OB crisis

[DebKRN, BSN]

Hello, This is my first post although I have been reading your posts for along time. I work as House Supervisor in a small rural hospital. In our hospital we care for every type of patients including peds and OB. Our OB department has 2 LDRP's and other close-by rooms which can be utilized for OB if needed.

A nearby larger town is having alot of trouble with it's Women's and Children's unit. Thier OBGYN's - all but one- have suddenly stopped taking Medicaid OB's. One of thier physician's is taking a select few. They are ending care of OB's as far along as 35 weeks.

These OB's are coming to our 3 family practice docs who do OB in large numbers. Our hospital usually delivers 100 (on average) OB's per year and only keep well OB's, high-risk OB's are sent to a large med center 80 miles away. (if we can get them there on time, that is) But this medical center is very good about sending a full crew by helicopter to us if we anticipate problems, and labor is to far along to transfer intrapartum.

Our OB docs said last week that they have 88 deliveries expected between now and December! (with our average being only 100 for the entire year)

At the same time, now, our OB coordinator changed to DON last week, the OB coordinator now is going to have 2 - 12 hr shifts per week to "coordinate" if an OB comes in during those 2 shift, she takes the OB. Her 3rd shift, she works the floor taking med-surg unles an OB comes in.

I have done OB for 17 years and feel very comfortable with it, but as house supervisors I'm obligated to cover the whole hospital incuding the ER, which lately has been a zoo. But I can see it coming that I'm going to be doing OB when the drop in and no one else is there to cover. Some shifts are covered by an on-call RN who maybe 30 miles away.

Also, corporate is cutting back on the entire nursing staff including

cutting back on hours the flex pool can work. The flex pool nurses are already finding other jobs. They are so absorbed in cost cutting, I don't think they are thinking about what coming.

I don't see anything being done to prepare for this OB rush! Over the weekend it was slow, so I went back to OB and cleaned and ordered supplies. Haven't seen the "new" OB coordinator yet at all.

My question is: What suggestions do you have to get administration going on preparing for this onslot of OB's.

Also they did mention training our experienced LPN's to assist the

RN's when there are multiple OB patients admitted. What can an LPN do and not do. Our labor patients have always been 1:1 with an RN.

Another question: Can docs kick out an OB from thier care as far along as the 3rd trimester? Thanks!

[canoehead, BSN, RN]

Geez, what a horrible situation.

If you are caring for OB pts for the first 30-45min of their stay you will be basically unavailable to the rest of the house for that time. Sometimes you could get away with a 5min run for supplies so long as another unit could hear your bell and would answer it- but some moms cannot be left alone...hmmm.

Is there an OB committee in your hospital that you could attend, let the docs, and officially notify nursing admin about your inability to be in two places at once. Most times other areas of the hospital can muddle through if they know you have an emergency going on elsewhere, but you must respond to codes/traumas so they should know in writing that you may have to leave an unassessed mom in the care of a non-OB nurse in extreme situations.

In an emergency situation you should be prepared to call the code team to help in OB- you acting as traffic director, assigning tasks while maintaining FHT, interpreting the strip and reassuring mom. Even just getting a recorder over to help frees you up to care for the pt. Make sure you have the fixings for a rapid c section prep, IV lines, speculum exams always in each labor room and then make everyone- lab, admitting, anesthesia, come to where you are for signatures, to pick up specimens, ask questions.

You mention having one RN on call- you will need two with that number of scheduled deliveries. We have LPNs in OB, they can do comfort measures for laboring moms, immediate postpartum hygiene and teaching, immediate care of healthy babies, and they can take over completely once you decide that mom and baby are stable postpartum, freeing the RN for the next labor, or allowing her to complete paperwork plus supervision for problems. WE staff with one RN, and one LPN at night, but our LPNs have been with us for years.

Sorry about the long post, but I hope some of this helps. Feel free to PM me if I can answer any more questions.

[shay]

Bump.

I don't have a clue what to do, but someone's gotta see this who does.

[DebKRN, BSN]

Thanks, those are some terrific ideas. I did leave out one thing, only 2 of the house supervisors have OB experience, myself and another. The others have no clue what to do if an OB presents

without an OB nurse in the building and don't seem to think think they need to know! They don't realize that if they are the house supervisor they should be able to handle any emergency care for any pt, but with OB, they say "I don't do OB!"

Thanks Deb

[Dayray, RN]

I can answer the LPN question ( I think). Well in my state anyway.. LPN's have a limited scope of practice in OB. We cant mess with drips thats the main problem. Also we cant take verbal orders and docs tend not to like being asked to wright orders as they are catching a baby.

An RN/LPN team could work well if its done wright. LPN could monitor the drips once they had been hung by the RN. If they switched off careing for one patient while the other was in with the other patient it would be okay.

[sunnybrook83]

The hospital is setting itself up for a lawsuit- while administration may not be attentive to staffing needs, tell them to ask their insurance company what they think!! Also, go to AWHONN and download their guidelines for staffing, present them to to the administrative body, and the Dept of medicine. And, get the MD's involved- unfortunately, admin. will usually listen to the MD's before the nursing staff.

As for the dr's at the other facility terminating care- they have to give reasonable notice to the patient (usually 4wks, I think). Also, I do not see how they can justify terminating care just because of someone's insurance when they already have a caregiver relationship established- any lawyers out there care to advise? Unfortunately, the medicaid population is frequently higher risk because of numerous factors- poor nutrition, lack of knowledge, smoking, drinking, etc... This could end up in some very bad outcomes for the babies and moms. I wish you luck in resolving this- let us know how it turns out.

[sunnybrook83]

Oh, and the other facility is not off the hook, no matter if the Doc's do terminate the pt- Cobra laws state that if a pt presents to a facility in active labor, the MD on call must take care of that pt regardless of insurance status. It was made to avoid the dumping of such pts like the Doc's are doing.

[P_RN, ADN, RN]

Have you called the state medical board and the department of social services or whoever handles Medicaid? While you're at it you need to recheck your OWN insurance. Sounds dreadful.

[ceecel.dee, MSN, RN]

If you and the other supervisor with OB experience aren't willing to be on call 24/7, I think the other supervisors should be taking in some seminars! Perhaps the docs do need to be made aware of your staffing issues, and sometimes the hospital administrator needs to be made aware of things like lost revenue due to patient transfers made necessary by staffing limitations. Nothing speaks to them like the almighty dollar! Your new DON should be well aware of the impending dilema and should make a presentation about this not being the time to cut staff!

Your hospital sounds very similar to ours and I truley empathize!

We do not utilize LPN's at all in L & D, but I think there is a role for them there.

[canoehead, BSN, RN]

Same as our hospital re only 2 sups able to do OB. THe others know how to put on a moniter and the "panic" signs on a strip although they couldn't manage a labor pt, they can do initial resuscitation (O2, position change, IV, call for help etc) So when a new labor pt comes in they get initial vitals, and put her on a moniter, start asking the questions on the triage form while the oncall OB RN comes in. If the woman happens to be crowning (OMG!) then the ER doc will come upstairs and do the delivery. Usually if she is that far along they keep her in the ER until the OB nurse comes in and says whether she is safe to make the trip upstairs.