A 30-year-old mother with appropriate prenatal care presents, at 39 weeks, to Labor and Delivery (L&D). Initial nursing assessment notes 6 cm dilation and a brow presentation. The nurse notifies the patient’s primary OB, who is not in-house. Initial monitoring is unremarkable, but after an hour, fetal distress is noted. There has still been no exam by an OB. Fetal heart tones are lost, at which point the OB Hospitalist is notified. Previously unaware of the patient’s presence at the hospital, the Hospitalist performs an emergency C-section. The baby has Apgar scores of 0, 0, 0 and does not survive.
Many hospitals have added OB Hospitalist or laborist programs to their clinical programs in an effort to ensure continuous, high-quality, and timely services to expectant mothers. Ideally, the availability of in-house 24/7, well-trained OBs complements the services provided by the patient’s primary OB. While routine labor most often progresses to uncomplicated delivery, complications can occur with little warning and place both mother and infant in jeopardy if immediate obstetrical care is not available. Open, clear, and collegial communication, including nurse-to-physician as well as physician-to-physician, lies at the core of maximizing the benefits of in-house and readily available expertise.
OB Hospitalists will usually defer to the judgment of a patient’s primary OB whenever possible, in recognition of the importance of the doctor-to-patient relationship and the role the primary OB has already played in the patient’s care prior to delivery. OB Hospitalists should, however, be fully aware of any potential concerns anywhere in L&D and be asked to assess any potential problems as early as possible. In well-run programs, in-house, 24/7 OB expertise helps to provide timely care when it is needed the most, without minimizing the role of the patient’s primary OB provider.
In a smoothly running program, all members of the team collaborate to ensure optimal care: “I’m on my way in, but could you take a look at my patient in bed 5 to be sure she is doing OK?” or “The patient’s primary RN asked me to check in on your patient, and here’s my assessment. What can I do to help?” Patient care and safety are enhanced when there is an open and mutually supportive relationship between L&D nursing and the OB Hospitalist as well as a professional and collegial relationship between primary OBs and the Laborists.
If communication from nursing to provider or from one provider to another is hampered or delayed due to process problems, personality conflicts, or for any other reasons, the results for patients clearly can be devastating. Delay in emergent delivery, when indicated, is a frequent reason hospitals seek external peer review to help identify opportunities for improvement in communication, chain of-command processes, and decision-making.
Since it began serving the needs of hospitals in 2003, MDReview has performed hundreds of external peer reviews aimed specifically at examining the care provided by OB Hospitalist programs and how effectively they coordinate care with primary, office-based OBs to support overall obstetrical care. In cases like the one above, MDReview’s experts can help identify the precise points at which communication could be improved and interventions expedited to avoid adverse outcomes. Whether external peer review evaluates questionable or extreme outcomes or just near misses, the analysis can provide valuable insights into opportunities for improvement.
As with most things health related, we know that prevention is far better than cure. We invite you to learn more about how MDReview can help your institution gain a clear picture of your OB Hospitalist program’s health