April 8, 2020

Is hospital design contributing to the US' high C-section rate?

Daily Briefing

    Research suggests that hospital design and layout may be contributing to the high rate of medically unnecessary cesarean sections (C-sections) in the United States, Bon Ku and Ellen Lupton report for Fast Company.

    Study details

    Previous research has shown that one-third of babies in the United States are delivered via C-section but nearly half may be medically unnecessary.

    To determine whether a hospital's design and layout are associated with a higher rate of C-sections researchers from Ariadne Labs, a health system innovation center, teamed up with MASS Design Group, a nonprofit architecture firm, to conduct a study. The study assessed the design and layout of a dozen hospitals to understand why C-section rates range from 7% to 70% across U.S. hospitals. The researchers evaluated a number of hospital features, including the:

    • Labor and delivery unit's size and shape;
    • Standardization of patient rooms;
    • Ratio of ORs to labor and delivery rooms (LDR); and
    • Distribution of nursing stations.

    The study found that certain design and layout features were associated with higher rates of C-sections.

    The distance between LDRs and nurse stations

    The researchers found long average distances between nurse stations—which are often considered the "control centers" or the central hub for activity in a labor and delivery unit—and LDRs may be linked to higher C-section rates.

    According to the researchers, the distance between LDRs and nurse stations varies widely across U.S. hospitals. For instance, at one hospital researchers looked at, the distance averaged 23 feet, while at another, the distance averaged 114 feet. The short distance meant nurses were seated a few steps away from all four rooms in their pod, whereas providers at the hospital with the larger distance said they often have to run from one room to the next to treat patients.

    Some longer units use a distributed nursing station model, with smaller substations located along the hall. However, some hospital staff said having the substations close to LDRs can impede patient confidentiality.

    The distance between LDRs

    The researchers also found the distance between LDRs may impact C-section rates. According to the researchers, sprawling hospital units can negatively impact a care team's workload and result in providers running between rooms to treat patients. At one hospital, an obstetrician told researchers he had to purchase gels for his shoes to move across the hospital's new unit. "The path going from room to room to go to a supply room, it really kills our staffing," he said.

    To minimize the distance providers have to travel to care for patients within a unit, Sharp Mary Birch Hospital for Women & Newborns clustered 22 rooms to maximize compactness and efficiency. Although the distance between LDRs at the hospital are the highest in the researchers' sample size, the hospital managed to maximize efficiency by clustering the rooms together.

    Higher ratio of ORs to LDRs

    In addition, the researchers found there may be a connection between a higher ratio of ORs to LDRs and C-section rates.

    According to the researchers, OR access is a critical factor in determining whether a hospital has the capacity to perform a scheduled or unplanned C-section. The researchers found hospitals with a higher ratio of ORs to LDRs may have higher C-section rates simply because there are fewer barriers for providers to perform the procedure. The researchers noted a number of factors determine the number of ORs available in a labor and delivery unit, including whether a hospital is serving a higher share of high-acuity patients, who are more likely to deliver their babies via C-sections. 

    Space for collaboration

    The researchers also found a lack of collaborative space might influence C-section rates. According to the researchers, collaborative spaces likely result in greater accountability among providers to offer their patients optimal care and reduce the intensity of their treatment. However, the researchers noted that increased accountability may not be linked specifically to higher C-section rates. For instance, the researchers noted a culture of accountability could result in more C-sections if patients are being closely monitored.

    Standardized rooms

    Another factor likely affecting C-section rates is room standardization. The researchers noted room standardization likely affects providers' workload and could result in higher C-section rates.

    According to the researchers, many experts claim standardizing a hospital room's headwall location likely helps providers be more efficient because they do not have expend cognitive energy reorienting themselves to a new layout when they move from room to room (Ku/Lupton, Fast Company, 3/9).

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