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Discussion

What would you do?

I work in a small ED that is part of a larger system. About a year and a half ago the powers that be decided that one of our sister hospitals needed to be a level 1 NICU. In doing that they closed the birthing center in our hospital. The sister hospital is but 10 mins away from us. I had a pt who signed in yesterday 32 weeks c/o heavy vag bleeding x 20 min. We triaged this girl, established IV access and started fluids and rushed her to the 10 min away L&D... we didn't waste any time but the process still took about 45 min because we had to call the squad and wait for them. Our ED doc said after the fact that we should have sent this girl straight to the L&D from our waiting room in their POV. At this point the inner nurse/former EMT in me is serioulsy conflicted because that just about goes against everything I've ever been taught. Would this not be sort of like abandonment? I know that the pt needs to be in the OR sooner than later and that adverse outcomes can happen if they're not but I also know that if I turn a pt away at the door of our ED and provide no care and something happens on the way to the other hospital something equally as bad can happen. I should say that I have the utmost respect for this doc that I work with and have never questioned his practice before, he is a well seasoned and respected member of our organization. I want to do what is best for the patient, but I'm still conflicted about what that is. Thanks for any input you have.

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    • Featured Replies

    The problem is you don't have a full service hospital but that's another discussion. The patient definitely needed continuing medical care. Yes the delay was not desirable but ask the doc what would happen if she delivered in the car, or worse they got into an accident. Can you say lawsuit? Per EMTALA the patient must be stabilized and in no chance of deterioration, not really possible in this case. But, by transferring by ambulance you took every step that could be taken to reduce the risk.

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    • Author

    Thanks. And yes I realize that the hospital has put us in a no-win situation when they closed our L&D. I would have even gone so far as to start some labs... I drew the blood but wasn't allowed to order any tests. A CBC would have been the very least I would have done and the results would probably had been available by the time she got to the L&D. I know this is going to come up again because we frequently get people who need to be in the birthing center for monitoring. I'm uncomfortable with the attitude that we can just schlep this girl in the car and send her on her way.

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    Divert her from the waiting room in her POV? Epic EMTALA violation. The patient must be seen by a provider, stabilized, and agree to the transfer.

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    I worked in a peds er and occasionally we'd have pregnant moms go in to labor. We could get mom registered, lined, fluids going, and transport packing her up in ~20 minutes. With a situation like that you need access to more prompt transport.

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    I used to work in a hospital that had closed its L&D in favor of its sister hospital and we have people stumble in all the time. I agree that its an EMTALA violation when they are sent from waiting room in a POV to other hospital. Most of our transfers went off without a hitch but if a catastrophe goes down, I can't imagine what I would think.

    I also see the patient's point of view. Its a $1,000 round here to ride the truck and I had a lot of respect for people who just said no. I think its important to inform the patient of the risks and let them decide.

    As for the protocols, I wouldn't have asked the MD what labs he wanted since the results can be seen in L&D at our sister institution. Being all ER nurse-like, I asked the l&D nurse what her protocol labs were when I called to give report one night. After that I ordered them, drew em off my fresh 18g in the hand like they like in L&D (with piggy tail) and sent em off. The only thing I didn't draw was the type and screen since the patient would need a new one when they got over there. I'm sorry but that's just good nursing practice and ultimately could help the patient.

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    • Experts

    They show up they get the MSE/triage/stabilization then transfer. It would be like saying the guy with active chest pain with SOB and diaphoresis should just go by family car from the waiting room because your sister hospital has a cath lab. :banghead:

    These EDMD's can be a real pain sometimes.....:sarcastic:

    Your ED doc is just PO'd because he has to see that bleeding pregnant patient...something NO ED likes....Transfer or send away without a MSE? It is a violation of EMTALA. The problem is you don't have to self report so the sister hospital can't report you...it's like reporting themselves. Now when you talk lawsuit......that's a whole new ball game.

    You are just going to have to be firm with this MD and turn a deaf ear.....I'd talk to your manager and medical director for advice.

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