By Heather Moore, CPHRM, CHC, AIAF, ARC
The last thing that should be on the mind of a woman going into labor is whether her weekend, holiday, or nighttime delivery is putting her and her baby at a greater risk of negative health outcomes.
Unfortunately, that risk is the reality within many labor and delivery units—a major concern for physicians, nurse midwives, and other essential providers who strive for optimal health outcomes. It also poses a difficult situation for health systems, which are always cognizant of medical malpractice exposure and risk.
A 2015 study by researchers at Northwestern University found adverse or potential adverse events occurred in approximately one in five women admitted to the hospital labor and delivery unit. And of those adverse events, 17% were judged to be preventable and related to poor healthcare management.
While adverse events in the labor and delivery unit can happen at any time, a study in the international journal Risk Analysis from January 2019 is the most recent in a series of reports confirming what has been dubbed as the “weekend effect” in maternal care. For this particular study, researchers investigated whether medical service quality (referred to as “clinical capital” by the authors) impacted maternal delivery complications.
Consistent with the findings of similar studies, the report found that delivery complications occurred at a higher rate during night shifts (21.3% more likely), on weekends (8.6% more likely), and during the holidays (29% more likely), when hospitals were understaffed and doctors with less experience were more likely to be working. Perhaps most disturbing, the authors concluded that hospitals can meaningfully attenuate this harm not through drastic changes, but through strategic scheduling of staff.
To be effective, strategic staffing would need to address issues identified in other studies as contributors to the weekend effect. Solutions include ensuring that more experienced staff, specialized diagnostics and therapeutics, and an adequate staff-to-patient ratio are available on weekends. Providers with on-call duties may also be suffering from increased fatigue during weekend and night shifts, which can in turn lead to delays in care. This is especially dangerous in situations requiring providers to be on high alert, such as in the labor and delivery unit.
Hospitals need not be powerless observers when it comes to adverse events, particularly when quality metrics and other reporting requirements indicate a dip in outcomes during nights, weekends, holidays, or any other significant and/or recurring periods of time. Strategic scheduling is just one component of a new imperative for labor and delivery units—moving from a reactive culture of risk management to a proactive culture of safety, regardless of shift time or day of the week. Yet ensuring high-quality, consistent care can be difficult, especially in rural or remote areas where physician shortages may be more acute.
For these and many other hospitals, the solution to resolving gaps in staffing and ensuring a consistent standard of care for all patients is the use of an OB hospitalist program. While there are different models of OB hospitalist programs, in a management company model, on-site OB/GYNs and certified nurse midwives provide coverage and support, either until the woman’s community-based obstetrician can arrive at the hospital or when the woman has no assigned obstetrician. With a clinician on-site at all times, urgent health concerns are quickly addressed by an OB/GYN with specialized training in those situations—during pregnancy emergencies, labor and delivery, and the critical “fourth trimester.” When the community obstetrician or delivering provider arrives, the OB hospitalist either turns over patient care or assists the obstetrician as needed to ensure successful co-management of the patient.
Research demonstrates the effectiveness of such arrangements in improving patient health outcomes. For example, a study in the Journal of Patient Safety examined adverse incidents at a hospital before and after the implementation of an OB hospitalist program. The study first looked at outcomes under a traditional model—where the hospital did not employ an OB hospitalist as part of the care team. Under this arrangement, 11 safety events occurred between July 2012 and September 2014 on the labor and delivery floor. A full-time OB hospitalist program was implemented in October 2014, and in the 25 months that followed, there was only one safety event associated with labor and delivery.
Other research validates the risk benefit. In 2016, Ob Hospitalist Group and one of its largest system partners undertook a study to analyze the key risk mitigation strategies that resulted in favorable loss trends/claim reduction for the system in recent years. The study identified the use of OB hospitalists as a valuable best practice initiative in driving down loss attributed to claim frequencies and cost per birth. The analysis identified a 31% reduction in serious harm incidents after implementation of an OB hospitalist program.
As healthcare leaders look for ways to improve performance measures, mitigate risk, and inspire confidence in the patients they serve, use of OB hospitalists offers an evidence-based solution to ensure that patients receive the highest standard of care—regardless of when they arrive in the labor and delivery unit.
Heather Moore is vice president of risk management, quality, and compliance for Ob Hospitalist Group, the nation’s largest OB/GYN hospitalist organization.