The third delay: understanding waiting time for obstetric referrals at a large regional hospital in Ghana

Abstract

BackgroundDelay in receiving care significantly contributes to maternal morbidity and mortality. Much has been studied about reducing delays prior to arrival to referral facilities, but the delays incurred upon arrival to the hospital have not been described in many low- and middle-income countries.MethodsWe report on the obstetric referral process at Ridge Regional Hospital, Accra, Ghana, the largest referral hospital in the Ghana Health System. This study uses data from a prospectively-collected cohort of 1082 women presenting with pregnancy complications over a 10-week period. To characterize which factors lead to delays in receiving care, we analyzed wait times based on reason for referral, time and day of arrival, and concurrent volume of patients in the triage area.ResultsThe findings show that 108 facilities refer patients to Ridge Regional Hospital, and 52 facilities account for 90.5% of all transfers. The most common reason for referral was fetal-pelvic size disproportion (24.3%) followed by hypertensive disorders of pregnancy (9.8%) and prior uterine scar (9.1%). The median arrival-to-evaluation (wait) time was 40 min (IQR 15–100); 206 (22%) of women were evaluated within 10 min of arrival. Factors associated with longer wait times include presenting during the night shift, being in latent labour, and having a non-time-sensitive risk factor. The median time to be evaluated was 32 min (12–80) for women with hypertensive disorders of pregnancy and 37 min (10–66) for women with obstetric hemorrhage. In addition, the wait time for women in the second stage of labour was 30 min (12–79).ConclusionsReducing delay upon arrival is imperative to improve the care at high-volume comprehensive emergency obstetric centers. Although women with time-sensitive risk factors such as hypertension, bleeding, fever, and second stage of labour were seen more quickly than the baseline population, all groups failed to be evaluated within the international standard of 10 min. This study emphasizes the need to improve hospital systems so that space and personnel are available to access high-risk pregnancy transfers rapidly.

The introduction of a midwife-led obstetric triage system into a regional referral hospital in Ghana

“…Waiting times from labour ward arrival to initial assessment also improved. Prior to the triage training, the median (IQR) patient waiting time from arrival to initial assessment was 40 (15-100) min, with a maximum wait time of 1 day 2.5 hrs (Goodman et al,2017). Following training, a review of 203 admissions between December 15-31, 2014 found that waiting times were reduced to 29 (11-60) min (p=0.007), which achieved the institutional goal of 30 min.…”

“…Data was collected from December 15 th -31 st , 2014 to determine the length of time women waited from arrival to initial assessment. This was compared to the baseline established in 2012 as reported by Goodman, et al, (2017).…”

“…During this period of time there was no increase in space or in staff numbers and the department was close to the breaking point (Srofenyoh et al, 2016). Data on waiting times were collected between September and November 2012 as part of a separate study (Goodman et al, 2017). This showed a median (IQR) waiting time from arrival to assessment of 40 (15-100) minutes with a maximum wait time of 1 day 2.5 hours.…”

Maternal critical care in resource-limited settings. Narrative review

“…49 In addition, over and above the delays before making the decision to refer, and in reach-ing the referral site, factors associated with a ''third delay", those incurred after arrival at the hospital, have been identified in a low middle-income country. 50 In response, a novel obstetric triage system has been introduced, successfully reducing the delay from arrival at the referral centre to the first assessment by a midwife. 51,52 Strategies to identify critically ill patients, enable early and appropriate management and thus prevent avoidable critical care admissions, are paramount.…”

Averting Maternal and Perinatal Mortality in Nigeria; Establishment of Obstetric Waiting Units; Targeting Uterine Rupture

“…4,16 Transportation is a challenge to women especially in rural settings where there are little or no means of transportation or access to health facilities where basic obstetric care could be given;hence, patients with ruptured uterus may end up losing both their babies and their lives. 3,4,18 Ruptured uterus may continue to be a common cause for maternal and perinatal mortality for sometime to comeif we standby and do nothing.…”