OR Manager - December 2019 - 21

OR business
L&D overhaul may produce greater efficiency, satisfaction
should screen for problems specific to
strong labor and delivery (L&D)
department is a key driver of
hospital success. L&D not only
contributes significantly to hospital profitability,
it plays an important role in
establishing and cementing patient loyalty.
And as hospitals increasingly take
responsibility for community health,
an effective birth program can make a
measurable impact on local healthcare
costs and outcomes.
A
However, many hospitals struggle
with managing the variable maternity
population. This leads to problems with
patient satisfaction, physician retention
and referrals, and financial results.
To avoid these problems, OR leaders
should explore strategies for improving
patient access to L&D, increasing
department efficiency, streamlining
mother and baby throughput, and optimizing
clinical outcomes.
Get off to a good start
In a typical L&D department, high-risk
deliveries are responsible for the bulk of
quality and efficiency problems. The key
to managing these deliveries is careful
triage. In most hospitals, the anesthesia
department is best equipped to lead
the development of an evidence-based
triage process. An effective triage system
enables the birth program to identify
high-risk patients and optimize them
prior to caesarean section or labor induction.
Key components of a strong
system are described below.
Perinatal phone screen
All expectant mothers should receive
a telephone-based screening at 32
weeks. The screening tool should include
basic surgical risk factors such
as body mass index greater than 50;
known or suspected bleeding disorder,
coagulopathy, or thrombocytopenia; history
of anesthesia-related complications
or family history of malignant hyperthermia;
significant heart, lung, or neurological
disease; and history of substance
abuse disorder, including current use
of Suboxone. In addition, the process
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pregnancy and/or delivery:
* preeclampsia
* anemia (hemoglobin of 11.5 or less)
* obstetric complications likely to lead
to operative delivery (such as placenta
previa or multiples)
* severe edema
* anatomic abnormalities of the face,
neck, or spine (stemming from surgery
or trauma)
* extremely short stature, short neck,
arthritis of the neck, or goiter
* abnormal dentition, small mandible,
or difficulty opening the mouth.
Preadmission testing
Patients who answer " yes " to any of
these screening questions should be
scheduled to visit the obstetric (OB)
preadmission testing (PAT) clinic. During
the visit, an anesthesiologist or nurse
practitioner should evaluate the patient
and create a plan for mitigating any
serious issues. For example, the OB
PAT team can evaluate severe edema
patients for possible blood clots or cardiac
issues and address any medical
problems prior to delivery.
Evidence-based lab matrix
The phone screen should also be linked
to an organized process for ordering
preoperative lab studies. For example,
following an evidence-based lab matrix,
patients with significant arrhythmias
should be referred for an EKG, a
prothrombin time/INR test, and a basic
metabolic panel.
L&D departments can also use the
scheduling process to identify issues
that could hamper efficiency. Some departments
have created a dedicated OB
scheduler role. Schedulers who focus
on perinatal care are better able to identify
problems proactively and ensure
compliance with state guidelines.
Most states do not allow elective
scheduled inductions prior to 39 weeks.
However, physicians sometimes lose
sight of timing and schedule inductions
outside of the guidelines. A dedicated
OB scheduler not only books the procedure,
but has the knowledge and expertise
to verify compliance with scheduling
guidelines as well as all other state and
federal requirements.
Create an efficient room schedule
Most L&D departments can benefit
from three improvements to the scheduling
system:
* Reserve adequate block time for
obstetric cases. OB blocks enable
efficient utilization of nursing staff
and obstetric equipment. Most hospitals
could schedule one or two full
obstetric blocks (7:30 am to 3:30
pm) per day, depending on anesthesia
availability. As a rule of thumb,
hospitals with 2,000 or more operative
births per year should consider
creating a dedicated OR within
L&D. Hospitals under this threshold
can usually accommodate operative
birth volumes with obstetric block
time in the main OR.
* Accurately estimate scheduled case
times. In some hospitals, all caesarean
sections (C-sections) are allocated
a flat 2 hours of OR time.
But this approach ignores surgeon
variability. At one hospital we visited,
scheduled obstetric surgery time
was 35% to 40% longer than actual
case time on any given day. We recommend
using historical data to assign
surgeon-specific case times for
operative births. Consider using an
Olympic average methodology: Identify
case times for a surgeon's last
10 C-sections, drop the high and low
values, and average the remaining.
* Use predictive analytics to match
capacity to demand. For example,
heat mapping techniques can be
used to create accurate demand
models for obstetric surgery (sidebar,
p 22). This enables OR leaders
to optimize staffing by day and hour,
right-size labor costs, and improve
surgeon satisfaction.
Continued on page 22
OR Manager | December 2019
21
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OR Manager - December 2019

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