Dr. Tessmer-Tuck said she found the Las Vegas study highly relevant because lots of hospitals throughout the country are now going through a similar transition from traditional on-call practice to around-the-clock coverage provided by rotating private practice community laborists, while pondering a possible move to full-time laborists.
Bruce Jancin/IMNG Medical Media
Dr. Jennifer Tessmer-Tuck
"This is where many of our hospitals are at: They’re in the middle phase, with private-practice docs being paid to stay in-house 24 hours in case there’s an emergency," according to Dr. Tessmer-Tuck.
She said she found particularly impressive the investigators’ calculation that a full-time laborist resulted in an average of one fewer cesarean section every 2 days in a population of primiparous, term, singleton patients, with a resultant estimated savings in patient care costs of $2,823-$3,305 per day. Because a laborist might be paid $2,500 per 24-hour shift, the reduced cesarean section rate alone covers the laborist’s salary. Those are the sort of numbers hospital administrators find persuasive.
"This is a message you guys should take home with you when you go back to your own program," she said.
While the Las Vegas study provides the first evidence to be published in a major peer-reviewed journal demonstrating superior clinical outcomes with the full-time laborist model, Dr. Tessmer-Tuck noted that in addition there are several published studies suggesting that hospitals experience fewer adverse events and markedly lower payouts for bad outcomes after they implement multipronged, comprehensive obstetric patient safety programs that include bringing a laborist on board.
"Liability has become a huge issue for us. Many hospitals implement hospitalist programs mainly in order to reduce liability," according to Dr. Tessmer-Tuck.
She cited a study by ob.gyns. at New York Presbyterian/Weill Cornell Medical Center in which they analyzed the impact of a comprehensive patient safety program initiated in stages beginning in 2003. The interventions included mandatory labor and delivery team training aimed at enhancing physician/nurse communication, development of standardized management protocols, training in fetal heart rate monitoring interpretation, creation of a patient safety nurse position, and, in 2006, introduction of a laborist.
It’s not possible to parse out just how much of the improvement in response to the multipronged safety program was the result of adopting the laborist model, Dr. Tessmer-Tuck said, but she noted the average yearly compensation payments for patient claims or lawsuits were $27.6 million during 2003-2006, plummeting to $2.5 million per year in 2007-2009, after the laborist was in place. Moreover, sentinel adverse events such as maternal death or severe neurodevelopmental impairment in a child decreased from five in the year 2000 to none in 2008 and 2009 (Am. J. Obstet. Gynecol. 2011;204:97-105).
Ob.gyns. at Yale–New Haven (Conn.) Hospital introduced a similar comprehensive patient safety program, also including implementation of a 24-hour obstetrics hospitalist, during 2004-2006. During 3 years of prospective follow-up involving nearly 14,000 deliveries, they documented a significant linear decline in obstetric adverse outcomes (Am. J. Obstet. Gynecol. 2009;200:492e1-8). They also administered a validated workplace safety attitude questionnaire four times during 2004-2009 and documented marked improvement over time in favorable scores in the domains of job satisfaction, teamwork, and safety culture (Am J. Obstet. Gynecol. 2011;204:216.e1-6).
Dr. Garite and Dr. Tessmer-Tuck reported having no germane financial relationships.