Life in the “old days”
Krista Wills, MD, lead physician of OB hospitalists at Presbyterian Hospital in Albuquerque, clearly recalls the days before the program started. Everyone was stretched a little too thin back then.
“The patient would be in triage until the doc could come by and evaluate her and send her out,” says Wills.
Depending on the physician’s location and office schedule, that wait could be several hours.
“If the mom came in in active labor and had not had any prenatal care, the doc whose name was on the ED [emergency department] call roster would be called and would have to come in and do the delivery,” Wills says. One of the problems with this system was that unassigned patients “who haven’t had any prenatal care in general tend to be high-risk patients, and for the community physicians it was just becoming an increasing burden. People did absorb it before, but it was something that creates not exactly friction but physician dissatisfaction.”
Presbyterian Hospital began its OB hospitalist program in January 2006. In general, its laborists have four main responsibilities:
- “We labor and deliver all the babies that come from high-risk mothers” that are cared for by a private group of perinatologists based at the hospital, says Wills. “We accept all the maternal transports from all over the state. The majority of these moms have had care in a small town in New Mexico—one of our regional facilities or just a small town—and the mom is either very sick and requires tertiary care or the baby is going to be born prematurely and needs a level III NICU.”
- “We take care of the unassigned patients who drop into the ED or OB triage area.”
- “We first-assist for a majority of the C-sections performed in the hospital.”
- “We are also a backup for our community doctors.” (“We’re not trying to take away their billings or anything like that,” Wills adds. “We just want to decrease our unattended delivery rate. And we just want to be able to get patients through triage more quickly.”)
Safety and continuity of care are among the benefits
At Middle Tennessee Medical Center in Murfreesboro, where the laborist program has been in effect for almost 20 months, the principal benefit has been increased safety—although that isn’t the only advantage.
“We’ve had three instances already since November of 2006 where we feel that there would have been a significant negative outcome either with a mother or a baby if we had not had a physician in house ready to go when that particular obstetrical emergency presented,” says Andy Brown, MD, vice president of medical affairs. “So we do feel that [the laborist program] provides a very good standard of care for the hospital.”
Overall, ObGyns in the community have been pleased with the program.
“It has actually allowed them to increase the size of their practices because they’re in much better control of what happens during the routine office hours,” says Brown. “They have better control over their office schedules.”
And the patients of those physicians?
“The vast majority of patients would be relieved to realize that there is someone there for an emergent situation,” Brown says.
Concurring with that observation is C. Brent Boles, MD. “We are very happy with the program,” he says. “I’m speaking with two hats on because I’m the medical director of the laborist program [at Middle Tennessee Medical Center], but I’m also a private physician.”
Boles confirms that a drive for ever-increasing safety was one of the concerns that prompted creation of the program.
“I wouldn’t say that it was the principal driving force, but it was certainly one of the top two or three reasons. Probably the consistency or continuity of care that is now easy to provide for the service call patients and the immediate coverage of in-house emergencies are the two major benefits to the community.”
Another benefit of the laborist model: It makes a trial of labor after C-section [vaginal birth after C-section (VBAC)] possible in hospitals that have 24/7 coverage. At Shawnee Mission Medical Center, the laborist program has greatly increased the number of VBACs.
“We had actually stopped laboring VBACs,” says Ohnoutka. “We mostly sectioned them.” Since the laborist program began, “we’ve seen a huge increase. There are some docs who really and truly believe in laboring VBACs and have hated not to be able to do it. So [the laborist program] has driven some volume here because other hospitals in our community aren’t doing it.”