Assessment of the Implementation of a New Patient-Focused Intradisciplinary Model of Care for Elective Cesarean Birth
Abstract Number: 7
Abstract Type: Original Research
INTRODUCTION: Over the past 3 years, annual deliveries increased from 3700 to nearly 5000, with Cesarean Births (CB) increasing from 800 to >1100 and elective CB increasing from 350 to nearly 600. Historically, 1 Anesthesiologist (24 x 7) is responsible for all procedures (24% CB, 70% epidural, >700 consults), including 3 elective CB slots per weekday (8am;10am;1pm). 17 Obstetricians deliver their own patients (Vaginal and CB) each weekday 8am-5pm. Consequently, unscheduled urgent or emergent CB consumed available Human Resources (HR) such that scheduled elective CB were often significantly delayed. The significant increase in workload highlighted insufficient Anesthesiologist HR which is well below the norm for tertiary-care teaching Maternity Units in NA (1) and far below minimum HR standards in the UK (2), suggesting the environment unsafe. As part of a review of the entire model of delivery of maternity services, a new "patient-focused" model of care for elective CB delivery was to be introduced and evaluated between Oct 01, 2009 and Jan 31, 2010. In the Historic Model of Care (HMC) 3 elective CB were scheduled each weekday whereas the new Patient-Focused Intradisciplinary Model of Care (PFIMC) implemented a dedicated elective CB OR Team, including a dedicated Anesthesiologist, assigned 5 elective CB per day, 2 days per week. The purpose of this quality improvement (QI) impact study was to compare the timeliness of access to the OR for women scheduled for an elective CB under the HMC versus the PFIMC. The primary outcome was the percentage of women entering the OR "on time" defined as within 5 minutes of scheduled elective CB.
METHODS: Following IRB approval, prospective data pertaining to all consecutive elective CB in July and August 2009 (HMC) and then all consecutive elective CB in October and November 2009 (PFIMC) was collected. Data was analyzed using unpaired T-test and Chi Square with a P < 0.05 considered significant.
RESULTS: Door to door OR time significantly decreased during the PFIMC (N=52) from 81.6 +/- 16.4 min to HMC (N=76) 71.1 +/- 13.3 min (P<0.001). During HMC, access to the OR was delayed 30 +/- 35 min (8am); 60 +/- 64 min (10am) and 84 +/- 62 min (1pm), with > 95% delays due to unscheduled CB. Access to the OR was significantly improved with 86.5% (45/52) PFIMC entering the OR "on time" compared to only 28.9% (22/76) HMC (P<0.0001). Of note, all 7 PFIMC delays were due to: (a) a lack of consent or (b) the Obstetrician was late or 3) both (a) and (b).
CONCLUSION: This QI impact study demonstrated that the implementation of PFIMC permitted the majority of women scheduled for elective CB to enter the OR "on time" and that significant OR efficiencies were gained. The PFIMC has also identified several issues pertaining to the much needed cultural change from Obstetrician-focused to Patient-focused care.
References: 1. Panni MK, et al IJOA 2006; 15: 284-9; 2. Anaesthetic Staffing Levels in Safer Childbirth: 2007 w