Midwife-Managed Care Boosts Satisfaction, Reduces Length of Stay in Obstetrics Triage Unit, Study Finds

April 25, 2013 — Summary of "Improving Satisfaction With Care and Reducing Length of Stay in an Obstetric Triage Unit Using a Nurse-Midwife-Managed Model of Care," Paul et al., Journal of Midwifery & Women's Health, March 13, 2013.

As patient satisfaction with care becomes increasingly important to payers for determining reimbursement rates and to consumers in making health care decisions, "there is a need to consider new models for managing obstetric triage units," which struggle with low satisfaction and long length of stay times, according to researchers led by Julie Paul -- a certified nurse midwife at Cambridge Hospital and Cambridge Birth Center and a course coordinator at Frontier Nursing University.

One potential way to boost patient satisfaction and reduce the length of stay is to use certified nurse-midwives/certified midwives (CNMs/CMs) and registered nurses to manage obstetric triage units in collaboration with ob-gyns, the researchers wrote. Although research has linked this care model with higher satisfaction rates in other settings, such as labor and delivery units, no studies have explored "whether CNM/CM models of care are associated with increased satisfaction with care and reduced length of stay in the obstetric triage unit," according to the researchers.

Methods

The researchers developed a quality improvement project to assess patient satisfaction with care and length of stay in a triage unit before and after the implementation of a CNM-managed model of care. The project involved women receiving care in an obstetric triage unit at a community-based hospital in the Northeastern U.S. that has approximately 4,000 births annually. In the first two weeks of the project, the unit followed a standard model of care in which a provider from a private office or the hospital's labor and birth unit would come to evaluate the patient. During the final four weeks of the project, a CNM, who was present in the triage unit all day, would evaluate the patient and collaborate with the woman's physician if her condition exceeded the CNM's scope of practice.

To measure patient satisfaction, the researchers asked women to complete a survey that included questions in six categories: amount of time spent with provider, information given, length of visit, overall care received, overall triage experience and wait time for provider. In addition, a triage unit coordinator recorded the times women entered and left the unit.

Results

During the six-week project period, a total of 272 pregnant women ages 18 and older received care at the obstetric triage unit. Women who were admitted to the labor and birth or antepartum units were not included in the study. The survey was completed by 37 of the 121 women who received care in the standard care group and 66 of the 151 women in the CNM-managed group.

"Overall, women were very satisfied to extremely satisfied with their care from both" models, but "significantly more of the women in the CNM-managed group were extremely satisfied with their care," the researchers wrote.

Women were significantly more likely to be extremely satisfied with care in the CNM-managed group for five of the six categories that were measured: wait time for provider, time spent with provider, length of visit, overall care received and overall triage experience. However, the two groups did not have statistically significant differences in terms of their satisfaction with information given.

The average length of stay was significantly shorter among women in the CNM-managed group at 94.7 minutes, compared with 122 minutes for the women in the standard care group.

Participants also were asked to answer two open-ended questions on what they found most helpful while at the triage unit and what they would improve. On the first question, women in both groups responded that the "elements of emotional support and knowledge provided" were the most helpful. The second most-common theme identified as being helpful "was reassurance provided by the staff/provider."

Only 30 women answered the question about what they would improve; 24 said that they "would not change a thing." Two of the remaining six who were in the standard care group suggested having the CNM or physician readily available in the triage unit, while the others made suggestions such as improving the waiting area or preregistration process.

Discussion

The project demonstrated "that satisfaction with care was increased" with the use of CNM to manage the obstetric triage unit, which is "congruent with the results of other studies examining women's satisfaction with midwifery care and time spent on the unit," the researchers wrote.

"Although the findings of this project indicate that women had higher satisfaction with CNM-managed care, it is possible that it was not the midwifery component of the care but simply having a dedicated provider staffing the triage unit," the researchers noted. They recommended that future studies directly compare CNM and physician care with regard to satisfaction and cost.

The study "demonstrates support for creating a collaborative, interprofessional midwife, nurse, and physician approach in the obstetric triage setting," the researchers wrote. Such an approach efficiently uses each provider's area of expertise, they noted, adding that it "frees up the physician for higher acuity patients and allows the CNM/CM the opportunity to practice to the full extent of her/his scope of practice."

The shorter length of stay in the CNM-managed model "translates into a more timely assessment," which can improve patient outcomes, and "also may result in cost savings due to provider efficiency and a quicker bed turnover," according to the researchers.

They concluded, "The creation and implementation of this midwife-managed obstetric triage model will place midwives in a position to improve the quality of the woman's experience."