Original Article
A retrospective analysis of factors associated with anesthetic case duration for cesarean deliveries

https://doi.org/10.1016/j.ijoa.2018.01.002Get rights and content

Highlights

  • Cesarean delivery duration is an important component of anesthesia workload.

  • Case data from a national anesthesia outcomes registry were analyzed.

  • Variability in case duration is mostly due to institution-level factors.

Abstract

Introduction

Accurately predicting cesarean delivery case duration is an integral component of designing appropriate workflow protocols and ensuring adequate provider availability. Our primary objective was to describe the variability of case duration, based on factors that we hypothesized would be influential, such as hospital facility type, United States region, time of day, case volume, and patient and provider characteristics.

Methods

We analyzed hospital-, patient-, and provider-level variables from the National Anesthesia Clinical Outcomes Registry, a voluntary registry created to share anesthesia-related data and outcomes. Multivariable linear regression was performed to assess the association of these variables to case duration.

Results

A total of 205 332 cases were included in the final analysis. The majority of these cases came from medium-sized community hospitals (50.8%). Mean and median case duration were 115 and 79 minutes, respectively. Mean duration was longest for cases performed at university hospitals (143 min, standard deviation 136 min). Case duration varied in clinically meaningful ways based on hospital facility type, United States region, presence of a Certified Registered Nurse Anesthetist, and anesthesia type. Differences were not clinically significant with respect to other variables studied.

Conclusion

This study analyzed national cesarean delivery data and determined factors associated with cesarean delivery duration. We showed that case durations varied in meaningful ways according to facility type, United States region, presence of a Certified Registered Nurse Anesthetist, and anesthesia type. Our work contributes to a small but growing body of research on optimal staffing models for anesthesia practices.

Introduction

Obstetric anesthesiology groups provide services on labor and delivery floors for labor analgesia and obstetric procedures, of which cesarean deliveries (CD) are the most common. There is significant variability between institutions’ staffing models and relative workloads, leading to difficulty in predicting and managing case volumes, designing optimal protocols, and ensuring adequate provider availability. The ability of a facility to do this well may improve patient outcomes and support appropriate resource utilization.

Duration of surgery is an important operating room efficiency metric.1 It is, therefore, essential to be able to model surgical duration in order to design more effective staffing models. The predictors of case duration are multifactorial, however, there is a paucity of data modeling provider and demographic factors that affect CD case duration. Survey data and small data reports from single institutions exist, but these data are based on self-report and are subject to non-response bias.2, 3, 4 Flood et al. used data from the American Society of Anesthesiologists’ Anesthesia Quality Institute (AQI) to analyze the number and duration of labor epidural analgesia procedures as they relate to productivity, finding a large inter-institutional variation in recorded duration that was due to billing and reimbursement models, rather than biology.5

As the need grows for appropriate and accessible obstetric anesthesia care, and as budgets get tighter and reimbursements shrink, anesthesia practices must have a thorough understanding of the factors that can affect their staffing models. Integral to this is the ability to understand the factors that affect CD case duration. Advance planning to avoid under- and overstaffing and monitoring of case volume variations can help improve the safety and quality of obstetric anesthesia care; and can potentially lead to greater financial stability of the practice.

The components of designing an effective obstetric anesthesia staffing model are complex, and therefore, it is important to describe the association of various facility, provider, and patient characteristics associated with case duration. The primary objective of this study was to describe the variability of case duration of CDs based on hospital facility types – particularly to compare duration of surgeries at university versus non-university healthcare facilities. Other important objectives were to compare how case duration varies based on United States (U.S.) region, time of day, hospital case volume, patient characteristics, and provider characteristics.

Section snippets

Methods

We analyzed the National Anesthesia Clinical Outcomes Registry (NACOR) database from the AQI to determine the variables that may be associated with CD case duration nationwide. The National Anesthesia Clinical Outcomes Registry is a voluntary submission registry created with the goal of sharing anesthesia-related data and outcomes, in order to define the demographics and evaluate the quality of care both nationally and locally.6 Data were collected from the Participant User Files 2010 to 2015.

Results

A total of 205 332 cases were identified in the NACOR and included in the final analysis. The characteristics of CD by different hospital facility types are detailed in Table 1. There were a total of 247 different facilities contributing CD data. The majority of cases came from medium-sized community hospitals (50.8%), followed by cases from large-sized community hospitals (29.6%). Overall case duration mean (115 min) and median (79 min) values are plotted on a histogram in Fig. 2, highlighting

Discussion

The results presented in this study contribute to the body of knowledge on the workload of obstetric anesthesiologists as it relates to the surgical duration of cesarean deliveries. We showed that CD duration correlated most strongly with facility type (university hospitals had longer case durations than other facility types), geographic location (longest in the Northeast), presence of a CRNA (shorter with a CRNA), and anesthesia type (longer with neuraxial), but did not significantly differ in

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