Plough Avery C, Galvin Grace, Li Zhonghe, Lipsitz Stuart R, Alidina Shehnaz, Henrich Natalie J, Hirschhorn Lisa R, Berry William R, Gawande Atul A, Peter Doris, McDonald Rory, Caldwell Donna L, Muri Janet H, Bingham Debra, Caughey Aaron B, Declercq Eugene R, Shah Neel T
Ariadne Labs at Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health, the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, and the Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; the Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Harvard Medical School, Boston, Massachusetts; the Health Ratings Center, Consumer Reports, Yonkers, New York; the Technology and Operations Management Unit, Harvard Business School, Boston, Massachusetts; the National Perinatal Information Center, Providence, Rhode Island; the Institute for Perinatal Quality Improvement, Silver Spring, Maryland; the University of Maryland School of Nursing, Baltimore, Maryland; the Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon; and the Department of Community Health Sciences, Boston University School of Public Health, and the Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Obstet Gynecol. 2017 Aug;130(2):358-365. doi: 10.1097/AOG.0000000000002128.
To define, measure, and characterize key competencies of managing labor and delivery units in the United States and assess the associations between unit management and maternal outcomes.
We developed and administered a management measurement instrument using structured telephone interviews with both the primary nurse and physician managers at 53 diverse hospitals across the United States. A trained interviewer scored the managers' interview responses based on management practices that ranged from most reactive (lowest scores) to most proactive (highest scores). We established instrument validity by conducting site visits among a subsample of 11 hospitals and established reliability using interrater comparison. Using a factor analysis, we identified three themes of management competencies: management of unit culture, patient flow, and nursing. We constructed patient-level regressions to assess the independent association between these management themes and maternal outcomes.
Proactive management of unit culture and nursing was associated with a significantly higher risk of primary cesarean delivery in low-risk patients (relative risk [RR] 1.30, 95% CI 1.02-1.66 and RR 1.47, 95% CI 1.13-1.92, respectively). Proactive management of unit culture was also associated with a significantly higher risk of prolonged length of stay (RR 4.13, 95% CI 1.98-8.64), postpartum hemorrhage (RR 2.57, 95% CI 1.58-4.18), and blood transfusion (RR 1.87, 95% CI 1.12-3.13). Proactive management of patient flow and nursing was associated with a significantly lower risk of prolonged length of stay (RR 0.23, 95% CI 0.12-0.46 and RR 0.27, 95% CI 0.11-0.62, respectively).
Labor and delivery unit management varies dramatically across and within hospitals in the United States. Some proactive management practices may be associated with increased risk of primary cesarean delivery and maternal morbidity. Other proactive management practices may be associated with decreased risk of prolonged length of stay, indicating a potential opportunity to safely improve labor and delivery unit efficiency.
定义、衡量和描述美国产科和分娩单元管理的关键能力，并评估单元管理与孕产妇结局之间的关联。
我们开发并实施了一种管理测量工具，通过对美国53家不同医院的责任护士和医师管理人员进行结构化电话访谈。一名经过培训的访谈者根据管理实践对管理人员的访谈回答进行评分，这些管理实践从最被动（最低分）到最主动（最高分）不等。我们通过对11家医院的子样本进行实地考察来确定工具的有效性，并通过评分者间比较来确定可靠性。通过因子分析，我们确定了管理能力的三个主题：单元文化管理、患者流程管理和护理管理。我们构建了患者层面的回归模型，以评估这些管理主题与孕产妇结局之间的独立关联。
对单元文化和护理进行主动管理与低风险患者行初次剖宫产的风险显著增加相关（相对风险[RR]分别为1.30，95%可信区间[CI]1.02 - 1.66和RR 1.47，95%CI 1.13 - 1.92）。对单元文化进行主动管理还与住院时间延长的风险显著增加相关（RR 4.13，95%CI 1.98 - 8.64）、产后出血（RR 2.57，95%CI 1.58 - 4.18）和输血（RR 1.87，95%CI 1.12 - 3.13）相关。对患者流程和护理进行主动管理与住院时间延长的风险显著降低相关（RR分别为0.23，95%CI 0.12 - 0.46和RR 0.27，95%CI 0.11 - 0.62）。
美国各医院之间以及医院内部的产科和分娩单元管理差异很大。一些主动管理措施可能与初次剖宫产风险增加和孕产妇发病率增加相关。其他主动管理措施可能与住院时间延长风险降低相关，这表明存在安全提高产科和分娩单元效率的潜在机会。
