How was BSOTS developed?

BSOTS was originally implemented at Birmingham Women’s Hospital. A mixed methods design was selected as the best approach for evaluating the impact of the introduction of the BSOTS. The objective was to evaluate recognised features of a robust triage system as described earlier (utility, validity, reliability and safety). Both quantitative and qualitative methods were used in a balanced way to access the key aspects of the phenomenon being investigated.

Results of the evaluation:

• More women who attended triage were seen within 15 minutes
• BSOTs was relatively easy to use and the triage decisions appear to correspond with the clinical situation and improve safety
• BSOTS has high inter-rater reliability and the system results in the same prioritisation of cases (independent of the clinician performing the role) and is consistent
• Midwives felt the BSOTS training had improved both their knowledge of and confidence in using the new system on completion and three months after implementation
• 81% of units that responded to a national survey did not have a formal triage system in place based on structured clinical assessment.

View the full published paper on this evaluation of BSOTS.

Between 2015-2016 the BSOTS bundle was rolled out to three additional maternity units and implementation was evaluated by the Collaboration for Leadership and Applied Health Research and Care West Midlands (CLAHRC WM). The maternity units involved were Royal Wolverhampton (New Cross), University Hospitals of North Midlands, and Shrewsbury and Telford.

Results of the evaluation:

• Limited results regarding timings within the triage department, due to lack of a comparator, difficulties with recorded timings, and missing data
• On average 61% of women were discharged home after their triage attendance, with the majority seen over a week later, mainly for scheduled antenatal visits
• No cases of serious maternal or neonatal outcomes within 24 hours of attendance at triage
• Excellent inter-rater reliability, with no apparent difference between band level and amount of triage experience
• Midwives reported that BSOTS training had improved their knowledge and confidence

All three sites continued to use the system after completion of the evaluation as they felt it was safer and improved the organisation of the department.

In May 2017 a consensus meeting was chaired by the Director of the Birmingham Clinical Trials Unit with representatives from the RCOG, the National Maternal and Neonatal Health Safety Collaborative, PROMPT (PRactical Obstetric Multi-Professional Training in obstetric emergencies), West Midlands Clinical Networks & Clinical Senate, Warwick Business School, and service users. At the meeting it was agreed that no further evaluation was required and that the team would explore the next phases of roll-out, with increased safety for mothers, babies and clinicians being the driver.

To that end, BSOTS has been included as a safety option by the National Maternal and Neonatal Health Safety Collaborative, with its implementation supported by local maternity Clinical Networks and the West Midlands Academic Health Science Network (WMAHSN). The Royal College of Obstetricians and Gynaecologists (RCOG) and Royal College of Midwives (RCM) also support the implementation of BSOTS.

BSOTS was awarded the AHSN WM Meridian Awards for Safety and Innovation in July 2019. The West Midlands AHSN supported further implementation and supported the move to provide the training and resources remotely (on the Meridian website) 2019-2020. This was escalated by the need to provide remote training in response to the COVID 19 pandemic in 2020.

BSOTS won the Maternity and Midwifery Services Initiative of the Year and was shortlisted for the Patient Safety Innovation of the Year at the HSJ Patient Safety Awards in 2020.

The features of a robust triage system can be evaluated according to the following four criteria:

Utility

• applied by clinicians with ease
• understandable
• simple

Validity

• measures what it sets out to
• clinical urgency

Reliability

• inter-rater reliability
• consistent
• reproducible measures by independent users

Safety

• appropriate treatment
• timely treatment
• objective clinical criteria.

Triage decision-making is an inherently complex and dynamic process, with decisions made within a time sensitive environment with limited information. When a triage category is selected there are three possible outcomes:

The ability of any triage system to achieve its aims is based on the assumption that decision making is consistent over time and among clinicians who use the scale. The chances of successful implementation of this programme will in part depend on the preparation of clinicians and their understanding of the new system.