GRACE is the real-time surge operations platform for Labor & Delivery. Weighted acuity, AWHONN-aligned staffing, AI shift intelligence, predictive alerts, and EHR integration — in one shared picture — so your team names the level, pulls the right lever, and documents the surge as it happens.
Why GRACE
L&D surges on a different clock than the rest of the hospital. GRACE is designed for that clock — not for month-end census reports.
One shared state across the charge desk, manager's office, and on-call phone. Room occupancy, acuity scores, AWHONN compliance, and surge level sync automatically — no save-and-refresh, no parallel spreadsheets.
Each room's acuity sums weighted clinical factors from the published staffing literature; nurse capacity is checked against AWHONN 2022 ratios every refresh. When ratios slip, GRACE shows the deficit in RNs, not vibes.
Surge-level changes, critical rooms, rescue events, and staffing-forecast gaps are logged, timestamped, and routed to the right roles — so activation is defensible and the next debrief starts with data instead of guessing.
Capabilities
GRACE isn’t a dashboard bolted onto a census feed. It’s an operational layer built for charge nurses, unit managers, and leadership — each pillar wired into the same live state.
GRACE packages the surge story developed with Amy Poso, RN, BSN, for leadership at a leading hospital in Texas: built so frontline leaders can plan before chaos—then scale activation across divisional units, external departments, and hospital-wide support.
GRACE uses four operational bands—Green through Black—each with its own definitions, key indicators, immediate actions, and resources that ratchet up by level. The framework is built for Labor & Delivery so charge teams, physicians, and leadership share one explicit language when volume and acuity tighten.
Staffing is appropriate for volume and acuity per AWHONN standards. Census on all units is below maximum capacity.
Staffing responsibilities are maximized for volume and acuity per AWHONN standards. Census on one or more units is near or at maximum capacity.
Staffing responsibility exceeds AWHONN standards for safe care because of volume and/or acuity. Census on one or more units is at or beyond maximum capacity.
Staffing is maximized, yet acuity and volume exceed the ability to honor scheduled work—induction and cesarean delays mount and patient flow for appropriate care is disrupted.
Evidence-based crosswalk from the literature to AWHONN 2022 Table 2 patient situations and modifier weights. Each room carries one **primary patient type** (mutually exclusive — labor evaluation, oxytocin labor, post-anesthesia recovery, newborn intermediate care, etc.) plus zero or more **modifiers** (mag, hemorrhage, FHR Cat II/III, equity flag, etc.) that stack on top. Charge teams tag what applies per room so GRACE can score, color-code, and refresh about every two hours. Independent nursing research in a high-volume L&D service reported that an AWHONN-aligned staffing model and gap analysis could reliably predict staffing needs there — conceptually aligned with making workload visible before ratios slip.
Room-level scores are meant to move with reassessment—usually aligned to the same ~2-hour interval as the daily tracking grid and unit snapshot.
For every active factor in a room: contribution = (base / weighted value) × (the level multiplier that matches present risk and staffing tier). Sum contributions for all active rows in that room to get the room score. Your implementation sets score-to-color bands; higher scores and tighter AWHONN ratios generally align with warmer room colors for faster situational awareness.
| Clinical criteria | Base wt. | Level 1 | Level 2 | Level 3 | AWHONN ratio |
|---|---|---|---|---|---|
| Triage — patient types (AWHONN) | |||||
| Labor evaluation — initial OB triage (1:1 first 10–20 min, then 1:2–3) | |||||
| Medical evaluation — non-OB complaint in pregnancy (1:1, then 1:2–3) | |||||
| Therapy / NST — antepartum testing or extended observation (1:2–3) | |||||
| Pre-procedural prep — pharmacologic cervical ripening (1:2) | |||||
| Induction start in triage — oxytocin initiated (1:1) | |||||
| Admission hold — boarder awaiting bed (1:2–3) | |||||
| Antepartum complications, stable (1:3) | |||||
| Antepartum complications, unstable (1:1) | |||||
| ROM evaluation / rule-out labor (1:2) | |||||
| Labor — patient types (AWHONN) | |||||
| Low-intervention labor — minimal / no pain relief (1:1) | |||||
| Active labor < 4 cm (1:2 routine monitoring) | |||||
| Intermittent auscultation labor (1:1) | |||||
| Oxytocin labor — induction or augmentation (1:1, high-alert med) | |||||
| Regional anesthesia — epidural maintenance (1:2) | |||||
| Labor with medical or obstetric complications (1:1 umbrella) | |||||
| Vaginal birth — birth event (2:1, one nurse for woman + one for baby) | |||||
| Cesarean — patient types (AWHONN) | |||||
| Cesarean — admission / pre-op (1:1) | |||||
| Cesarean — intra-operative (1:1 circulator + 1:1 baby nurse) | |||||
| Cesarean — post-anesthesia recovery (1:1 first 2 hr) | |||||
| Postpartum couplet — patient types (AWHONN) | |||||
| Mother–baby couplet care (1:3 couplets, mixed acuity) | |||||
| Postpartum with complications, stable (1:3) | |||||
| Newborn — patient types (AWHONN ratio ladder) | |||||
| Newborn stabilization (transitional) | |||||
| Newborn continuing care (1:3–4) | |||||
| Newborn intermediate care (1:2–3) | |||||
| Newborn intensive care (1:1–2) | |||||
| Newborn multisystem support (1:1) | |||||
| Newborn complex critical care (≥1:1) | |||||
| Other — patient types | |||||
| Non-OB / GYN holding (rate as med-surg, 1:4) | |||||
| High-risk modifiers | |||||
| Magnesium sulfate infusion (first hour 1:1) | |||||
| Pre-eclampsia / PIH management | |||||
| Maternal cardiac disease | |||||
| Maternal pulmonary disease | |||||
| Morbid obesity (BMI ≥ 40) | |||||
| Poorly controlled diabetes / IV insulin | |||||
| IUFD / fetal demise | |||||
| Active hemorrhage | |||||
| Bereavement / perinatal loss care | |||||
| MEWS / MEOWS trigger active (un-acknowledged) | |||||
| MEWS acknowledged — RN evaluating, expected physiology | |||||
| Labor modifiers | |||||
| Indeterminate FHR (Category II) | |||||
| Abnormal FHR (Category III) | |||||
| TOLAC / VBAC attempt (continuous EFM) | |||||
| Multiple gestation in labor | |||||
| Active pushing (second stage) | |||||
| Birth imminent (last 30 min + first 2 hr) | |||||
| Epidural initiation (≥30 min continuous bedside) | |||||
| Postpartum & newborn modifiers | |||||
| Postpartum hemorrhage / stabilization | |||||
| Day-of-cesarean couplet flag (couplet-mix rule) | |||||
| Newborn surgery / circumcision (peri-op) | |||||
| Centralized fetal telemetry monitoring | |||||
| Care-environment modifiers | |||||
| Interpreter-mediated care | |||||
| Dedicated labor-support role needed | |||||
| Equity / SDoH risk (uninsured, language, disparities) | |||||
| Care-complexity / nurse-fatigue marker | |||||
Level columns reflect escalating nursing intensity (e.g. care assistant / RN with expert support through expert nurse). The AWHONN column encodes recommended patients-per-nurse guidance for that line.
Example only: Room A sums to a moderate score → yellow tile. Room B stacks high-weight factors at Level 1 → red tile.
For a tiered list of sources (peer-reviewed research through AWHONN standards and posters), see Evidence & professional context.
A shift through GRACE
Here’s how the platform lives alongside a charge nurse’s day — mapped to moments that already exist on the unit, not net-new meetings.
Charge nurse logs in and sees the live unit — rooms, acuity, AWHONN status, assignments, and any overnight alerts already surfaced.
Update labor phase, Mag, couplets, epidurals. Scores refresh per-room; color tiles reshuffle without a single save button.
The 2-hour level prediction and 8-hour staffing forecast flag likely Red before it lands, with the drivers spelled out so you can justify activation.
Surge-level change, critical rooms, AWHONN shortfall, or a rescue event fire the right alerts to the right job roles per your matrix.
Claude drafts a structured debrief from the live data; you edit, confirm missed-care / rescue entries, and hand off with one record.
AI shift intelligence
GRACE uses Anthropic’s Claude for the things a charge nurse doesn’t have the hands for: writing, summarizing, pattern matching. Every AI surface stays tethered to the live unit state on screen — no stale inputs, no hidden context.
Turn the qualitative “controlled chaos” into structured insight tied to the numbers on screen. No free-form guessing; every assertion maps to a room, a ratio, or a factor.
One-click paragraph summary for any room — factors, nursing level, assignment, trajectory — useful for handoffs, rounding calls, or family communication.
End-of-shift report pre-filled from the data: peak acuity, compliance %, rescue events, missed care, next-shift watchouts. Edit, confirm, ship.
The prediction engine explains itself — rising acuity, postpartum bed backlog, time-of-day risk — so charge teams can defend activation calls.
“Controlled chaos” reads clearly in the numbers: three active inductions, a 1:1 Mag room, and triage holding two ROM rule-outs. Workflow rating 3 matches what the data shows — staff absorbing load but momentum rising.
Likely Redat ~15:30 driven by rising acuity and postpartum bed backlog. Consider pulling one call RN now and escalating to the Women’s director per Yellow playbook.
Illustrative preview. Your unit’s charts populate as snapshots accrue.
Evidence & outcomes
GRACE persists AWHONN compliance with every snapshot, then computes time-weighted adherence across days, weeks, and months — so leadership can show the board how the unit actually ran, not how it felt.
Research context: Lyndon et al. (2025) linked labor nurse staffing adherence with hospital cesarean and VBAC rates. GRACE is operational decision support, not outcomes prediction. See the evidence page →
Integrations
GRACE ingests ADT, census, and staffing data via the same protocols your IT team already supports. A FHIR mapping layer auto-populates acuity factors so charge nurses spend less time typing and more time on the floor.
Admissions, transfers, discharges from Epic populate room state in real time.
Encounter + Condition + Observation resources mapped to acuity factors automatically.
Bed availability and downstream capacity for antepartum, postpartum, GYN transfers.
Scheduler-of-record pushes on-duty RNs; GRACE reconciles against AWHONN-required.
Lightweight periodic census push for shops that don't expose HL7/FHIR.
Historical data and dry-run backfills for go-live and benchmarking.
Escalation
GRACE ships with a Job-Role × Notification-Type matrixso the nurse manager isn’t woken for every room change and the bedside RN isn’t buried in daily-summary emails. Admins set the defaults; users can opt out of specific notifications from their account page.
| Job role | Surge | Room crit. | Rescue | AWHONN | Debrief |
|---|---|---|---|---|---|
| Nurse manager | |||||
| Charge nurse | |||||
| Staff RN | |||||
| Educator | |||||
| Admin staff |
Resolution order: system setting → role matrix → user override. Admin wins at the top; users keep the last word on their own inbox.
Every capability in GRACE today — the platform your charge nurses already use during pilots at partner hospitals.
Green → Yellow → Red → Black with definitions, key indicators, immediate actions, and resources at each band. Phase I–III patient-placement scripts (hallway, PACU, OR, temporary space) activate as capacity tightens.
An expanded clinical factor catalog — labor phase, induction, epidural, Mag, pre-eclampsia, hemorrhage, TOLAC/VBAC, couplet care, telemetry, labor support, interpreter, bereavement — sums into a per-room score that drives color-coded tiles and total unit load.
Required-nurse count vs. nurses-on-duty, the 2-RN minimum floor, 1:1 rooms called out by name, and a running shortfall counter. A per-snapshot compliance record feeds time-weighted adherence on the history page.
Assign RNs to rooms, enforce 1:1 clinical situations automatically, and see each nurse's workload as patients are added. Reassign with one click when the census shifts mid-shift.
Claude-powered room summaries, structured shift debriefs for handoffs, interpretation of the unit's qualitative “feel,” and natural-language acuity narratives that stay tethered to the data on screen.
A 2-hour level forecast plus an 8-hour staffing-demand forecast with time-of-day risk and rising/falling momentum. Charge teams see the projected RN gap hours before it lands, with drivers spelled out.
HL7 v2 ADT, FHIR R4 (with a mapping layer that auto-populates acuity factors), and REST endpoints for census, staffing, and batch loads. Connect Epic, TeleTracking, and more without double entry.
Per-room timelines, acuity heatmaps, surge-level distribution, and an outcomes view that plots AWHONN adherence against cesarean and VBAC trends over time. Research-grade and benchmarking exports are built in.
Shift debriefs capture missed-care events, failure-to-rescue / near-miss incidents, and a staff well-being signal — turning shift stories into structured data for quality review and staffing committees.
Admins configure a Job-Role × Notification-Type matrix so the right people get the right alerts. Three layers — system setting, role matrix, personal preference — resolve in order, with an admin override at the top.
Rehearse the surge response on synthetic census without touching live data. Perfect for onboarding charge nurses, tabletop drills, and refining your local indicator thresholds.
Indicators track flow, not just census: patients held in L&D when postpartum, antepartum, or triage back up — the real constraints that steal beds and magnify risk.
Research context: Simpson et al. (2023), Simpson (2015), Lyndon et al. (2025), AWHONN (2022), and others document variation in labor nurse staffing adherence and its relationship to outcomes. GRACE does not replace AWHONN standards, collective bargaining, or clinical judgment; it makes workload and escalation visible so leaders can act earlier.
Full evidence library →Register your hospital, invite your charge team, and start tracking your first shift today. Real-time dashboard, AI shift intelligence, AWHONN compliance, and EHR integration — all included.
