Destination and Bypass - Maternity

[Arctickat]

Hi kids, I've been asked to put together a destination and bypass protocol for maternity patients. The current practise is to transport the patient to our local ER that has only one doc on call and bare bones obstetrical equipment. He's asked if the patients, the typical demographic being in a community 20 minutes away, could be transported to a hospital with appropriately trained docs and equipment. This would mean a transport time of close to an hour. He'd already asked another ambulance service and they insisted that they have to transport to the nearest hospital, I disagreed and told the doc that we are to transport to the nearest appropriate facility.

Given that the local ER is not equipped to handle deliveries and definitely not complications, I intend to put forth a destination and bypass protocol that would have these patients transported to a facility that can safely handle the situation.

Do any of you have such a protocol in place already that I could copy....errrr use as a template?

[Kiwiology]

If the local hospital is not equipped to handle obstetrics then any obstetric patient must go to the appropriate hospital? There's your policy or am I missing something?

OB/Gynae is not my thing, seriously, the whole four hours of education I haz on "pregnancy, birth and the newborn" is just not adequate, but rather oddly I can remember the risk factors for ectopic pregnancy off the top of my head cold from memory like if you asked me "what are the risk factors for ectopic pregnancy?" regardless of whether I am having a massive shit, mowing the lawn or viciously dehumanising somebody i dislike with a tire iron I can tell you

[mikeymedic1984]

I would convene a meeting between the local hospital with no capability, the closest hospital with capability, and the two ambulance services. To me, it should be no different than stoke, AMI, and Trauma, the patient should go to the most appropriate. The problem is that without clearly defined responsibilities and an agreed to protocol from each side, you will get the following:

1. Non provider hospital may abuse and no longer accept ANY pregnant patient. An 18 year old pregnant woman, in her first trimester, with the flu could go to the non-providing facility.

2. The hospital that does provide may get pissed now that they are getting every pregnant woman from that county (or area), and what if their doctor practices at another hospital (the patient should go where their Dr. delivers) ?

3. I would like to hear the rationale for "we can only go to the closest". Is it because they are a small service with limited units (if so, maybe an agreement can be made with your service or another local private service to be dispatched along with them on all OBGYN and let the other service transport). Is it because they are just lazy and want to get back to the station for TV time (then they have to step up to their responsibilities). Or is it because they are a private, and they want to get the secondary hospital to hospital transport (it is wrong but it happens).

You can write the best protocol in the world, but without input from each steakholder it is doomed from the start.

[flightmedic608]

Hello Arct, are you in the United States or abroad? Are your patients in active labor, high risk OB, having complications or a simple transfer? If you are in the US you have to take EMTLA (Emergency Medical Treatment and Active Labor Act) laws into effect when making any sort of protocol for your providers. That, and you would want to have medical direction involved when making a decision about a patient in labor and bypassing physican level care, there are many factors to consider. Abroad I am not sure of what legal responsibilities exist.

[Arctickat]

Mikey and Flight have good questions and input, Kiwi...you're next to useless.

My apologies for not being more specific, my wife was rushing me out the door. To answer Flight's question, we're in Canada. Mikey, the local facility is on board as is the receiving facility. They don't have any issues at all with the practise, and are actually under the same Health Region the issue is just that it's never been done before and the bureaucrats at the regional offices seem to be scared that something might go wrong.

The framework of my proposal would include the following factors in a decision tree:

3rd trimester? Yes/No

Contractions Greater than 5 min apart? yes/no

Membranes intact? yes/no

External Exam shows no indications crowning or prolapse? yes/no (I need to reword this question to something easier but you get the idea)

All answers Yes, transport to far away hospital, No to any, contact medical control.

In most cases they are expecting to give birth in one of three facilities and we could typically transport them directly there too because that's where they've been doing their doctoring. As far as your thoughts Mikey on why the other service refuses to transport to anywhere else, I can't say...but I suspect that your last idea is the most likely because that would be the greatest source of revenue.

[Just Plain Ruff]

I think that if the local yokal hospital has no capability to deliver or take care of the newborn then they would be high on the list of facilitles who would be saying, BYPASS US PLEASE. But if they aren't then you have to assume that it's a dollars decision only and that is terrible medicine and downright dangerous medicine.

[Arctickat]

No, the local hospital wants to be on bypass, the other hospital wants to accept the added maternity cases, it's just that the Health Region and Provincial Bureaucrats seem to be reluctant to risk babies being born in ambulances...even though it happens all the time.

[flightmedic608]

Hi, I am not familar with the legal practices in Canada, but will comment based on what experience I have from here in the US. I would be very cautious is allowing any transport of a third trimester patient who is in active labor to be tranported to a facility that is approximately one hour away. And although I do agree that babies are born in ambulances throughout the world, what if there is an unknown complication? What if the neonate is born in arrest? I would error on the side of caution, if I had an imminent delivery and given the choice I would deliver with a physcian at the bedside. Even if that facility had no OB/GYN capability, the idea of having multiple hands/minds in case something goes wrong is one that I like. It sounds like this may something for the local and tertiary hospitals to sit down and formulate a transport plan/policy. I know this may not be the information that you are looking for, but I would not like to resuscitate neonate and mother at the same time whether by ground or rotor. Good luck with a very tough (high litigation - OBs have one of the highest litigation rates) issue

Edited May 2, 2012 by flightmedic608

[mikeymedic1984]

Being in Canada does throw a monkey wrench in it. In the US, the EMTALA laws were created because of incidents like these, where the hospital staff would put the patient back in the car and say go to hospital ABC, we dont do "babies" here. Therefore, all US hospitals/ERs have to provide a medical screening exam / emergency treatment, and then arrange an appropriate transfer. I guess the question is, does your hospital have the capability to deliver babies, but just cannot take care of high risk deliveries ? The problem you are going to run into is that most of these patients will be complaining of back pain, abdominal pain, or bleeding/spotting; regardless of trimester it would be hard for medics to know the level of stress the infant is in, but on the other hand, if you take the patient to a hospital that you know does not have OB, and then the baby dies, you have the same risk as if you bypassed the closest hospital for a further one. One suggestion would be to ask the local hospital if they would allow you to stop in, have them check FHTs, and then let you go among your merry way ?

[Arctickat]

Good advice Flight, but given the current situation, this would actually be an improvement. Current practise is:

• Pick up patient at residence and transport to local facility;
  
• Local doc examines patient, then sends her back into the ambulance to one of two locations, one is 175km, the other is 235. Unless childbirth is imminent, they will not deliver the baby here. Closest I've come is that we loaded the mother up and 15 minutes later we're on the side of the road delivering the baby. Heck, once the mother is in the ambulance we're not even allowed to run L/S unless she's unstable.
  
• Our doctors are not trained, or at the least, are typically not current in PALS or NRPS, but we are.
  

This bypass would have the patient in the care of an obstetrician likely before we would even leave our local hospital to transport to the other two facilities.

There is a difference between imminent childbirth and 3rd trimester labour. A woman could be in labour for minutes, hours, or even days, thus the critical decisions that must be made to decide where to transport. If childbirth is imminent, then we'd go to the local facility.

Mikey:

This request for bypass is coming from our local hospital specifically because they do not want us to bring maternity patients in, just to have them be referred. We have the ability to monitor FHR in the ambulance. I believe this is the crux of the matter:

Years ago women started to travel further afield to the care of an obstetrician rather than deliver their babies locally, it got to the point that the revenue that local doctors were getting from maternity cases was actually less than the insurance premiums for elective childbirth, so they dropped the insurance with the exception of emergency childbirth and send out every possible maternity that isn't imminent. The ambulance company has better insurance coverage than the docs do. Since the docs stopped doing deliveries, the hospital no further had reason to retain the infant care/delivery equipment.

Personally, I don't care one way or the other, if we transport or not.

Edited May 2, 2012 by Arctickat