Abstract
Our goal is to demonstrate how a full-time laborist program was fully integrated and accepted into a busy urban hospital serving voluntary medical staff from the community while improving quality metrics including the reduction in Total Cesarean Sections (CS), Primary CS, and Nulligravida Term Singleton Vertex CS rates. This was a retrospective study of CS rates from 2012-2015 at a single center following the institution of a comprehensive program to improve quality and safety. Key components of the program included: (1) Recruitment of a Medical Director and 4 full-time laborists with no private practices of their own who provided 24/7 oversight and supervision of all patients on the unit. (2) A web-based electronic scheduling program with decision support and hard stops was implemented for scheduled CS and labor inductions. (3) A collaboration was established between the laborists and the hospital's Maternal-Fetal Medicine (MFM) specialists to provide external cephalic version (ECV), second-opinion consultations for elective primary CS, and consultations for all patients admitted less than 36 weeks' EGA; and a midwifery practice to promote vaginal birth. (4) A full-time Patient Safety Nurse was recruited to assist the Medical Director to facilitate communication, team training, data collection and analysis, and best practices such as safety huddles for laborists and nurses. Data was extracted from an integrated electronic medical record for analysis. An average of 3700 of births/year took place during this time period with community practitioners attending the majority of births. The total CS rate and the primary CS rates decreased while the Vaginal Birth After CS (VBAC) rate increased (Table 1, Figure 1). The elective (non-medically indicated) induction of labor prior to 39 weeks was reduced to 0%. The decline in the CS rate from 30% to 20% led to an overall reduction of ∼400 Cesarean deliveries per year. The full-time laborist program initially alarmed the community practitioners; however, hospital champions facilitated discussions between laborists, MFMs, community physicians, midwives, nurses, and patients about timing of scheduled births, management of high risk pregnancies, VBAC, and ECV. The culture shifted on the unit to promote patient safety, quality, and best practices while supporting professional satisfaction of the community practitioners in private practice, residency training, and the faculty practices.View Large Image Figure ViewerDownload Hi-res image Download (PPT)
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