Published Sep 25, 2003
We are in the planning stages for a new hospital that will be completed in about 5 years. We are currently debating between LDRs with family suites to follow on the M/B unit or LDRPs. We are a level 3 hospital that does about 3000 deliveries a year.
The nurses strongly want LDRs. We have had visitor control problems in the past and in fact have just instituted a stricter visitor policy in L&D based upon patient requests.
We don't see how we can keep this control with post partum visitors in the mix. We also have staffing concerns based upon how laboring patients will be spread out on the unit as it will be very large.
The L&D and M/B staff have strong desires to continue in their areas of expertise and not do it all in an LDRP unit.
Any thoughts for us as we make these decisions?
There are so many questions here to answer. I hardly know where to start. In my career, I have worked in three different community hospitals: 2 that did LDR and my present facility which is an LDRP.
As a nurse, I like LDRP better because I can do all three areas and it also gives the nurse and her patients the chance to have some continuity. Sometimes (but not always) it is so nice to have the patient you had (in labor and for her birth) the next day when you can continue a relationship withher as you help her care for her baby. The reverse can also be true.
However, I would have to agree with you about the visitor problem. We even have that issue in a small place so I can imagine what you are facing in a facility the size of yours. In considering that question, I can certainly see how you would lean toward LDR's for security as well as confidentiality.
Getting everyone crosstrained to LDRP is a monumental take and you have to have a strong manager who will keep at it and weed out those RN's who do not fit the LDRP mode. It is never an easy task. We did it but it took a long time. I would have to say now, however, that there is not one nurse on our staff who would ever go back to the way it was before we went to LDRP (and we have several staff who were here in the "old days" of separate staffs for M/B, L&D, and NSY).
LDRP's can also present a problem when we get busy and then have to move newly delivered moms out of the LDRP's into c/s rooms because we need the labor space.
Getting nurses who want to cross train to do so would be a real plus as far as some continuity from LDR to the M/B side. The more the better.
I think, if you are asking my opinion, having done both, and given the size of your unit and population, I would have to say to go with LDR's. I think, probably in your case, a separate M/B unit and an LDR are the way to go.
Betsy RNC. (a real LDRP supporter but also realistic)
I have found LDRP concepts work BES and are MOST COMMON in smaller community hospitals, rather than very large university/inner city systems. In the smaller hospitals, the expectation *is* all the nurses will be cross-trained, and generally, ONLY nurses who can do ALL skills are hired where I work due to this being in place. I PREFER (and the patients seem to, also), the closeness and ease of an LDRP for lots of reasons. Getting to know patients better and following them through their stay is great ---- this is not often done in big hospitals where LDR/PP is the way it works. I also like not having to shuffle new-delivered moms and families ---(and all their STUFF)---from one room to another. THEY appreciate this too.
But in a big hospital, it's hard cause so many nurses are either well-versed in LABOR/DELIVERY, or MOTHER/BABY or NEWBORN/NICE care and rarely move between the areas except in circumstances that are unavoidable.
I would imagine LDRP one-room concept is more economical cause two rooms are NOT involved in turnover of ONE couplet's stay. Housekeeping issues sure are easier! Less confusion for visiting family/friends also when ONE room is the only one used. Yes, there are occasions where we are SLAMMED when moms/babies have to move to surgical rooms. That is not too often, thankfully!!!!
It may take some doing, but you can do this. The patients LOVE it!!!! But expect some serious resistance from those RN's who do not wish to cross-train, like Betsy says.
I would prefer myself to work in NICE (I assume you mean NICU, but can't figure out the E), he, he, stupid pun I know, I know, Just made me smile.
Back to the subject I totally agree w/ Blue eyes, I just cant see LDRP working in a high volume area with any ease. UNLESS they had the MBU/LD staff working together and sticking w/ their specialties, handing off a patient after recovery to the MBU nurse, that would ruin the continuety of the care of course but, I know of one hospital that ended up doing it that way after the upper management built a whole new unit that way and ran into HUGE staffing problems and HAD to do it that way, it is a city hospital and to have adequate staff they ended up doing it that way. I was offered a job there and had to decline becuase the matrix was quite confussing and it could get quite crazy there, having to move some patients back to the woman's unit due to lack of space, their delivery rate went up after the move to the new unit, because pts, and MDs like this for "family centered care" but it too has it's own issues. I myself prefere LDRs, becuase being new I want to master L/D before taking on further responsibilities. MBU has tons of teaching and it takes alot to help these families adjust to their newest member, they need that expert care. I agree it works well in smaller hospitals. Just my way of thinking.
Why not have 2 units? The last large hospital I was at had a LDR unit, mainly for higher risk patients, who would go to PP after delivery. There was also a LDRP unit, mainly for low risk women, so the staff had the choice to stay in their own area or be cross trained and work LDRP. Or even just make one corner of the unit LDRP and have the rest traditional LD.
We have also been talking about having the two types of units. The problems I see with this are that the L&D nurses I work with, like to work with both high and low risk moms. It also reminds me of when we used to (back in the day) have labor rooms/DRs and birthing rooms. For many high risk patients who turned high risk at the end of their pregnancy it meant not only were they worried about their pregnancy but also their plans changed. It also poses a problem when you are full in the LDRP unit and it then becomes a dissapointment. I would much rather have one or the other. Also what happens when things turn high risk in the middle of labor?
I hadn't found many moms complained about what type of unit they were on because they knew they were not guranteed a LDRP anyways. It can be a bit of a bummer for moms who really want it, but in the end it never seems to be a really big thing because a healthy baby is the most important part of the event. They would be asked if they had a preference at admission and we would try to accomodate those who had their hearts set on LDRP, but most didn't even care. I got a lot of "Whatevers" when I worked admission!
Those with simple health issues were not automatically kept from the LDRP rooms and were only moved if they had to go to the OR, same as those on high risk. The screening occured at admission and wherever they went was stuck with them, so LDRP rooms would occasionally have emergencies. The staff working LDRP are expected to be able to handle an emergency same as those in high risk, because like you say any labor can become an emergency.
The high risk unit was for reeeaaaaalllllyyyyy high risk patients (24 weekers, drug users, PIHers on mag, etc.) that would automatically be sent there after being screened at admission. This unit was placed the closest to the OR. It made more sense to have high risk patients clustered near the OR than all over a big unit.
The type of unit seems much more important to the staff than it ever does to the moms. Us L&D nurses worked in both high and low risk, so it was never an issue of being "stuck" with one.
I have worked where LDRP was the only model. The problems were that staff were not adequately trained and visitors not respecting the visiting hours. We wound up getting REALLY strict on our visiting policy (support person allowed 24 hours a day and the support person can change, other visitors between 4 and 8 pm ONLY). Moms really liked the restrictions because they could actually rest, but you need a staff commited to enforcing them and people willing to see that family centred does not mean allowing 16 people to visit at 2 am.
As for the training, the hospital wound up paying for courses and preceptorships, but they still lost a fair number of staff. Some people will never be able to work all areas and you have to decide if that is an acceptable loss to your facility.
I anted to respond to SmilingBluEyes comment about housekeeping in an LDRP. I want to add that the housekeeping issues are just as bad or worse on an LDRP. Often, we have to move patients (in the time of high census) from their LDRP room to a c/s room (on our unit, of course). It still requires everyone hoofing all the stuff to a new room. Usually, we have the family move the stuff while the surgery is still going on.
great discussion, but I just wanted to add my two cents on this. Thanks.
we rarely have to do this where I work, Betsy.
I guess it depends on the unit and how busy it is. That is why I said at a medium-large to large hospital, this probably will NOT work unless you have both types of units in the same facility.
we RARELY EVER USE two rooms for ONE patient, except if we have a baby in our nursery and mom is changed to border status. So it works very well for US.
Having worked in small and large LDRP, LDR-P, L, D, R, P and large ultra high risk LDRP units, I would like to make this suggestion. Put yourself in the patient's position. Suppose you delivered this afternoon and you are trying to sleep, but the lady next door is having a very painful posterior delivery and is quite vocal.
Same patient in labor and you are a severe pre-eclamptic. Suppose that you are in labor, and have been for 24 hours. You are finally ready to deliver, and your nurse wants to move you to the delivery room.
Now Suppose you have labored, delivered a beautiful baby, and recovered, taken a shower and are ready to get some well deserved rest. Wouldn't it be nice to move to a new cool clean different bed?
I vote for LDR-P and so far as the High risk OB patients, they could be on a specified area of the labor unit (that could be closed off if needed) or in a completely separate unit, depending on how much room you anticipate needing. I have worked in both and they both worked well.:kiss
There should be NO difference in the training of staff just because of the model of the unit (LDR vs. LDRP). labor is labor. You don't train someone on a general med -surg floor depending on the type of patient they have.
I agree that visitors are a problem but they are no matter what type of unit you have. Maybe it's just easier if it's a more closed unit.
One very slow evening many years ago, I called every hospital maternity unit in the state of Connecticut to see what their visitor policies were. With only about two exceptions statewide (due to being in high crime areas) all the hospitals had open visiting hours.
EXCELLENT POINTS BETSY!!!!!!!!!!!!!!!!!!!!!!!!
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