How To: Providing Obstetrical Services When Understaffed
In recent years, more OB units in rural areas have experienced closures and maternity care deserts have grown. In response, many rural healthcare organizations are exploring creative approaches in their efforts to maintain OB and gynecology (OB/GYN) services for their patients. The National Rural Health Association describes some of the approaches hospitals and policy makers have taken to try to maintain OB services, such as addressing costs of maternity care, increasing staffing levels, and consolidating health systems.
Combining units and going "on diversion" may also be considered creative approaches to addressing staffing issues in OB units, but such efforts raise potential risks.
OB Merging with Medical-Surgical Unit
Combining a medical-surgical unit with an OB/GYN unit does not appear to be a typical solution to an understaffed OB department. Although there are instances in which OB services from multiple locations combined into one, particularly during the height of the COVID-19 pandemic, merging similar departments from different locations is significantly different from merging different departments with different responsibilities.
There are several aspects the organization must consider before implementing this merger, including but not limited to the following:
- Standards of care. Regardless of where OB services are provided, the standards for providing safe care, including regulatory and accreditation requirements, are the same. Nurses, medical assistants, and other caregivers who do not have postpartum, mother-baby, nursery, and/or labor and delivery (L&D) experience require robust training, orientation, and validated competencies. In addition, the organization must ensure that, if the units are combined, they meet the capabilities listed under the levels of maternal care by the American College of Obstetricians and Gynecologists (ACOG).
- Staffing levels. OB staffing issues are a major concern. Staffing levels must be evidence-based according to recommended standards. In addition, all staff (e.g., L&D, postpartum, mother-baby) should be cross-trained so that they can float to areas where needed if the situation arises. If the medical-surgical unit is combined with OB, there may be medical-surgical nurses who do not want this change to occur, and vice versa; some may even leave the organization because of the change.
- Risk assessment. There is a great deal of risk involved in combining two departments. The organization should consider peer networking and connecting with other critical access hospitals and their local chapters of ACOG, the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), and the Society for Maternal-Fetal Medicine, as well as the American Society for Health Care Risk Management. The organization may also wish to consider hiring an outside party to assess the risks involved. In addition, the organization should consider seeking Maternal Levels of Care Verification from the Joint Commission. Although this involves an additional cost, it may help the organization evaluate the benefits and risks of their proposed plan.
- State regulations. Depending on the state the organization is in, there may be regulations related to the structure of hospital departments and scope of care.
- Security. Hospital security systems in the medical-surgical department may need to be upgraded to accommodate situations specific to the L&D department, such as those designed to prevent infant abductions.
Putting the OB Department "On Diversion"
Diversion is typically a term applied to the emergency department (ED). EMTALA laws require hospitals that do not provide maternity services or who are short on OB staff to provide emergency screening for pregnancy-related issues as well as life-saving care. State laws and regulations may also apply, like in this case, in which an Oregon hospital that planned to divert pregnant women to another hospital faced sanctions from the Oregon Health Authority.
Therefore, even if a hospital requests to go on L&D diversion, if a patient's condition is unstable and the hospital requesting diversion is the closest/most appropriate hospital for the patient, they are required to care for the patient. Hospitals can screen and stabilize the patient in the ED and then transfer the patient to another facility if they cannot provide services, but the referral facility must be notified and must agree to accept the patient.
If the organization is concerned about not having enough OB staff on hand to meet patient needs, it may want to consider partnering with local emergency medical services (EMS) and other hospitals in the region to ensure that they can provide OB care to patients. It should also ensure that referral agreements are up to date.
In addition, the organization should consult its legal/compliance department to ensure that any policies they are considering do not violate EMTALA laws. This issue can be particularly difficult to navigate since the Dobbs v. Jackson Women's Supreme Court decision has resulted in more conflicts between state and federal laws and greater confusion related to emergency abortion access. Such situations are complex and rapidly changing, and the organization's legal, compliance, and risk management staff will need to keep abreast of any related laws and regulations.
The organization should consider convening a meeting with executive and clinical leadership (e.g., ED director, chief nursing officer, chief medical officer) and the legal, risk management, and compliance departments to coordinate a plan. The organization should also consider reaching out to their state hospital association; state medical, nursing, and EMS boards; and state chapters of relevant professional organizations (e.g., ACOG, AWHONN, Emergency Nurses Association, American College of Emergency Physicians, American College of Healthcare Executives) to see if state-level efforts are being coordinated.
Additional resources that may be helpful include the following:
- Understanding EMTALA (American College of Emergency Physicians)
- Rural Hospital Closures Threaten Access (American Hospital Association)
- Emergency Medical Treatment and Labor Act (EMTALA) (Centers for Medicare and Medicaid Services)
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