Triage Obstétrico, Código Mater y Equipo de Respuesta Inmediata Obstétrica: Lineamiento Técnico

Objectives

Reduce preventable maternal morbidity and mortality by strengthening timely, equitable and high-quality obstetric emergency care, addressing disparities in access and quality, and supporting progress towards a maternal mortality ratio of 30.0 by 2018.[1][2]The guideline establishes obstetric triage, the Maternal Code and the Immediate Obstetric Response Team (ERIO) as an integrated framework for rapid assessment, prioritisation and emergency management during pregnancy, childbirth and the puerperium.[3][4][5]

• Standardise obstetric triage as a first-contact process that classifies women by clinical severity, reported symptoms and vital signs, determines whether immediate care or safe waiting is appropriate, and directs patients to the suitable treatment area.[6][7][8]
• Prioritise life-threatening conditions through a three-level system: Red Code for emergencies requiring immediate action, Yellow Code for qualified urgency, and Green Code for non-qualified urgency.[9][10]
• Provide timely diagnosis, initial stabilisation, comprehensive treatment, referral and safe transfer for women with obstetric emergencies or relevant pre-existing, concomitant or intercurrent conditions.[11][5]
• Mobilise multidisciplinary expertise through the Maternal Code and ERIO to detect, control and treat obstetric emergencies wherever they arise in the hospital.[9][12][11]
• Improve service quality by applying homogeneous, evidence-based and context-adapted criteria; reducing waiting times and unnecessary admissions; improving communication with patients and families; and optimising available clinical and technical resources.[7][13]
• Promote prevention and continuity of maternal care through pre-pregnancy consultation, prevention of pregnancies at the extremes of reproductive age, post-obstetric-event family planning, risk-based pregnancy monitoring and specialist referral.[3]

The framework is grounded in Mexican constitutional, health-law, administrative and clinical-record provisions, alongside national standards on maternal and perinatal care, health information, emergency services, intensive care and healthcare infrastructure.[14]It also aligns with the 2013–2018 Specific Action Programmes on Maternal and Perinatal Health and on Quality and Health Education.[14]

Implementation

Implement a continuous hospital-based emergency-care model across public and private secondary- and tertiary-level obstetric services, adapting arrangements to each institution’s regulations, infrastructure, staffing, equipment and available resources.[3][7][15]Obstetric triage provides the entry point, the Maternal Code activates an alert for red-code emergencies, and ERIO delivers coordinated multidisciplinary stabilisation and support for definitive treatment or transfer.[4][12][16]

• Operate triage 24 hours a day throughout the year in a clearly signposted, adequately lit location with direct access from the waiting area and proximity to reception, emergency assessment, resuscitation and labour-and-delivery services.[13][17]
• Equip triage with basic furniture and clinical tools, including a desk, chairs, binaural stethoscope, sphygmomanometer and thermometer, and assign trained nursing, midwifery, medical or obstetric and gynaecological personnel rather than staff in training.[13][17]
• Assess patients through observation, clinical questioning and vital-sign measurement, including consciousness, haemorrhage, convulsions, breathing, skin colour, blood pressure, heart rate, shock index, respiratory rate and temperature.[18][10]
• Transfer red-code patients through immediate Maternal Code activation; personally hand yellow-code patients to responsible medical staff for care within no more than 15 minutes; and direct green-code patients to a waiting area for medical assessment within no more than 30 minutes, maintaining visual observation for reassessment or reclassification.[19][20]
• Establish an institution-specific Maternal Code activation protocol using paging, audible or visual alerts capable of notifying the multidisciplinary team in a single event, and permit designated clinical personnel to activate the alert from any hospital area.[12]
• Ensure ERIO attends within no more than three minutes after activation and continues coordinated care until the patient is stabilised and definitive management or transfer is determined.[16][18]
• Staff ERIO with administrative coordination; obstetrics and gynaecology; intensive care or anaesthesiology; neonatology or paediatrics; general surgery; nursing; laboratory; blood-bank or transfusion services; imaging; social work; and patient transport, with substitutes to cover absences and simultaneous calls.[21][22][23]
• Define role-specific actions covering obstetric diagnosis and treatment, resuscitation and organ support, anaesthesia and airway management, fetal assessment, neonatal preparation, surgery, nursing care, urgent laboratory testing, blood-component provision, imaging, family communication and transport.[22][23][16]
• Maintain clinical and operational records, including triage classification, Maternal Code activation and ERIO arrival times, assessment findings, treatments, medicines, fluids, blood products, investigations, procedures, team attendance and documented handover to the receiving service.[24][25][26][27]
• Assign state, regional, jurisdictional and hospital management to disseminate the guidance, provide training and drills, manage resources, supervise delivery, evaluate compliance and follow up implementation.[7][13][5][15]
• Monitor monthly service demand, green- and red-code proportions, triage waiting time, classification effectiveness, reclassification, handover adherence, Maternal Code activation patterns and ERIO response time; use simulations and results to identify improvement opportunities.[28][29][30][31]

Implementation does not specify budgets, unit costs, financing sources, funding gaps or economic assumptions, but requires hospitals to plan and manage the necessary human resources, physical space, supplies, emergency equipment and alert systems within their available capacity.[17][12][21]

Monitoring & Evaluation

Monitoring combines outcome surveillance for maternal mortality with operational, quality and timeliness measures for obstetric triage, Código Mater and the Immediate Obstetric Response Team (ERIO). The maternal mortality ratio fell from 89.0 in 1990 to 38.9 in 2014, with a projected value of 30.0 for 2018.[2]Historical monitoring draws on the National Institute of Statistics and Geography, the Ministry of Health’s General Directorate of Health Information, preliminary epidemiological information and corrected registered-birth calculations.[1][2]

• Monitor maternal mortality and its principal causes, which in 2014 included indirect obstetric causes, hypertensive disease of pregnancy, other direct obstetric causes, haemorrhage and abortion.[2]
• Use administrative control, supervisory activity and evaluation criteria to assure the quality of triage actions and compliance with operational objectives.[4]State, regional, jurisdictional and hospital management personnel are responsible for dissemination, supervision, evaluation and follow-up within their areas of responsibility.[7][13]
• Record every triage assessment on the designated form, incorporate it into the clinical record and document interventions in control censuses.[19]Record Código Mater activation, ERIO integration, the activation area, patient details, interventions, medicines, solutions, blood products, investigations, participating personnel and handover details.[24][25][26]
• Maintain clinical records containing relevant patient and health-personnel entries, records, attestations and certifications in the required formats.[32]Document ERIO activities in logs or specific reports and include the ERIO intervention form in the clinical record.[22]
• Reassess patients not initially identified as life-threatening, including continued visual observation and reclassification of green-code patients where necessary.[13][19]Use reclassification results to improve staff training and the obstetric triage process.[30]
• Monitor monthly emergency-service demand through the average number of obstetric patients treated per hour; the stated threshold for considering establishment of obstetric triage is more than five patients.[28]
• Measure monthly the proportion of green-code patients, using green-code attendances divided by total emergency attendances multiplied by 100, against a stated baseline below 85%.[28]Measure the proportion of red-code obstetric emergencies monthly, using red-code attendances divided by total attendances multiplied by 100, against a stated baseline of 2%.[29]
• Monitor monthly average obstetric triage waiting time, calculated as total waiting minutes divided by attendances, against a stated baseline below 15 minutes.[29]Monitor classification effectiveness monthly by comparing ERIO-confirmed emergencies with patients classified as red code in triage, against a stated baseline of 100%.[29]
• Measure monthly the percentage of patients reclassified from green to red, with a stated baseline of 0%, and monthly adherence to the handover protocol, with a stated baseline of 100%.[30]
• Monitor monthly Código Mater activations as a proportion of patients treated in obstetric emergency and hospitalisation services, with a stated baseline of 2%, and monitor their distribution by care area, with stated baselines of 90% in emergency services and 10% in other hospital areas.[30][31]
• Monitor the monthly average ERIO response time from Código Mater activation to full team integration, with a stated baseline of three minutes.[31]The operational process also requires the team to arrive within no more than three minutes after activation.[16]
• Use emergency-service registers of pregnant patients, the Automated Hospital Discharge Subsystem for Código Mater data, and records maintained by the ERIO coordinator and administrative nurse as indicator data sources.[30][31]Conduct regular simulations to identify improvement opportunities and support continuous improvement.[5]

The material defines indicators and standards as tools for identifying deviations, assessing quality and judging sustained successful practice.[32]It does not specify complete calculation methods or targets for every indicator, a unified reporting hierarchy, audit schedule, sanctions, independent accountability mechanism or broader surveillance system.[4][5][15]

Costing & Financing

No explicit budget, costing methodology, unit cost, financing allocation, funding source, funding gap, resource-mobilisation target or economic assumption is provided for obstetric triage, Código Mater or ERIO implementation.[3][15][21]

• Plan and manage implementation within each institution’s regulatory framework, infrastructure, equipment, staffing and general resource capacity.[7][17]
• Provide physical and material inputs for triage, including an appropriately located and signposted area, a desk, chairs, binaural stethoscope, sphygmomanometer and thermometer.[17]
• Maintain alert and emergency-response capability through paging, audible or visual alert systems, emergency-area equipment, a resuscitation trolley and a red emergency box.[12][21]
• Ensure availability of trained multidisciplinary personnel, supplies, medicines, solutions, dressings, blood components, laboratory services, imaging and patient transport, without assigning monetary values to these requirements.[21][22][23][16]
• Optimise available technical and medical resources during high demand or scarcity, while adapting local arrangements to avoid duplicated triage functions.[3][33]

Accordingly, the source identifies resource requirements and institutional management responsibilities but does not quantify the financial resources needed to establish, operate, train or monitor these services.[17][19]