Abstract
In many instances no provision is made for obstetric analgesia service (OAS) because it is thought to be costly, labor intensive, and lacking in adequate reward. Because staff expense is the major direct expense involved in an OAS and workloads are unpredictable, a pilot study was conducted to quantify manpower costs by prospectively monitoring the time spent providing OAS to 55 parturients at Duke University Medical Center. A modified form of the classic time-and-motion studies developed for use in industry and later adapted to hospital work was used. This design is based on developing labor standards using a series of timed observations with times recorded by the staff performing a given task. All time spent at the bedside was recorded. Nearly half of the women studied were nulliparas. Labor was induced in 40 percent of cases. There were 34 spontaneous vaginal deliveries and 11 cesarean deliveries.The bedside time for managing a labor epidural averaged 90 minutes, about half of which was needed to position the block, confirm adequate analgesia, and document the procedure. An average of six bedside visits were made during continuous lumbar epidural analgesia, but the number of visits did not correlate with the total time spent by anesthesiology staff at the bedside. Nulliparas required significantly more staff time (104 vs. 79 minutes), which reflected not more visits but longer ones. The total time spent in direct clinical activities for placing and monitoring anesthesia, including continuous presence during operative delivery, averaged 9.2 h/d, or 64 hours in a single 1-week period. To meet demand over the course of the study required 1.15 full-time equivalent (FTE) attending anesthesiologists. The figure rose to 2.0 FTE after allowing for paid time off and to 2.5 FTE after allocating one nonclinical day each 5-day work week for such activities as research and teaching. Actual staffing with 1 FTE attending anesthesiologist required at least 3.0 FTE for round-the-clock coverage, and the adjusted figure was 4.4 to fill one position. The cost per OAS patient was $325 assuming that an anesthesiologist would be available to meet all demands for OAS. The average indemnity reimbursement for OAS in fiscal year 1998 was $299. Medicaid reimbursement for this period, approximately $421,000, failed to cover the actual staffing costs of $516,000. There is a shortfall in covering OAS costs in this setting, even with intermittent staffing and taking account of positive-margin operating room activities. At present, full-time dedicated obstetrics staffing is not profitable.Anesthesiology 2000;92:851–858