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Excerpt
Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
Anesthesiology, 92: 851–858, 2000
Obstetric analgesia services (OAS) have been characterized as costly, labor-intensive, and poorly rewarded. The workload is unpredictable, and staff requirements are difficult to forecast. A pilot study sought to identify the manpower costs to the anesthesia providers of operating OAS. The costs of providing both attending anesthesiologist coverage for on-demand (intermittent) and for around-the-clock (dedicated) services were examined.
The prospective study recorded the time spent managing labor epidural catheters in a total of 55 parturients. In a modification of classic time and motion studies developed for industry, the staff performing the task recorded their own times for activities. The individual anesthesia staff kept an account of all time spent at the patient’s bedside, from the preoperative chart evaluation to the postprocedure visit. Time measurement for management of OAS stopped when the decision was made to perform cesarean section (CS).
During the study period, 42 (76%) labor epidural catheters were placed by the resident on duty supervised by the on-site attending anesthesiologist, 7 (13%) by the certified registered nurse anesthetist supervised by the on-site attending anesthesiologist, and 6 (11%) by the attending anesthesiologist without assistance. There were 34 spontaneous vaginal deliveries, 5 vacuum-assisted deliveries, 4 low or outlet forceps deliveries, and 11 CSs. The mean duration of OAS was 412 min and the mean bedside anesthesia staff time 90 min. A mean of 6.3 visits were made to each patient’s bedside. The calculated labor cost for intermittent staffing was $325 per patient. Dedicated staffing, the actual practice at Duke University Medical Center (DUMC) requires a cost of $728 per patient.
The cost per OAS patient was not covered by average indemnity ($299) or Medicaid ($204) reimbursements. Dedicated obstetric staffing cannot operate profitably at DUMC, and breaking even cannot occur with Medicaid reimbursement. Because operating room reimbursement subsidizes OAS costs, it is possible to break even under indemnity reimbursement.
