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New Series #1-Admission and NSVD of laboring patientsFrom: MBK80@aol.comMon Dec 30 23:17:41 1996
Thank you for supporting this concept. The format is open to improvement, criticism etc. Lets not give up intellectual individualism but share ideas that will help each of us continue to be creative, productive and cost effective. For the first case in the series, lets discuss the tests and supplies we use as we care for the laboring patient. Lets assume for this case that the result will be a NSVD. VBAC and C/S to be discussed at another time. These are uncomplicated primigravidas and multiparas. 1-Admission- Admission should be ordered when patients are in active labor. Admission in the latent phase (<3cm) may result in prolonged labor, unnecessary invasive procedures, higher c/s rates, and greater expense. Admission of the patient with PROM at term may be deferred until the patient goes into spontaneous labor (many clinicians will prefer to have a reactive nst prior to allowing this patient to go home to await the onset of labor. I dont want to get into a discussion here regarding this issue, the main point is that just because PROM has occured, admission does not have to be automatic. Our experience is quite favorable with conservative management when appropriate with resultant lower cost and no increase in morbidity. Yes, the B strep issue is a concern. Tests ordered- CBC -No more preps and enemas. U/A seems to be a waste of money. The blood bank may accept a "tube to hold", without charge, to be later used for a type and screen if needed. Of course this assumes routine prenatal labs have been previously obtained (type rh, hbsag, rubella titer, ab screen, sickle prep, hiv, rpr) Monitors- as you deem necessary- Many hospitals now are on a case rate and monitoring does not cost more, however, remember it "costs" the hospital to use a monitor , for its monitor paper, fileing, nurse observers, etc. I think we are all familiar with the literature on monitoring . Remember that internal monitors are very expensive. IV's- are they really necessary in many laboring patients??Just food for thought for those of you still using them routinely.Obviously, we are not discussing those patients with epidurals, PCA's etc., but even those patients requesting IV analgesia may ask not to be "tied" to an IV. Delivery- Remember that gases, and placental pathology are expensive. I know of many that do these routinely. It is difficult to not be cost effective at delivery.Its usually during labor that we consume so many expensive resources. Most of us are using a standard delivery pack. Food for thought- did you ever look to see how much of the pack you don't use. Do you use drapes??? We don't and it really isn't necessary. Certainly many hospitals require docs and midwifes to gown and use protective shields. This is for each to decide on for safety. Getting the L/D area to customize the delivery set up based on what members of the dept. use might be helpful to reduce costs. Post Partum- we dont do any labs unless a PPH is incurred. Analgesia per patient request but certainly not a need for epidural narcotics. We have found many of the typical epifoams, proctocreme and stool softeners are not necessary. We stopped using them a few years ago. Liberal use of ice packs and sitz baths after 24 hours works nicely. Discharge home any time after 8 hours with good home support in a motivated, educated patient, to 24-48 hours based on individual needs. For the most part we find our patients wanting to leave after a 1 night stay. Many docs keep their patientsd 2 days by routine , and this is expensive.We do many circumcisions in the office due to scheduling and working around the pedi visit. Following this approach has produced a c/s rate in the 15-20% range and a cost profile placing my associate and myself in 2 of the top 3 cost effective positions in our dept.. We've had no serious complications, infections, readmissions, neonatal problems etc. Please add any suggestions regarding these ideas for all to share.
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