michael Bullard,
and the National Obstetrical Triage Working Group for
their input and Laura McMurphy for technical assistance.
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