Samia El Haj Ibrahim

Variation in childbirth services in California: a cross-sectional survey of childbirth hospitals.

OBJECTIVE The objective of the study was to describe the resources and activities associated with childbirth services. STUDY DESIGN We adapted models for assessing the quality of healthcare to generate a conceptual framework hypothesizing that childbirth hospital resources and activities contributed to maternal and neonatal outcomes. We used this framework to guide development of a survey, which we administered by telephone to hospital labor and delivery nurse managers in California. We describe the findings by hospital type (ie, integrated delivery system [IDS], teaching, and other [community] hospitals). RESULTS Of 248 nonmilitary childbirth hospitals in California, 239 (96%)responded; 187 community, 27 teaching, and 25 IDS hospitals reported. The context of services varied across hospital types, with community hospitals more likely to have for-profit ownership, be in a rural or isolated location, and have fewer annual deliveries per hospital. Results included the findings of the following: (1) 24 hour anesthesia availability in 50% of community vs 100% of IDS and teaching hospitals (P < .001); (2) 24 hour in-house labor and delivery physician coverage in 5% of community vs 100% of IDS and 48% of teaching hospitals (P < .001); (3) 24 hour blood bank availability in 88% of community vs 96% of IDS and 100% of teaching hospitals (P = .092); (4) adult subspecialty intensive care unit availability in 33% of community vs 36% of IDS and 82% of teaching hospitals (P < .001); (5) ability to perform emergency cesarean delivery in 30 minutes 100% of the time in 56% of community vs 100% of IDS and 85% of teaching hospitals (P < .001); (6) pediatric care available both day and night in 54% of community vs 63% of IDS vs 76% of teaching hospitals (P = .087); and (7) no neonatal intensive care unit in 44% of community vs 12% of IDS and 4% of teaching hospitals (P < .001). CONCLUSION Childbirth services varied widely across California hospitals. Cognizance of this variation and linkage of these data to childbirth outcomes should assist in the identification of key resources and activities that optimize the hospital environment for pregnant women and set the groundwork for identifying criteria for the provision of maternal risk-appropriate care.

Anesthesia Complications as a Childbirth Patient Safety Indicator

BACKGROUND:The Agency for Healthcare Research and Quality (AHRQ) has established multiple sets of indicators for quality monitoring and improvement. One such set is the patient safety indicators (PSIs), which focuses on potentially preventable hospital complications after surgeries, procedures, and childbirth. Our objective in this study was to determine the prevalence of childbirth-related anesthesia complications by method of delivery and to evaluate the variation in complication rates across hospitals using the AHRQ PSI methodology and a modification specific to childbirth with the goal of determining the relevance of tracking anesthesia complications as a potential PSI for childbirth. METHODS:The technical specifications of the experimental Anesthesia Complication Quality Indicator, one of the PSI defined by AHRQ, were modified to create a childbirth-specific indicator that included all childbirth admissions (vaginal and cesarean deliveries) and complications from general and neuraxial anesthesia/analgesia. Using California hospital discharge data, we calculated hospital-specific rates, adjusting for age, race/ethnicity, and pregnancy complications. RESULTS:A total of 508,842 deliveries occurred in 254 hospitals in California in 2009. Hospitals with <200 annual deliveries (N = 12) were excluded from analyses. Among 242 hospitals, the rate of anesthesia complications was 0.13% for the standard AHRQ study population (adult surgical admissions, which included cesarean deliveries). The childbirth-specific rate of anesthesia complications was 0.31%. When stratified by method of delivery, complication rates were 0.49% for cesarean delivery and 0.22% for vaginal delivery (P < 0.0001). The unadjusted mean (SD) was 0.34% (0.34%), with range (0%–2.46%). The rates of 13 hospitals (including their 95% confidence limits) remained in the upper quartile as outliers, with adjusted rates from 0.52% to 2.13%. CONCLUSIONS:Rates of childbirth-related anesthesia complications may provide an opportunity to identify hospitals with extreme rates that may provide insights into systematic ways to improve patient safety.

Do laborists improve delivery outcomes for laboring women in California community hospitals

OBJECTIVE We sought to determine the impact of the laborist staffing model on cesarean rates and maternal morbidity in California community hospitals. STUDY DESIGN This is a cross-sectional study comparing cesarean rates, vaginal birth after cesarean rates, composite maternal morbidity, and severe maternal morbidity for laboring women in California community hospitals with and without laborists. We conducted interviews with nurse managers to obtain data regarding hospital policies, practices, and the presence of laborists, and linked this information with patient-level hospital discharge data for all deliveries in 2012. RESULTS Of 248 childbirth hospitals, 239 (96.4%) participated; 182 community hospitals were studied, and these hospitals provided 221,247 deliveries for analysis. Hospitals with laborists (n = 43, 23.6%) were busier, had more clinical resources, and cared for higher-risk patients. There was no difference in the unadjusted primary cesarean rate for laborist vs nonlaborist hospitals (11.3% vs 11.7%; P = .382) but there was a higher maternal composite morbidity rate (14.4% vs 12.0%; P = .0006). After adjusting for patient and hospital characteristics, there were no differences in laborist vs nonlaborist hospitals for any of the specified outcomes. Hospitals with laborists had higher attempted trial of labor after cesarean rates, and lower repeat cesarean rates (90.9% vs 95.9%; P < .0001). However, among women attempting trial of labor after cesarean, there was no difference in the vaginal birth after cesarean success rate. CONCLUSION We were unable to demonstrate differences in cesarean and maternal childbirth complication rates in community hospitals with and without laborists. Further efforts are needed to understand how the laborist staffing model contributes to neonatal outcomes, cost and efficiency of care, and patient and physician satisfaction.

Easy as ABC: A System to Stratify Category II Fetal Heart Rate Tracings.

Objective To evaluate whether a subcategory system for category II tracings can improve team communication and perinatal outcomes. Study Design We collected data prospectively for 15 months, first using the NICHD system, followed by the ABC system, which divides category II tracings into subcategories A, B, and C, each representing increased risk for metabolic acidemia. We surveyed providers about communication effectiveness and agreement on tracing interpretation for each system. In cases where the communication system was used to alert an off-site physician about a category II tracing, we compared arrival to L&D and NICU admissions. Results The ABC system was preferred (69%, n = 152) and considered a more effective tool for communicating concerning fetal status (80% vs. 43%, p < 0.01). Participants also reported greater agreement on tracing interpretation (79% for ABC vs. 64% for NICHD, p = 0.046). When an off-site physician was contacted about a category II tracing (n = 95), they were more likely to arrive to L&D (44% vs. 20%, p < 0.01) and have fewer NICU admissions (0% vs. 6%, p < 0.01) with the ABC system. Conclusion The ABC system resulted in improved team communication, increased physician response, and decreased NICU admissions. Using standardized communication may offer a useful strategy for identifying and expediting care.

Communication With Staff During Hospitalization for Childbirth: The Patientʼs Perspective [1R]

INTRODUCTION: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores impact hospital reimbursement. Patient-provider communication is a key driver of these scores. We explored the role of communication in childbirth hospital admissions from the pregnant womans perspective. METHODS: We performed a systematic and comprehensive literature search regarding patient-reported outcomes (PROs) in childbirth, organized them into categories, and mapped them to a conceptual framework. In collaboration with a community partnership of clinicians and childbirth advocates, we held focus group sessions among pregnant and recently pregnant women from different racial/ethnic and socio-economic populations in Los Angeles County to determine womens priorities among these categories. Sessions utilized a standardized script for facilitators and were recorded, transcribed, and translated as needed. Using ATLAS.ti, responses were organized into themes and mapped to the categories. RESULTS: Nineteen categories of PROs were identified, including clinical outcomes and processes of care, eg, labor and pain management, and patient-provider communication. For the 6 focus groups (N=41), communication was the most prevalent theme identified, and related concerns were associated with negative childbirth experiences. Among Spanish speakers, concerns included not being understood, and translator availability. African-American women acknowledged being understood; however, they felt ignored and placated. Medicaid-insured women voiced a lack of privacy when communicating with providers. CONCLUSION: Communication with hospital staff was the principal concern during childbirth for a diverse sample of women; these concerns varied by race/ethnicity and insurance status. As maternity patients contribute to HCAHPS scores, strategies for addressing these concerns are critical for childbirth hospitals.

The Laborist: Is This New Trend Associated With Higher Rates of Primary Cesarean Delivery?

INTRODUCTION: Many hospitals across the nation use laborists, yet little evidence exists to suggest how this affects patient outcomes. We aim to determine if the presence of a laborist is associated with primary cesarean delivery rates. METHODS: We designed and validated a survey to collect information on policies and practices on labor and delivery units across all hospitals in southern California. Hospital-level primary cesarean delivery rates were obtained from the California Office of Health Planning and Development. Recursive partitioning algorithms were used to evaluate the primary cesarean delivery rates. We evaluated structural variables associated with primary cesarean delivery including obstetrics–gynecology resident teaching, presence of laborists and volume (low volume=200–2,000 deliveries per year; midvolume=2,001–3,500 deliveries per year; high volume=3,500 deliveries or more per year). Analysis was weighted by delivery volume. Logistic regression was performed to confirm these results. RESULTS: Seventy percent of hospitals responded (84/121). Recursive partitioning algorithms showed an initial branch point by hospital volume with comparable primary cesarean delivery rates among these (low volume: 19.9%, midvolume: 18%, high volume: 19.7%). The second branch point differed by hospital volume. Teaching status was most discriminant for low-volume hospitals, whereas the presence of a laborist was most discriminant for midvolume and high-volume hospitals. The highest and lowest primary cesarean delivery rates were in nonlaborist hospitals with midvolume (17.6%) and high volume (22.5%), respectively. Controlling for structural risk factors, logistic regression showed no statistically significant difference between primary cesarean delivery rates across groups. CONCLUSION: Among southern California hospitals that participated in the survey, primary cesarean delivery rates are comparable to the state average of 17% and did not vary significantly among hospitals with laborists.