The average hospital charge for a cesarean delivery (C-section) at Tift Regional Medical Center (TRMC) is $7,300, compared to $3,700 for a vaginal delivery. The average length of stay for a C-section was 3.5 days, compared to 1.7 days for a vaginal delivery. Given the cost of a C-section compared to vaginal delivery, there is a need to reduce the costs of the procedure without reducing the quality of care received. A reason for the increased cost is the utilization of the surgical staff to perform the C-Section care.
In addition to costs, the quality of patient care is less than satisfactory because the surgical nurse does not have an opportunity to form a relationship with the patient, there is additional pain postpartum, and the hospital stay is longer. This paper will demonstrate a collaborative approach to improving obstetrical patient care while reducing costs for that care.
Tift Regional Medical Center is named in honor of Tifton’s founder, Henry Harding Tift. In 1940 a new 35-bed Tift County Hospital opened to serve Tift County, later it was enlarged to 60 beds.
On November 1, 1965, Tift County Hospital became Tift General Hospital with the opening of a new 85-bed facility on 18th Street. Now with over 190 beds, Tift General Hospital was renamed Tift Regional Medical Center in 2000. The facility is fully accredited by the Joint Commission on Accreditation of Healthcare Organizations.
With a reputation as an innovative provider of quality health care, Tift Regional Medical Center is an acute care facility that serves as the regional referral center for all of South Central Georgia.
Tift Regional Medical Center offers a full range of services, including a 24-hour emergency department and an after-hours medical clinic for non-urgent care. The facility employs over 800 people and is the largest health care provider in the area. TRMC contributes 57.5 million dollars to the local economy (TRMC, 2004). The medical staff includes more than 85 physicians that provide oncology, rehabilitation, occupational health, skilled nursing, cardiovascular procedures, and neurodiagnostic care. The mission of the hospital is to provide quality health to the community through preventive, inpatient, and outpatient services. The care is to be rendered heeding the financial well-being of the hospital and the patient’s final (TRMC, 2004).
The obstetrical department is a self-contained area dedicated to the care of the pregnant woman just before and through the delivery of the infant and the care of the newborn during and after delivery. According to the Labor and Delivery Director, Jeannie Anderson, “the C-Section rate is about 26% of all births at TRMC” (personal communication, May 17, 2005).” Currently, the obstetrical staff does not assist with cesarean deliveries; instead,d a team from the surgical services department is called to assist with the procedure.
Performing C-Section deliveries has negatively affected the operational budget of the surgical services department because there is a surgical technologist and a registered nurse on call for this purpose. Tonia Garrett, Surgical Services Director, states, “the OR budget impact is $250,000 annually (personal communication, May 18, 2005). While the budget impact is a concern, new ACOG guidelines impelled the facility to review the current practice standards. Mrs. Anderson states, “The guideline, recommends that the infant is to be delivered within 30 minutes after a C-Section has been ordered (personal communication, May 17, 2005). Few people live close enough to arrive and set up for delivery in less than 30 minutes. For TRMC to comply, the on-call staff must stay in the hospital. To remain true to the mission of TRMC there is a need to collaborate and develop a plan for the Obstetrical unit’s autonomy.
The Performance Improvement Plan of Tift Regional Medical Center is designed to support our mission, and provide a defined system of planning, designing, and assessing the care provided. The plan also facilitates compliance with the American Nurses Association’s Standard VI: “The nurse collaborates with the patient, family, and other health care providers in providing patient care”(Blais, et. al., 2002, p 201). A project on the agenda of the Quality Management department is the development of a program to train and educate the obstetrical nursing staff to become autonomous in providing full-service care to their patients.
The Quality Management Director, Angie King, has appointed a team of professionals from Labor and Delivery to address the need for improvement in C-Section care. This is to be a collaborative project between the operating room and labor and delivery staff. The team consists of two nurses from each department and a physician champion. The team will use the FOCUS-PDCA method for developing this project. FOCUS is an acronym for the words find, organize, clarify, understand, and select. PDCA is an acronym for the plan, do, act, and check results. The following tableaus an abbreviated description of the process the team took to improve the C-Section care at TRMC(2004).
Performance Improvement Project
C-Section Care: Department of OB
F: Find a Project
Project Name Cost Reduction for C-Section Care
Team Leader Angie King, QM Director
Team Member Jeannie Anderson, L&D Director, Tonia Garret, Surgical Services Director, Pam Long, RN (OR), Laura Phillippi, RN (L&D)
MD Champion Sandra Brickman, MD
The Project is: New: On-Going: √ Date Start: May 26, 2005
Expected Completion Date: December 01, 2005
Brainstorm Session: May 26, 2005
The team met to discuss issues, concerns, and current practices regarding C-Section care at TRMC. Financial and personnel impact information provided.
U: Uncover Mrs. Anderson expressed the need for additional training and education from the OR staff. She also expressed concern about staff resources. She expressed the need to know what happens when the nurse goes to the OR for the C-Section. “What is the usual procedure in other facilities?”
Mrs. Garrett conveyed to the group that other facilities treat the C-Section the same as the care provided for a patient’s delivery that is imminent. This means it would be the same as providing one-on-one care as is the current practice for mothers delivering vaginally at TRMC.
Dr. Brickman validated Mrs. Garrett with information from Northside Hospital and Medical College of Georgia, where she practiced previously.
Laura Phillippi provided a list of nurses that have practiced in other facilities that performed CSection care. She suggested that the team begin with training the OB staff to circulate the cases and continue to provide the CST from the OR until they were comfortable with circulating. The team agreed this would decrease costs and improve
continuity of care. Scrub training would be tabled for the next FOCUS PDCA project.
Pam Long developed an education and training program that would provide C-Section coverage from the OR until three teams on each shift were trained to circulate the C-Section procedure. These teams would then train the other staff with the OR on-call staff as a resource if needed.
Academic Education: Each Wednesday from 2 PM to 4 PM for four weeks. Pam Long to educate regarding perioperative patient care to include: Aseptic Technique, Safe ESU use, Anesthesia Care, and Procedure Counts.
Practical Education: OB staff will observe and learn the techniques for perioperative care in the main OR during GYN procedures. Laura Phillippi will assist with all non-call C-Sections with a participating OB nurse. The on-call staff will continue. If possible the participating OB staff will assist.
D: Do The team agree to begin the PDCA portion Jon une, June 1, 2005on with a target completion date of December 1, 2005.
The team agreed to monitor progress weekly. The team will meet each Monday morning to discuss problems, obstacles, and changes that are needed.
The team plans to adopt the process development when complete. It is expected that in January 2006 there will no longer be a nurse on-call for circulating C-Sections for OB.
In conclusion, “a collaborative approach to health care ideally benefits clients, professionals, and the health care delivery system” (Blais, et.al., p 204, 2002Toby to curb the costs associated with C-Section care at Tift Regional Medical Center, a plan has been developed to eliminate the need for on-call personnel for C-Section care. This initiative is expected to decrease the operating cost by approximately $175,000 in the first year. Additional benefits will be: less time for the case to begin because there is no need to wait for on-call surgical staff to arrive and increased patient satisfaction. After all, the same labor nurse will continue to provide care during the procedure. The team involved in this project has worked diligently to benefit the client and the facility.