I thought we might start by having a place to post the ideas behind porting a labor triage system over to MGH. We are currently at about 1600 births/year. I would be interested in your thoughts regarding the volume and possible viability of a triage system hn

-- Anonymous, March 22, 1999

Answers

I will get in touch with our county clinic obstetrician, who has been leading the OB hospitalist idea which has fallen on such hard times. Hopefully he will sieze on the triage unit as an alternative

-- Anonymous, March 24, 1999

A Labor Triage Unit offers several opportunities to enhance care in L&D. First it offers an area for the initial evaluation of several pertinent clinical questions such as: 1. Is the patient truly "in labor" (ie; strong contractions, 2 minutes apart) or not? 2. Is that just "bloody show" or is this an abruptio placenta? 3. Are the patient's membranes ruptured or not? The old system we had at ABMC required that the patient be admitted to a labor room to do this evaluation. If the answers to the above questions were answers that meant that the patient did not need admission at this time it was difficult to discharge the patient once they (husband, labor coach, video equipment, relatives) had moved in. In addition, if the patient was discharged the room required a full housekeeping cleanup at much time and cost. The result was that a lot of patients that didn't need immediate admission were admitted anyway since "they were already there". Since they weren't "in labor" many spent the night sleeping or getting Pitocin when they could have just gone home and come back in a few hours. The Labor Triage Unit offers an environment that is compatible with a short, quick, answer one question, evaluation. It acts somewhat like an ER in that it does not create the expectation of admission but only of evaluation. Secondly, the nurses that work in the Labor Triage Unit are chosen to facilitate this rapid evaluation. Additionally, if the patient IS in labor and does require admission the initial evaluation of dilatation and station is done by a nurse that is doing this "all the time" and has a consistant, hopefully reliable, ability to produce this clinical data. If the patient is admitted to a labor room for this evaluation the variability in the clinical data is greatly increased. The ability to account for savings due to institution of such a unit is difficult to measure. Empirically, the obstetricians "know" it saves money. But we have been unable to find a formula to confirm this perception. We looked at the average variable cost of a delivery; but there are so many variables that impact that number that any savings got lost in things like "c-section rates", "increase in post-term inductions", "VBAC's" etc., etc. If you want to persue this you should first demonstrate a need. Are the patients currently having their initial evaluation in a labor room? Is the clinical data variable to the point that the obstetricans are skeptical of the data? Are a lot of patients being admitted to L&D who are not in "true labor"? If some, or all, of the answers are "yes" there may be a need. To attempt to implement, I suggest that you get a "project champion". Non-obstetricians WILL NOT WORK. You need an OB, and perferably one who has the respect of the Marin OBs. I would suggest George Lee from CPMC. CPMC had th initial unit the we copied at ABMC. He is very enthusiastic and genereous with his time for this cause. He came to ABMC on two separate occasions to discuss and support the effort. If you can find a local OB to hook up with both the idea and George it will become easier. I would be happy to provide some data from ABMC to further support our effort and know of at least one OB from ABMC who would proably agree to come to Marin to talk about the ABMC experience. If we could do it at ABMC with a group (and I use the word in its loosest possible form) of extremely independent and internally competative obstetricians then it's doable elsewhere. We currently have 92% of all women coming to L&D going through initial evaluation in the Labor Triage Unit. Good luck!!!

-- Anonymous, March 23, 1999