OB Triage-wondering how other hopsitals compare to mine

  1. At my hosital, all of our OB patients present to the ER, where they are assessed and then sent to us if further monitoring is required. Once we receive them, they are again assessed (fetal monitoring and another admission assessment) and the doctor is notified of the results. However, if they are determined to be in false labor by the nurse, they cannot be discharged home until the physician sees them. Thus, they sometimes stay overnight just for braxton hicks contractions (which sucks for the patient!). In other hospitals where I've worked, we were able to discharge them with the doctor's phone order (for false labor). My hospital states that every other hospital is wrong and that it is an EMTALA issue. How do you guys do it at your hospital? I'd like to get feedback on my scope of practice as an L&D nurse and other hospitals' policies and procedures.

    HardDaysNight
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  2. 24 Comments

  3. by   shay
    Uhhhhhhhhh..........I sure hope that's not an EMTALA violation, 'cause if it is, we're all up in the violations at MY hospital!!! We can d/c with a telephone MD order. This is the 2nd hospital where I've worked that this was the case. The others had residents, so no doc seeing the pt. wasn't an issue.

    Pleeeeeeeeeaaaaaaaaasssssssseeeeeeeee tell us when you find out if this is true or not!!! :uhoh21:

    Ya know, I think I'll ask NrsKarenRN about this...she seems to be very much on the up and up about EMTALA............
  4. by   sbic56
    We have always assessed our moms right on the unit as long as they were established patients of one of our OB docs/midwives. After a full maternal/fetal assessment we call the care provider, give a telephone report. If it is something that can be taken care of without the doctor making an immediate visit, we do whatever is needed then admit them or discharge them with instructions. Often the midwives will come in because they want to, but there is no mandate to do that. If they have no care provider they have to go through the ED and will most likely come to us for OB related treatment after the doctor there assesses them and speaks with the OB on call. I doubt that every other hospital is wrong, but there may be some underlying reason at your hospital, I suppose. True, it is a hassle for the patient! Not to mention tying up a bed with a non acute patient. I'd think the hospital would see it doesn't make much fiscal sense.
  5. by   HardDaysNight
    sbic56: I totally agree with you. Do you know if there are standards with AWHONN or some other entity (EMTALA) that would state such. I want to be able to show this on paper to our administrators. They've been doing it this way FOREVER, and you know how it is in small hospitals: "This is they way we've always done it.....". Its frustrating!
  6. by   NRSKarenRN
    Hi Poppin in here with research info.....Karen


    4. What are the provisions of EMTALA?
    http://www.uplaw.net/faq.htm

    A pregnant woman who presents in active labor must, for all practical purposes, be admitted and treated until delivery is completed, unless a transfer under the statute is appropriate. The statute explicitly provides that this must include delivery of the placenta.

    In essence, then, the statute:

    imposes an affirmative obligation on the part of the hospital to provide a medical screening examination to determine whether an "emergency medical condition" exists;

    imposes restrictions on transfers of persons who exhibit an "emergency medical condition" or are in active labor, which restrictions may or may not be limited to transfers made for economic reasons;

    imposes an affirmative duty to institute treatment if an "emergency medical condition" does exist.

    Additional regulatory provisions

    The regulation [42 CFR 489.24(a)] adds the following:

    The person who does the examination must be specifically determined to be a "qualified medical person" by the hospital bylaws. The hospital must make the designation in its bylaws or rules and regulations. The regulation also provides that the person must "meet the requirements of 42 CFR 482.55", although that rule really has no substantive requirements.

    Another section [42 CFR 489.20(q)(1)] requires that the hospital post a conspicuous sign which notifies patients and visitors of the right to be examined and to receive treatment. The sign must be in a form approved by the Secretary of Health and Human Services.
    -----------

    42 CFR 482.55 Condition of participation: Emergency services.
    http://www.scha.org/Public/PhyMdcreI...P_for_hosp.pdf

    The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice.

    (a) Standard: Organization and direction. If emergency services are provided at the hospital-

    (1) The services must be organized under the direction of a qualified member of the medical staff;

    (2) The services must be integrated with other departments of the hospital;

    (3) The policies and procedures governing medical care provided in the emergency service or department are established by

    and are a continuing responsibility of the medical staff.

    (b) Standard: Personnel. (1) The emergency services must be supervised by a qualified member of the medical staff.

    (2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency

    procedures and needs anticipated by the facility.


    The point here is that :
    1. Emergency services must be SUPERVISED by medical staff.

    2. Adequate Medical qualified must be available to meet written emergency procedures.

    If your facility states that Medical staff must perform physical exam on patients presenting in ER prior to discharge then the hospital would be deemed negligent for only relying on Nursing assessment and NOT having physician physically examine the patient prior to Discharge. All depends on ER policy....CHECK IT OUT. Karen



    ---------
    EMTALA Action Points

    9. Treat OB patients with contractions as unstable patients under the law.
    http://www.tsged.com/cobraematala/EM...ion_Points.htm

    ---------------
    THE "20 Commandments" OF COBRA/EMTALA

    http://www.medlaw.com/20com.htm


    Hope this helps!!! Also Posted in OB.
  7. by   HardDaysNight
    I understand the ER part of it But what if the patient is actually admitted to the labor and delivery unit to be observed. Can I discharge them from the hospital even though the patient is not actually an ER patient?
  8. by   shay
    THANKS KAREN!!! Okay, well, then...I suppose I'll have to check out my hospital's/unit's policy.

    Again, thanks for the info!!!
  9. by   sbic56
    Great info, Karen. Answered some questions I had, too.

    HardDaysNight:
    At our small hospital, the doctor has to see the patient in order to discharge them once they are admitted. I wish I could tell you exactly why it is; will have to check it out myself when I go back to work.
  10. by   NRSKarenRN
    As a Medicare licensed facility, must follow it's rules for all patients, even if other insurer providing payment.


    42 CFR 482.22 Condition of participation: Medical staff.

    (5) Include a requirement that a physical examination and medical history be done no more than 7 days before or 48 hours after an admission for each patient by a doctor of medicine or osteopathy, or, for patients admitted only for oromaxillofacial surgery, by an oromaxillofacial surgeon who has been granted such privileges by the medical staff in accordance with State law.
    http://www.scha.org/Public/PhyMdcreI...P_for_hosp.pdf
  11. by   BugRN
    Dear Hard Days Night, I used to work in a small community Hospital and we had a policy of a point system we used before calling in the doc. If a woman presented to the ER under 20 wks, they stayed there and were processed there. If over 20 wks, we got them and evaluated them. Different items had a point score and if their total was over 6 I believe, Then they needed an MD consult to be discharged or admitted. They were something like if contracting 2 points, if Less than 5 min apart 2 points, and how many weeks gest. so many points too,and others I can't remember, sorry!! We would monitor them, then call the midwife or md with the info and the score. By EMTALA law the docs had to come in if they were over 6 because then it was considered dangerous to send them home. This scoring worked for transfers too, if they were too unstable to move. It helped get some of the old dinosaur docs off their a**s and get in if they had a pt. w/ a 6 score 'cause they couldn't dispute it, they even had to sign it and it was put in the pt.'s chart. good CYA stuff! Hope this helped.
  12. by   HardDaysNight
    I sure wish that you could remember the point system you went by. But thanks, that does help. Maybe I can suggest a similar system at my hospital.
  13. by   bbnurse
    We too, faced this question. An EMTALA guru came and stated unequivocally, that IF our hospital wrote into their bylaws WHO could do the OB triage (screening), it was not a violation. The OB nurses do the assessment, monitor FHT, UC, VS, urine dipstick and call the info' to the physician. He/she may discharge by phone. Some still choose to come eyeball the patients. That's OK with me. Other hospitals in the area around all were calling each other to determine what the practice is. One shared with us that even in the "large" hospitals, they were following this practice and had State Health dept or someone challenge them so they were nervous too. Our "Unassigned" (drop ins) go to the ER and actually have a physician examine them and talk to the OB docs. So that, determines whether it is an "emergency" and the "stability" of the labor pt. for us. If we refuse care, or ship without these medical screenings, THAT is indeed EMTALA violation.
    We need some clear thinking sometimes on these regulations, don't we? Why do the inspectors interpret them differently than the legislators who write them?? Ever wonder how they get a job as the official "nitpicker"??
  14. by   NRSKarenRN
    Agree with bb nurse. What you write in your policies and procedures AND YOUR DOCUMENTATION will determine if EMTALA is being followed.

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