Exploring the third delay: an audit evaluating obstetric triage at Mulago National Referral Hospital

Jennifer Forshaw, Stephanie Raybould, Emilie Lewis, Mark Muyingo, Andrew Weeks, Kate Reed, Logan
Manikam and Josaphat Byamugisha
Background:
The World Health Organization Maternal Mortality Rate Ration (MMR) is 310 per 100,000 live births
compared to United Kingdom’s MMR of 12 per 100,000. In 2011, the MMR of Mulago Hospital was 576 per
100,000 which are higher than the national average. The Eleanor Bradley Fellowships who are British
obstetricians are selected to work at the said hospital for 1 year. British OB in collaboration with the Mulago
Specialists developed and “Traffic Light System” which identifies who should review the patient and
“Manchester Triage System” is used to recommend time frame of the assessment. This was introduced to the
Mulago Hospital labor ward.
Aim:
After two (2) years of its implementation, the study aims to:
1. Determine the timeframe of patient from entry to the Emergency department to HCP assessment.
2. Identify common delays and its consequences.
3. Identify if the tool was used consistently; it is appropriate to the department and to identify problems of
the tool and its implementation.
4. Compare timeframe when tools are used.
5. To identify and evaluate other strategies that allows some women to be prioritized than others.
6. Provide method in re-auditing triage system.
7. To follow up on the Mulago Hospital’s Maternity Department’s recommendations following presentation
of the audit results.
Methods:
A prospective audit of the obstetric admissions department was carried out at the Mulago Hospital.
Data were obtained from tagged patient journeys using two data collection tools and compiled using
Microsoft Excel. StatsDirect was used to compose graphs to illustrate the results.
Results:
a. Demographics
64% of the patient received antenatal care, 29% presented with no prior antenatal care and 7% were
referred abnormal presentation and complains of labor pains.
b. Timing
The longest waiting time period was between entries to the department until at the desk where
patient files are created with an average length time of 192 minutes. Timeframe took longer at night
between 8pm to 8am with the longest waiting time at 6am to 7am.
c. Triage
46% of the patient was informally triaged. Green was commonly group followed by yellow, red and
blue.
d. Observation
The most common vital signs taken were blood pressure in 47% of patient; FHT was auscultated 55%
of the time.
e. Effect of known delays
There were 33% of delays during the process and 70% were due to lack of staff.
f. Management in the assessment room.
Most common management given wan conduction of Urinalysis, giving of oxytocin and artificial
rupture of membranes.

Conclusion:
It is hypothesized that the ‘Traffic Light System’ is not being used due to its focus on examination finding and
diagnosis, implying that it is not suitable for an early stage in the patient’s journey. Replacing it with a simple
algorithm to categories women into the urgency with which they need to be seen could rectify this.