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9 February 2016

Major Corporations Including Coca-Cola and Macy’s Band Together to Take On Rising Healthcare Costs

The private sector has joined the impetus toward value-based care, and in a big way. Twenty of the nation’s largest companies announced Friday that they have formed the not-for-profit Health Transformation Alliance. The Alliance, which includes American Express, Coca-Cola, HCA, IBM, Marriott, Macy’s and Verizon, is aiming to dramatically shift the way companies provide healthcare benefits. Its website asserts that “The health care status quo cannot be maintained” and that its members are bringing their collective resources to bear to “fix what’s broken and transform the corporate health care marketplace to help our employees, retirees and their dependents.” 

The Alliance will focus on improving healthcare supply chain efficiency by reducing redundancies and waste. The participants, which provide coverage for roughly 4 million employees in total, will begin sharing and aggregating their data on employee health spending and outcomes as early as this year to help them identify which treatments and providers deliver better outcomes. They potentially could use incentives or recommendations to encourage employees to choose those providers.

According to a Wall Street Journal article by Louise Radnofsky, some members say the Alliance will consider forming a purchasing cooperative to use their collective market power to negotiate lower prices and might also “take a hard look at the industry’s middlemen, such as pharmacy-benefit managers and the third-party administrators.” The Alliance is expected to announce a pilot project for 2017 that will focus on lowering prescription medication costs. Participants hope that additional companies will join this cross-industry initiative.

This push by many of the country’s top corporations adds to the already building pressure that government mandates and incentives are putting on the U.S. healthcare system to deliver value-based care. Health providers who do not transform their care model to deliver demonstrably value-based care quickly could soon risk losing revenue based on corporations’ analysis of their cost/quality of care value proposition.

Here are a few strategies to consider that can help your hospital or health system improve outcomes, patient satisfaction and efficiency:

4 February 2016

The Drive for Process Improvement Part 1: Making Champions of Believers

Three leaders from the International Consortium for Health Outcomes Measurement (ICHOM) – a nonprofit founded by organizations known for progressive business practices and rigorous research: Harvard Business School, The Boston Consulting Group and the Karolinska Institutet – published an article in Harvard Business Review that analyzes the success some healthcare organizations have had in implementing patient outcomes measurement programs. The article lists five steps that should be applied when implementing major change or process improvement within healthcare systems. This blog post is the first in a series of five that critique and nuance each ICHOM step from a Kaizen perspective.

Identifying a Champion

The first imperative outlined by the ICHOM is finding leadership that is invested and enthusiastic about the process change at hand, otherwise known as believers. Although the need for believers in any change is apparent, the benefits that may be derived from capitalizing on a believer’s unique perceptions, passion and leadership qualities are essential to effective transformation of a department and implementation of change. A Kaizen approach demands identification of specific individuals among a group of believers that may be enabled as a champion of the change you are trying to implement.

Champions have specific qualities that optimize the development of process improvement strategies. Any champion must demonstrate a passion for process improvement. Champions frequently take initiative on account of an obvious need for change or an inability to meet departmental goals. An ideal champion has stable, influential networking in their current system.

Developing a Vision

Development of vision is a crucial step in the formation of a champion who will advocate for robust process improvement. Vision may be an inert quality within a champion or it may be necessary for the administrative staff demanding improvement to encourage and develop a strong vision to pursue perfection in departmental functions. In any case, administrative staff must be available to assist a champion in refining vision and ensuring the visibility of the champions approach to process excellence within the department.

The greatest challenges further display the resolve of the strongest champions. Model champions are conditioned by seemingly insurmountable challenges. Ken Colaric, M.D. of Saint Mary’s Medical Center in Blue Springs, Missouri recognized that his Emergency Department used an antiquated model of sequential ED care that prevented patients from seeing ED professionals as they became available. In the course of a three-day Kaizen event, Dr. Colaric championed the development of a streamlined, efficient model of care that reduced average stay times by 30 percent and reduced the “left before being seen” rate by a staggering 88 percent. The vision Dr. Colaric pursued has resulted in Saint Mary’s swift transformation to a model of efficiency.

Team Building

An ideal champion recognizes that individuals are not responsible for the successes and failures of their team. Rather, the success of a system is dependent on the team’s communication and dedication. A team cannot build trust and synergy if it overly scrutinizes its constituents as it attempts to improve departmental functions. Instead, scrutiny must be devoted to the process to determine inefficiencies and opportunities for improvement. Champions may thereby mentor members of their team and effectively guide the greater group. Ultimately, an ideal champion elevates and inspires those around them.

The champion and the members of their team thereby gain knowledge of the process through direct observation. As team members begin to understand the dynamic nature of process improvement, they become believers as well. In this manner all team members realize that active engagement by all stakeholders is necessary to implement positive change. Entire teams of believers that recognize the benefits of constructive criticism and the dangers of complacency set themselves apart from their competition.

The secret to a successful team is a champion who does not simply demand discipline, but inspires it as well. Kaizen thought makes it clear that it is not simply enough to find believers to most effectively implement organizational change, rather you must find a champion capable of creating believers.

Final Thoughts

A Kaizen event may be a fixed point in time, but the philosophy is derived from the Japanese word for improvement. As a philosophy, Kaizen demands consistent awareness of the drive toward process improvement. For this purpose, you must encourage transparency, as trust is essential for every hospital team. A simple way to promote awareness and transparency is to place a visualization of progress to a departmental goal in a visible location. Give your team a statistical reason to believe in systemic improvement. It is possible to implement substantive Kaizen change through simple actions within your department.

27 January 2016

Three Sheridan Physicians Make List of Top Ambulatory Surgery Center Leaders

We are pleased and excited to announce that three Sheridan doctors have been included in Becker’s ASC Review’s annual list of ASC industry physician leaders to know. The doctors named include:

 
  • Nader Fahmy, MD: Dr. Fahmy is an anesthesiologist with Liberty Anesthesia & Pain Management in Freehold, NJ. He works with a number of medical centers including CentraState Medical Center, Freehold Surgical Center, Center for Ambulatory and Minimally Invasive Surgery and Northern Monmouth Surgical Center.

 

  • Andy Kim, MD: Dr. Kim is medical director at Princeton Anesthesia and is Director of Surgical Specialists of Princeton in New Jersey. He is board-certified in both anesthesiology and pediatric anesthesiology. After his anesthesiology residency at Massachusetts General Hospital, he completed his pediatric anesthesiology fellowship at Boston Children's Hospital.

 

 

 

  • Michael Pham, MD: Dr. Pham is an anesthesiologist and director of Jersey City’s Liberty Ambulatory Surgery Center, which offers treatment and surgery pertaining to numerous specialties including colorectal surgery, general surgery, gastroenterology, gynecology, neurologic surgery, orthopedics, vascular surgery and pain management. The ASC is accredited by The Joint Commission.

 

 

 

At Sheridan, we enthusiastically promote the professional development of our physician leaders to drive healthcare innovation and best practices among our client facilities. We are pleased to further recognize the exemplary leadership of these three outstanding Sheridan physicians. Congratulations!

25 January 2016

HCAHPS: Challenges of Increasing Patient Satisfaction in the ED

As healthcare reimbursement continues to shift to a value-based scale, patient satisfaction scores are playing a larger role and are receiving more attention from hospital executives.

According to a recent article in HealthLeaders, 1.5% of all Medicare payments in 2015 are based on a hospital’s Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score. This will increase to 2% by 2017. While elements of patient satisfaction and quality scores have always been a priority for healthcare providers, the increasing monetary value that is tied to these metrics elevates those issues even more. The following graph, which was included in the HealthLeaders article, illustrates this shift in priorities.

As the graph illustrates, there is a tremendous focus on patient satisfaction – which can be a difficult metric to achieve in the emergency department. Sheridan’s own Dr. Catherine Polera spoke with FierceHealthcare’s Ilene MacDonald about this issue and how to achieve patient satisfaction in the ED. As chief medical officer for Sheridan’s emergency medicine division, Dr. Polera knows how important patient satisfaction is in the ED, and the barriers to achieving it.

The first challenge is evident: the emergency department is a place where doctors are short on time and can be dealing with critical situations — conditions that make it difficult to exceed patients’ expectations for the timeliness of their care and the attention they receive. As Dr. Polera points out, all patients in the ED want to be seen immediately, but doctors and nurses often need to triage in order of acuity. Many patients are not aware of the intake processes, so the key is matching perception to reality. Communication is key here, and triaging must be explained so as to match patient expectations with reality. If patients do not expect that they will be seen immediately, they are more likely to be understanding of a reasonable wait. Be real; if there is a wait, apologize. Try to connect with the patient. Assure them that you acknowledge their complaint is legitimate.

The other challenge is one that plagues doctors in all departments: lack of customer service training. Dr. Polera rightly makes the point that many hospitals expect doctors to take it upon themselves to improve the patient experience though they have never been trained on how to do so. This is an aspect of training that can easily be incorporated into ED orientation and continuing education programs.

Dr. Polera can speak about these difficulties from her own personal experience. She struggled with patient satisfaction scores fresh out of residency. She often used complicated medical jargon when explaining diagnoses to patients; but over time, learned to treat patients as she would her friends or family members. “It’s not enough to know the medicine,” says Dr. Polera. “You have to be a well-rounded provider. The expectation is that we do more than get [diagnosis and treatment] right. We are doing it in a timely manner and with a smile on our face.”

14 January 2016

Elements of a Successful Maternal-Fetal Medicine Program

Expectant mothers have a lot on their minds, and those who are facing high-risk pregnancies are under significant stress. They require not only education and counseling but also close, ongoing medical monitoring to mitigate the risks and improve the chances of a safe and healthy delivery. A successful maternal-fetal medicine (MFM) program helps ensure that both mothers-to-be and their developing babies receive optimal care.

The Role of MFM Physicians

In its 2014 special report on the maternal-fetal medicine subspecialists’ role within a health care system, the Society for Maternal-Fetal Medicine (SMFM) defined the scope of maternal-fetal medicine as including specific elements of preconception care, specialized prenatal care, labor and delivery and associated complications, obstetric complications, maternal complications, fetal anomalies, fetal complications, fetal testing, gynecologic issues related to pregnancy and their impact on pregnancy, and postpartum care. The role of the MFM physician complements that of obstetric care providers. MFM subspecialists provide consultations, co-management or transfer of care for complicated patients.

While acknowledging that more research is needed to evaluate the impact of MFM care on outcomes, the SMFM report cited several published examples of evidence of improvement. These include primary MFM subspecialty care of high-risk patients resulting in less prematurity, lower cesarean section rates, fewer low 5-minute Apgar scores, and lower perinatal mortality rates, as well as the association of MFM-designed and -led care in a recurrent preterm birth prevention clinic with reduced rates of recurrent spontaneous prematurity and major neonatal morbidity as compared to patients treated by their primary provider.

MFM Services and Procedures

A successful MFM program should provide the following services and procedures:

  • High-Resolution, Targeted Ultrasonography - Including Tele-radiology 
  • Fetal echocardiography
  • Co-Management of multiple gestations
  • Co-Management of preterm labor and other antepartum conditions
  • Co-Management of other maternal medical conditions during pregnancy including but not limited to diabetes, hypertension, autoimmune disorders, thyroid, thrombophilia, etc.
  • Transabdominal Cerclage (TAC)
  • Assessment of Fetal Well-Being
  • Transabdominal/Transvaginal Chorionic Villus Sampling
  • Diagnostic and/or Therapeutic Amniocentesis
  • Percutaneous Umbilical Blood Sampling (PUBS)/Intrauterine Fetal Transfusion (IUT)
  • Transvaginal (McDonald or Shirodkar) and Transabdominal Cerclage
  • Preconception Counseling
  • Referral, when appropriate,  for interventional fetal surgery, including:  sacrococcygeal teratoma, congenital diaphragmatic hernia , open neural,  twin-twin transfusion and laser therapy for fetal tumors  among others

In addition, an MFM program should provide access to an extensive array of screening and diagnostic genetic tests, including:

  • Genetic Counseling and Genetic Carrier Screening
  • First Trimester Nuchal Translucency/Nasal Bone and/or Sequential Screening
  • Non-Invasive Prenatal Testing (NIPT) – Analysis of Fetal DNA in Maternal Blood

Implementation Challenges

A successful MFM program can add a lot of value for a hospital, but setting one up is often challenging. Hospitals that begin building a program without a fair amount of prior MFM-specific management experience among the leadership find it difficult to cost effectively develop and maintain all the necessary capabilities. For this reason, it's not uncommon for hospitals and health systems to rely on more experienced partners to develop and eventually manage their MFM departments; the partner's experience managing dozens of MFM programs often means the difference between profit and loss for the entire department.

Contact Sheridan Healthcare today if you would like to learn more about how we help hospitals across the country develop and manage world-class maternal-fetal medicine programs.

7 January 2016

Improved Care through ED-Hospitalist Integration

Improving communication and collaboration between emergency department physicians and inpatient doctors, such as hospitalists and intensivists, has numerous benefits to physicians, hospitals and patients. An integrated model increases patient throughput and patient satisfaction, decreases costs stemming from redundant treatments, and improves patient safety and quality outcomes.

The transition of care from the emergency department to an inpatient bed is a complex process with numerous steps and moving parts, and is consequentially a difficult process to streamline. Hospital departments have traditionally operated within separate silos, focusing on the state of their intradepartmental communication rather than interdepartmental communication. This lack of interdepartmental communication and teamwork has been thrust into the spotlight recently due to regulations changing the way hospitals are reimbursed for the care they provide.

With these changes, there is increased pressure to put patients in the right level of care (inpatient, outpatient, observation) based on that patient’s diagnosis. Hospitals that do not correctly level patients stand to lose money by not being reimbursed fully by insurers for the care provided. Additionally, patients are often hit with surprisingly high medical bills if they are leveled incorrectly, contributing to dissatisfaction. Ineffective communication during the transition may also lead to duplicated testing or treatments by the other department, resulting in wasteful redundancies for the hospital.

Therefore, hospitals have a lot riding on the quality of communication between ED and inpatient departments. How can hospital leaders increase the amount of integration between these two departments? Below are several ideas:

  • Ensure that each department understands the other’s goals, challenges and metrics. Establishing mutual goals and measurements of success can accelerate this process by making each department’s performance dependent on the others.
  • Reassess the communication channels at your facility. Do the members of each department have easy access to the members of the other department and, if not, what needs to change in order to make that possible?
  • Have department leadership attend the meetings of other departments. This keeps each department up to date on the needs, challenges and goals of the other department. Additionally, each will have a voice in the planning processes of the other and therefore an incentive to stay engaged.
  • Hold a time and space for members of different departments to get to know each other on a more personal level. This can improve trust and overall morale within and between departments.
  • Create a standardized criteria for patient leveling. Even if the communication lines are open and the trust between departments is strong, department collaboration will break down without a standard definition of inpatient admission versus observation admission, etc. Standardized admission criteria alleviates confusion about which department is responsible for a patient and increases the timeliness of decisions — creating a smoother flow of patients and improving patient satisfaction and quality outcomes.

Emergency and inpatient departments have a lot of overlap and are mutually dependent on one another to provide the highest quality outcomes for patients. Integrating these two teams of physicians can be one way to ensure that this overlap is seamless and to realize all the benefits that come with enhanced intradepartmental teamwork.

22 December 2015

Why Innovative Emergency Departments Recruit and Retain the Best Doctors

An earlier Sheridan blog post discussed hospitals’ need for defined and strategic recruitment and retention programs, especially in emergency medicine. The ugly truth is that emergency medicine will continue to be an “undersupplied specialty” for at least 20 more years. Since emergency medicine physicians also experience the highest rate of burnout among all specialties, it’s clear that recruiting and retaining the best of the best in emergency medicine will be a significant challenge for hospitals and health systems moving forward.

According to a recent Medscape article, “feeling like just a cog in a wheel” was the sixth leading cause of burnout for physicians in 2015. Of all the other factors that can lead to physician burnout, this is the one that hospitals can exercise the most influence over (unlike other factors, like the computerization of healthcare or the impact of the Affordable Care Act). Empowering physicians to take ownership of the processes and protocols within their departments and find opportunities for improvement is one way to alleviate that “cog” feeling. Not only can hospitals help physicians feel more fulfilled in their careers, but in doing so, the hospital as a whole stands to benefit.

Encouraging physicians to find innovative ways to improve inefficiencies in the ED empowers physicians to change the status quo. Physicians have intimate knowledge of the operations within their department and can have extremely insightful views on what needs to be fixed. Giving physicians a venue in which to raise these issues and offer solutions increases their engagement and job satisfaction, while also identifying process improvements. Furthermore, when process improvements are generated by the physicians themselves, they are automatically invested in the success of their solution. This helps overcome one of the biggest impediments to change within the hospital – physician buy-in.

Sheridan recognizes that committing to their physicians personal and professional growth is crucial to attracting and retaining the top talent. Recently, Sheridan held its first annual Innovate Emergency Medicine (iEM) Conference, which gave Sheridan physicians an opportunity to share ideas and learn from one another’s departmental innovations. Emergency medicine physicians from Sheridan facilities around the country came together to present unique ideas for improving the ED, particularly in response to changes brought on by the ACA, mobile technology and other factors that influence the modern ED. At this year’s conference, physicians shared ideas on improving communication among staff members, driving innovation and change within a hospital, and the changing role of technology in medicine.

The iEM Conference is an exceptional venue for physician’s innovations, but smaller, simpler channels can be just as effective. Sheridan also hosts an online physician portal where doctors can swap challenges and ideas. The company also conducts a Leadership Academy, which offers ongoing education and training for Sheridan clinicians. All medical directors participate in this collaborative environment, which focuses on effective communication, process efficiencies and other operational issues.

Allowing physicians to have a say in the way their departments are evolving is one of the best ways to combat physician burnout, and should be a part of any effective retention strategy. In the end, both parties win because the hospital benefits from the physician’s perspective and direction.

Stay tuned for an upcoming video from the iEM conference. If you want to learn more about how Sheridan helps hospitals run efficient emergency departments that attract staff and increase patient satisfaction, check out our “The Evolving Emergency Department” white paper.

15 December 2015

Value-Based Care and Population Health: The Anesthesiologist’s Role

By Dr. Adam Blomberg, National Education Director, Anesthesiology Division

In a recent article in the Wall Street Journal, Geisinger Health System CEO David Feinberg shared some very useful insights into how his health system approaches population health. Chief among them were the importance of integrating care delivery with one's insurance plan and taking a data-driven approach to patient care. I agree with all of Dr. Feinberg's ideas in the article, but wanted to add one important point: in addition to integrating care delivery and insurance, hospitals must also better integrate their staff to ensure they're operating as efficiently as possible.

When it comes to care coordination, I would argue that overall, healthcare has a long way to go before we see a truly integrated healthcare delivery system. While many systems in the United States – such as Geisinger – are effectively integrated, there remains a critical disjoint between the different levels of care throughout most of the industry. Within the hospital, there are often dozens, if not hundreds of process flaws resulting in reduced coordination, rework, increased costs and reduced patient safety. While efforts have been made to address these issues at the department level, what is needed is a comprehensive evaluation of the community’s needs relative to the existing infrastructure. This appraisal is a key part of delivering value-based care and managing population health.

As value-based practices advance, a few core medical specialties (PCPs, hospitalists, intensivists, anesthesiologists, and others) will take the lead in coordinating patient care efforts across the continuum. In my experience, one of the most critical players in achieving this integration is the anesthesia team – and, in particular, their management of the perioperative process.

One universal opportunity for improvement is the preoperative testing process, including the multitude of moving parts involved in safely “clearing” a patient for surgery. Regardless of whether the patient is scheduled for elective (IP or OP) or emergency surgery, the provider must ensure that the patient is physically able to cope with the stress of anesthesia and invasive surgery. It is the duty of the anesthesia care team in coordiation with the surgeon and patients PCP to make the final decision – but in many cases, the methods they have for communicating this information to both patients and teammates are inadequate.

At Sheridan, we address this challenge using ClearPATh, our proprietary pre-admission testing framework. ClearPATh facilitates value-based care by helping anesthesiologists reduce or eliminate unnecessary testing, consultations and preoperative visits. Most importantly, it gives them the tools to coordinate all the aspects of patient care that they touch, which increases efficiency and frees up other OR resources. For example, PCPs spend less time coordinating with the hospital and anesthesia team, allowing them to see other patients; likewise, hospital providers are freed from performing numerous unnecessary evaluations to clear their patients for surgery.

If we think of the healthcare system as an assembly line, with each element contributing to end product (population health), we recognize that the details and incremental improvements matter at least as much as the overall strategy. Dr. Feinberg gets the big picture parts of value-based care right, but it's important to remember that the little details can matter just as much.

If you'd like to learn more about how Sheridan uses ClearPATh to help anesthesiologists at our partner hospitals deliver better care, check out this blog.

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7 December 2015

Strengthening Radiology: The Importance of Standards

Top executives at health systems realize that establishing radiology standards is a primary concern for their hospitals. Healthcare organizations must aim to develop best practice criteria and establish tangible goals for radiology practices, particularly since there are no national regulatory standards. Ignoring the challenges and maintaining the status quo will not work; the impact of radiology on the quality and cost of care is simply too high.

As mentioned in our previous blog post, it’s clear that the majority of hospitals will not be able to meet all their imaging needs using internal resources alone. To ensure quality across both internal and external radiology resources, clear and stringent standards must be put in place. Because radiology primarily concerns the transmission and interpretation of digital data, it is easier to standardize than many other services. And once standardized, these improvements can be easily scaled to serve all the hospitals and radiology groups within a health system.

When coupled with an increasing demand for specific subspecialty resources, the need for standardization – both in terms of quality standards and process design – makes new paradigms for radiology management necessary. One of the most useful new management methods is distributed radiology, which uses software to network subspecialists remotely. This gives individual hospitals a much wider range of specialty resources than they would typically be able to afford, while also reducing costs and improving patient care. It also helps with standardization: as demonstrated in our last blog post, radiology operations often become fragmented as health systems grow, with each individual hospital in the system developing its own process. These processes become much easier to standardize and scale when they're managed with a distributed radiology program.

Distributed radiology platforms also eliminate the old constraints of geography and time, which both limit patient care. When hospital-based radiologists are connected with a system-wide and comprehensive support network of subspecialists, the highest standard of patient care becomes available constantly. Only the largest health systems can achieve continuous access to all subspecialty resources using in-house resources alone, and even the ones that can find it very difficult to maintain profitability.

Distributed radiology platforms work so well because they're able to deliver these resources more comprehensively, systematically and cost effectively than in-house systems can. In particular, they excel in five key areas:

  1. Workflow routing, which ensures that the right radiologists are reading the right studies every time, taking into account subspecialty expertise, availability, payer regulations and more;
  2. Integrated quality processes (such as double-blind and secondary reviews for high risk cases) in all studies where they are needed;
  3. Real-time decision support and live subspecialty consultations at the point of care;
  4. Data standardization for reporting, benchmarking and analytics by facility, referring physician, radiologist, modality and patient setting; and
  5. Mobile capabilities, including delivery of critical findings for faster communication, access to radiologists for on-demand consultations and access to patient information (including final reports, addendums and images).

To learn more about how distributed solutions can help your health system build a robust and comprehensive radiology offering, check out our white paper or read the other posts in our radiology series.

1 December 2015

Platelet Count Considerations for Labor Epidural Catheter Placement Guidelines

The Society for Obstetric Anesthesia and Perinatology (SOAP) Patient Safety Committee surveyed its members to assess current practices surrounding labor epidural catheters and platelet counts. The survey results highlighted the varying parameters for requiring a routine platelet count prior to labor epidural placement in low-risk patients.

The clinical significance of thrombocytopenia and the need to routinely obtain a platelet count on all parturients prior to a neuraxial block are areas of debate. Causes for thrombocytopenia range from gestational thrombocytopenia, idiopathic thrombocytopenia, preeclampsia and HELLP syndrome. According to Anesthesia and Analgesia, there is a 5-7 percent incidence of asymptomatic thrombocytopenia (platelet count less than 150K) in women presenting for delivery. The ASA guidelines strongly agree that obtaining a platelet count in patients with suspected or existing preeclampsia, HELLP syndrome or a suspected coagulopathy reduces maternal anesthetic complications. However, the ASA obstetrical guidelines state that “The anesthesiologist’s decision to order or require a platelet count should be individualized and based on a patient’s history, physical examination, and clinical signs. A routine platelet count is not necessary in the healthy parturient.” Unfortunately, no data define the platelet count that will insure against the occurrence of an epidural hematoma. Most clinicians feel comfortable with a platelet count between 80-100,000, although if platelet counts are stable and there are no confounding comorbidities, some practitioners will proceed with platelet counts as low as 50,000. When faced with a low platelet count or downward trend in platelet number, a thorough history and physical exam directed at any evidence of petechiae, ecchymosis or oozing from IV sites is needed.

The balance between efficiency and safety cannot always be easily reconciled when timely pain relief could outweigh clinical best practices: pain is considered “the 5th vital sign” and timely pain relief can contribute to overall patient satisfaction. Similarly, abnormal lab results often necessitate further testing that can be of low clinical yield and cause further procedural delay. Laboratory turnaround times for specimen processing can be a source of provider and patient dissatisfaction.

The decision to perform a neuraxial block depends on many factors: history and physical exam, laboratory findings, and clinical course. Considerations when developing guidelines for your unit include:

  1. Are there individuals who can reliably assess which patients require a platelet count?
  2. Are there individuals who can accurately evaluate patients throughout the labor processes? If a patient’s condition changes to show signs and symptoms of preeclampsia, it must be determined whether there is an appointed provider who can evaluate and order a platelet count.
  3. Are there anesthesia practitioners in your group who are not comfortable proceeding without a resulted platelet count if one is ordered, even if the parturient is healthy?

Determine what a “healthy parturient” is for your particular unit and develop guidelines. For patients who have no signs or symptoms of preeclampsia and lack comorbidities, ordering or waiting for a platelet count may not be warranted. In high risk patients who have attendant comorbidities, or who have a suspected coagulopathy, obtaining a platelet count may be advisable. It is important for all practitioners and staff, including labor and delivery nurses and obstetricians, to agree which patients fall into each category so that each patient receives the care indicated for their situation.

Discuss laboratory requirement rationale with obstetricians and nurse leadership. It is worth investing the time to discuss management decisions with staff. Often there are reasons to proceed with neuraxial analgesia in the presence of low platelet counts. For example, explaining the traumatic nature of an epidural needle and catheter compared to a single shot spinal technique can support particular clinical decisions. Similarly, the desire to avoid intubation can support a neuraxial approach when faced with a low platelet count.

Operationalize a reasonable and safe approach to routine lab studies. It is important to develop a reasonable, livable and safe protocol for your particular unit’s patient population and clinical environment. Anesthesia practitioner experience in regional anesthesia skill sets often varies within a group practice. There must be allowance for individual practice and consideration for evidence-based clinical choices. Members of an anesthesia department should discuss parameters for lab requests to avoid confusion and delay in patient analgesia. Varying practices exist due to institutional differences and group culture, so implementation and sustained change of lab requirements should include education of obstetricians, nurse midwives, and labor and delivery nurses regarding supportive evidence for platelet count requirements. Continued adherence to lab requirements necessitates departmental consensus and ongoing support of established criteria. Clear and well communicated policies can help support both safe and efficient neuraxial analgesia.