The Wall Street Journal
7/12/2006 â€“ P. D1
THE INFORMED PATIENT
By LAURA LANDRO
Amid Soaring Liability Costs, Hospitals Curb Use of Drugs And Other Procedures to Speed Labor
Hospitals are conceiving new programs to make childbirth safer, amid mounting evidence that overuse of labor-inducing drugs for preterm deliveries and other common practices in the delivery room are endangering both mothers and infants.
Driven by soaring liability-insurance premiums for their obstetrics units, hospital groups are adopting policies to discourage or prohibit births induced before the minimum 39 weeks recommended by maternal and child health experts, unless medically necessary. They are curtailing the use of drugs such as the hormone oxytocin to start or speed up contractions, which in too-high doses can lead to ruptures of the uterus, fetal distress and even death of the infant. And they are limiting the use of forceps and vacuums that can help coax babies from the birth canal but also lead to injuries such as bone fractures and nerve damage.
With communication breakdowns at the root of 85% of all adverse events reported in obstetrics units, hospitals are also taking steps to ensure better teamwork, such as making sure electronic fetal monitors that trace baby's heartbeats are interpreted the same way by both doctors and nurses.
Despite the sharp rise in elective inductions in recent years, which may account for a third or more of all induced births in some hospitals, research shows that delivering babies even a few days early is associated with higher rates of emergency Caesarean deliveries, admissions to the neonatal intensive-care unit with respiratory distress and other problems, and longer-term health issues for children.
The new programs are already changing the experience of childbirth in a growing number of hospitals around the country -- making it harder to schedule deliveries on a convenient day for the doctor or patient, or to give the maximum dose of oxytocin to advance a long and difficult labor. But they are also helping to reduce risks that can lead to devastating harm. Salt Lake City-based Intermountain Healthcare began requiring doctors to obtain special permission to induce delivery earlier than 39 weeks. Intermountain, which operates hospitals in Utah and Idaho, reduced elective inductions at less than 39 weeks to 5% of all births today, from 27% before the program started in 2001.
"The OB is its own little world in a hospital setting, and 99% of the time it's a happy and nice place," says Kathy Connolly, assistant vice president of risk management at the insurance-management unit of Premier Inc., an alliance of 1,500 nonprofit hospitals. But obstetricians don't always adhere to guidelines for elective induction set by groups like the American College of Obstetricians and Gynecologists. They often schedule deliveries around their own office hours or travel plans, and don't always take the time to document care in patient records, increasing hospital liability, she says.
While harm during labor and delivery is rare, relative to the number of births, obstetrics-related cases accounted for 8.1% of all physician-malpractice payment reports to the National Practitioner Data Bank, a federally maintained clearinghouse that maintains data on physician conduct. The median award for a childbirth-related claim involving hospitals and obstetricians was $2.5 million between 1997 and 2003, the highest of any specialty.
The nonprofit Institute for Healthcare Improvement is now expanding a program it launched last year with hospitals affiliated with Premier and Ascension Health, the largest Catholic health system, called "Idealized Design of Perinatal Care." It offers two "bundles" of practices -- one to be used during a decision to electively induce, and one for managing labor that isn't progressing -- which include determining fetal age, monitoring the fetal heart rate, and assessing the readiness of the mother's cervix. While hospitals have long followed such practices to improve outcomes in childbirth, IHI says the key is using all the practices in concert more consistently than many hospitals do.
Managed-care giant Kaiser Permanente, with 32 hospitals, is rolling out its own perinatal patient safety program in its eight national regions, including drills of simulated maternal and fetal emergencies. Doctors and nurses who undergo the new training program interact with specially designed mannequins implanted with a mechanical baby. "Emergencies are rare events in labor and delivery, so it's hard to keep your skills up," says Annie Herlik, Kaiser Permanente director of national risk management.
One of the biggest challenges is reconciling two different sets of terms that nurses and doctors have long used to read fetal heart monitors, developed by their respective professional organizations. Nurses for example, used the term "decreased/minimal" to mean zero to five beats per minute, while to doctors, the same term means three to five beats per minute. The differences have lead to miscommunication about when a baby might be in distress -- and created big liability risks for hospitals.
A new, single set of guidelines was published eight years ago by the National Institute of Child Health and Human Development, but doctors and nurses often fall back on habits they were trained in. Many hospitals are now requiring nurses and doctors to learn the newer guidelines together; Kaiser, for example, is using 20-minute videos that introduce the common language.
Hospitals also are educating mothers-to-be about the risks of early induction, which both mothers and doctors sometimes push for. At Premier-affiliated Baystate Medical Center in Springfield, Mass, for example, staffers conduct informed-consent discussions about oxytocin at the hospital instead of leaving it to a doctor's office visit.
Oxytocin is a hormone released during labor that causes contractions of the uterus. The most common brand name is Pitocin, which is a synthetic version. It's often used to speed or jump-start labor, but if the contractions become too strong and frequent, the uterus becomes "hyperstimulated," which may cause tearing and slow the supply of blood and oxygen to the fetus. Though there are no precise statistics on its use, IHI says reviews of medical-malpractice claims show oxytocin is involved in more than 50% of situations leading to birth trauma.
"Pitocin is used like candy in the OB world, and that's one of the reasons for medical and legal risk," says Carla Provost, assistant vice president at Baystate, who notes that in many hospitals it is common practice to "pit to distress" -- or use the maximum dose of Pitocin to stimulate contractions.
Some hospitals in the IHI program are already meeting or exceeding the target of reducing rates of harm to infants below 3.3 incidents per 1,000 births, compared with a national average of 6.34. At the eight-hospital Seton Health Network, part of the Ascension system, birth-trauma rates have fallen to nearly zero from about three per thousand, and doctors are using vacuums and forceps just 4% of the time, compared with 7.5% before the program's launch in January of 2004, says Frank Mazza, vice president of medical affairs for Seton, based in Austin, Texas.
Intermountain Healthcare says its program has led to a sharp drop in birth complications and decreased the lengths of stay in labor and delivery, cutting costs by $500,000 annually. However, the new efforts are meeting some resistance from obstetricians, who aren't used to having their wings clipped. "It has been hard to get doctors to go along because they don't necessarily believe the risks," says Ware Branch, who heads Intermountain's 39-weeks-gestation program.
Gary Hankins, professor at the University of Texas Medical Branch at Galveston and chairman of the practice committee of ACOG, says doctors can cite hospital policies in declining to do preterm elective deliveries, which are sometimes requested by mothers tired of being pregnant. Elective inductions are "a real life dilemma" for doctors, he says.
The top six contributors to obstetrics litigation:
â€¢ Failure to recognize fetal distress
â€¢ Failure to perform timely Caesarean birth
â€¢ Failure to properly resuscitate depressed baby
â€¢ Inappropriate use of labor-inducing drugs
â€¢ Inappropriate use of vacuum/forceps
â€¢ Failure to communicate
Source: Premier Inc. (from industry data)
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