According to data from the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project, childbirth is the number one reason for inpatient stays in the U.S. With this service line making up much of their business, hospitals should and do take good care of their patients who are also expectant mothers. But there is room for improvement, especially in the earlier days of pregnancy, when things can go wrong.
Most hospitals don’t have an obstetrician in-house 24-7, so when pregnant women present to an emergency department after a cutoff date, about 20 weeks, they don’t see an emergency department physician. Instead, they are brought up to the labor and delivery department. There, they see a highly skilled nurse and are often discharged without ever seeing a physician.
“It’s the only place in the hospital you can present with an urgent or emergent need and not see a physician before discharge,” says Renee Nelson, vice president of operations with Delphi of TeamHealth.
According to Ms. Nelson, there are two major problems with the current way pregnant patients receive emergency care. During the four to six hours patients often wait in a triage area, they may be held for an extended period of time without ever seeing a physician. The inability to see a physician, along with the uncertainty of a long wait time without answers, may cause confusion and anxiety, which lowers patient satisfaction scores.
As an added consequence, return ED visits within 24 hours are much higher when patients see a nurse without seeing a physician.
“The nurse has to give his or her communication to the physician, who has to interpret it and give it back. There can be plenty of miscommunication and confusion, so it’s common for those patients to show up 24 hours later,” says Ms. Nelson.
Benefits of the OB-ED
Enter the obstetrics emergency department. It replaces the labor and delivery nurse triage and converts emergency services for pregnant women to a department that works in conjunction with the main ED. It is staffed by a board-certified OB/GYN physician.
For women who would normally be sent to labor and delivery for emergencies after 20 weeks, an OB-ED offers them a chance to see a hospitalist physician relatively soon after presentation. “For patients, an OB-ED increases satisfaction. They get to see a physician, ask all their questions and receive answers. In addition, they are treated and released in two hours or less,” says Ms. Nelson.
Having round-the-clock support from a board-certified obstetrician also increases nurse satisfaction, which results in nursing retention, according to Ms. Nelson. The reinforcing component of OB-EDs supports nurses in their scope of practice, and they know there is a physician in-house if a patient is having a serious
emergency.
Another benefit OB-EDs can present to hospitals is a net-revenue opportunity. With an OB-ED, hospitals are better able to receive reimbursements for their resources, as they can bill an emergency department facility charge, rather than charging for an outpatient labor and delivery visit. They recover the same revenue they would as if a patient stayed in the main ED instead of moving to labor and delivery triage. Ms. Nelson says though OB patients are subject to ED co-pays they didn’t have in labor and delivery, they are willing to pay, given the improved quality of care.
Planning for an OB-ED
Creating an OB-ED involves significant, but doable, changes. First, it relies on an in-house OB-hospitalist group or program.The Obstetrics-Emergency Department 39
In and of itself, this is relatively expensive; however, Ms. Nelson advises if a hospital’s delivery volume is more than 1,200 infants per year, an OB-hospitalist program will most likely pay for itself with revenue coming in from facilities.
In regards to staffing, an OB-ED program requires round-the-clock physician coverage as well as at least one specialized labor nurse, which most ED triage units already have in place. Other than OB physician coverage, an OB-ED requires very little increase in resources, no construction and no capital investment. In fact, most OB-EDs can be created in the same space hospitals use for labor and delivery triage, says Ms. Nelson.
“Hospitals need expertise and planning to convert triage to an OB-ED setting,” cautions Ms.Nelson, noting specialty EDs are a relatively new concept and do not yet have formalized guidelines for hospitals to meet. State departments of public health still expect a combination of ED and OB guidelines to be met, however.
Streamlining the process are companies like TeamHealth.
“Because there are no specific guidelines for specialty EDs, that’s where TeamHealth can be of value,” says Ms. Nelson. “TeamHealth has the knowledge to work with experts and identify in each state what guidelines will be, so hospitals can more efficiently redesign their standard of care for labor and delivery emergencies.”
To Ms. Nelson, the OB-ED makes sense. “In the labor and delivery triage model, the door-to-disposition time is six hours. In an OB-ED, it’s two hours, which includes higher quality care, higher satisfaction and always seeing a physician,” she adds.
