What if your hospital loses OB coverage?

[GeneralVeers]

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One of the three hospitals in the system I work at is closing down their L&D services due to "low volume" as they are losing money. The result is that potentially we will now have to manage patients in active labor in the ED.

To me and most members of my group this frightening, as EMTALA in this case potentially conflicts with appropriate patient care. We can't deal effectively with most OB emergencies, we can't do epidurals, we can't do c-sections.

My understanding is that EMTALA was designed to prevent hospitals from transferring out patients in active labor due to insurance reasons. I'm not sure how EMTALA addresses active labor patients showing up at a hospital with no L&D support. Any thoughts?

 

[quinsy]

my hospital doesn't have OB.
My understanding is that you can still stabilize the patients and transfer them like you would any other if they need care that cannot be provided at your facility.

Last time I had a girl mistakenly show up at our door in labor (it doesn't happen often because anyone who's had prenatal care knows to go to the right hospital), we checked the fetal heart rate, did an initial H&P and exam including a quick sterile vaginal exam to show she wasn't imminently delivering, and transferred her off to the other campus for L&D. If she's imminently delivering, I would imagine we would deliver the baby but once delivered and stabilized, transport both mother and baby to the other campus. There is also a NICU transport team at the other campus who could come to pick up a sick neonate if needed. Luckily, our other campus is only a few minutes away.

 

[dmitrinyr]

One of the three hospitals in the system I work at is closing down their L&D services due to "low volume" as they are losing money. The result is that potentially we will now have to manage patients in active labor in the ED.

To me and most members of my group this frightening, as EMTALA in this case potentially conflicts with appropriate patient care. We can't deal effectively with most OB emergencies, we can't do epidurals, we can't do c-sections.

My understanding is that EMTALA was designed to prevent hospitals from transferring out patients in active labor due to insurance reasons. I'm not sure how EMTALA addresses active labor patients showing up at a hospital with no L&D support. Any thoughts?

That would be a frightening reality... What do you do when a pregnant pt shows up and quickly develops severe eclampsia or something else requiring immediate C-section? ED docs are not trained to do this procedure and even if you wanted to do it to help the pt, you still wouldn't as the margin for error is so small while the liability is huge on your part. It's all good when it's a normal delivery with no complications and so you can just transfer mom and baby to nearby L&D facility, but sometimes it's the deliveries that look like they will be normal and with no problems that end up needing a crash-section, symphysiotomy, pressors, etc.

Most of the time, ED docs don't see as many L&D patients to be truly confident in many difficult situations. Just my opinion.

 

[Apollyon]

my hospital doesn't have OB.
My understanding is that you can still stabilize the patients and transfer them like you would any other if they need care that cannot be provided at your facility.

Last time I had a girl mistakenly show up at our door in labor (it doesn't happen often because anyone who's had prenatal care knows to go to the right hospital), we checked the fetal heart rate, did an initial H&P and exam including a quick sterile vaginal exam to show she wasn't imminently delivering, and transferred her off to the other campus for L&D. If she's imminently delivering, I would imagine we would deliver the baby but once delivered and stabilized, transport both mother and baby to the other campus. There is also a NICU transport team at the other campus who could come to pick up a sick neonate if needed. Luckily, our other campus is only a few minutes away.

Interestingly, this is exactly the same scenario where I'm at, save the exception that the other campus is more than just a few minutes away. Otherwise, agree with above.

 

[GeneralVeers]

My hospital admin is so far saying that we can't transfer patients in "active labor" to the other hospital that has L&D (only 10 minutes down the road).

I've asked for clarification as to what they mean by "active labor".

Sure if baby's head is already sticking out, that delivery should probably be completed, but if she's having contractions and dilated greater than 5 cm I still think the transfer should happen.

 

[dchristismi]

We have a similar setup: not crowning -> immediate transport to the OB hospital down the street.

The other night, one of my partners had an imminent delivery (head at the perineum) of a 22 weeker with unsure dates. They called EMS, and he, the charge nurse and the medics all took the pt down the street for an in-person handoff to the OB. I think if it had been a term delivery, we would have gone ahead, but they opted for "don't push!" and run. (We have minimal newborn rescus equipment, and certainly weren't equipped for the potential 23-24 week survivor.)

Now the baby I delivered in the parking lot was a little different. Term, multip, mom did all the work. Still, nervewracking!

We do have a policy that if the patient is unstable, the OB comes to the patient. We had a crashing ectopic a couple of weeks ago, and the OB came to her and used our OR. We have a courier system in place, but can use EMS as well. I don't know how the OB got there that time, but it worked. (It's an OB Hospitalist program, so they're in house 24/7)

 

[Apollyon]

If we're teetering on the borderline, I'll often give a dose of terbutaline to slow things down so there is less likelihood of surprises in the ambulance.

 

[docB]

We've had this problem at Desert for years. I don't go down there much any more but anyone with an OB/Gyn problem that can't get dcd gets transferred to Sunrise. Sometimes the "Are they too far along to transfer?" question can get kind of gray. Several of our docs (including me) have gone on the ambulance with the patient up the street. I agree. It's nerve racking.

From an EMTALA standpoint I think that as long as you're transferring everything that's in labor out you're ok. Even if you send one that drops on the bus as long as you are consistent it's more a question of malpractice/failure to diagnose imminent delivery than an EMTALA issue. Gotta love EMTALA, makes a malpractice suit look attractive.

Where EMTALA would become a problem is if your hospital sets up some system where OBs are admitting their own laboring patients but not the unassigned.

I also agree that you have to get administration straightened out on what they mean by not transferring "active labor." Contractions 10 minutes apart on a 2 cm dilated primip is "active labor" and should absolutely be transferred so their current stance is silly and dangerous.

 

[med2UCC]

We've had this problem at Desert for years. I don't go down there much any more but anyone with an OB/Gyn problem that can't get dcd gets transferred to Sunrise. Sometimes the "Are they too far along to transfer?" question can get kind of gray. Several of our docs (including me) have gone on the ambulance with the patient up the street. I agree. It's nerve racking.
.

Dude, try 2.5 hours in the back of the bus with a patient who is a)39 weeks, b) having contractions Q4-5min, c) 4 cms dilated at the originating hospital d)G2P1 with e) 1st baby delivered in 45 minutes start to finish, traveling over an extremely twisty 2 lane coastal road in the backwoods. I went with the crew because, although the EMT's were technically trained to deliver babies, neither had come any closer to the process than watching a video about it😱. We got her to the church on time, thank goodness, but I don't want to be doing that again any time soon.
We are the only OB hosptal for a population of approximately 104,000 people with an area of around 10,000 square kilometers, so long anxious rides are kind of the norm around here, unless the Mum comes into town the week she is due and stays with friends/family until the baby arrives. And no, I don't live in the North of Canada. Cheers,
M

 

[Zanegray]

I just finished my OB rotation and they made me scrub on some C-sections saying - Its good for you to know how to do this in case you work at a smaller community hospital that doesn't have OB. I said, "All due respect, but the ONLY c-section I am doing is a post-mortem c-section." And I meant it! I think I would call gen surg.

What do any of the general surgeon's at your hospitals think about this? It seems they should be called (or alerted at least) for backup in case a c-section is necessary. They would be more qualified than us to do this right?

 

[EM OR BUST]

Any way your group can get out of working at that one hospital? Anything in the contract that states they must have OB coverage? Can you request that the majority of your shifts not be at this hospital?

 

[docB]

I just finished my OB rotation and they made me scrub on some C-sections saying - Its good for you to know how to do this in case you work at a smaller community hospital that doesn't have OB. I said, "All due respect, but the ONLY c-section I am doing is a post-mortem c-section." And I meant it! I think I would call gen surg.

What do any of the general surgeon's at your hospitals think about this? It seems they should be called (or alerted at least) for backup in case a c-section is necessary. They would be more qualified than us to do this right?

You would encounter a great deal of resistence in trying to get a surgeon to do a C-section, and I'm putting that lightly. In reality even if you could force a surgeon to do it you'd have to call the chair and spend so much time in the effort that the point would be moot.

You'd also have to know what's in your surgeon's delineation of priveledges. I suspect their DOPs don't include C-sections so you'd really never be able to get anywhere with that.

Case in point my hospitals have no ENT coverage. Most of the surgeons do have tracheostomy listed on their DOPs. Without fail every time a surgeon winds up having to do a trach they immediately remove it from their DOPs.

Any way your group can get out of working at that one hospital? Anything in the contract that states they must have OB coverage? Can you request that the majority of your shifts not be at this hospital?

Not to speak for Veers but I'm failry familiar with the situation. The group covers all of that hospital chain's EDs in the area. Bailing on that hospital would put all the other contracts in jeopardy so it's not a viable option.

I'd be very surprised if the contract said anything about OB coverage. Even if they still provided the coverage (I actaully suspect they'll still have OB/Gyn coverage for ectopics, VB that needs a D&C, etc.) but no L&D floor you're equally screwed.