Rural Obstetrics Workgroup Meeting Minutes

Monday, February 6, 2012
9:00 - 11:00 a.m.

Members/Guests present - Tom Crowley (Saint Elizabeth’s Medical Center, Wabasha), Chris Harff (Sanford Thief Rivers Falls Medical Center), Glenn Haugo (Renville County Hospital, Olivia), Scott Johnson (OB/GYN, Chief of Surgery, St. Mary’s Hospital, Duluth), Frank Lawatch (Swift County-Benson Hospital, Benson), Holly Rudol (RN, Swift County-Benson Hospital, Benson), Kim White (Recruiter, Mayo Health Systems)

MDH staff –Paul Jansen, Kristen Tharaldson

Obstetric Services in Rural Hospitals

Renville County Hospital (Olivia, MN) – In Renville County (pop. 17,000), there is one Critical Access Hospital located in Olivia and three clinics located in Olivia, Hector and Renville. The clinics were purchased in 2007 and prior to that were physician owned. The primary service area has a 15 mile radius and is home to 10,000 people. The secondary service area covers near Redwood Falls to Willmar and is home to 13,000 people. For aging services, there is adult daycare and food, housekeeping & maintenance services available. Home health services are provided by the county and there is no senior housing. The hospital employs 123 persons including 25-40 part-time employees. The average patient census for this hospital is 6.5 with 12-16 patients representing a high patient census. The hospital serves 24,000 patients per year and the emergency room serves 10,000 patients per year. Health care providers include family practice physicians, a general surgeon, a CRNA and nursing staff.

Renville County Hospital does provide obstetric services. In the past, seven family practice physicians did obstetrics. Now five family practice physicians include obstetrics in their practice. The certified nurse anesthetist (CRNA) does epidural procedures. Cesarean section coverage is provided by one family practice physician and the general surgeon. Two other providers are available in nearby Redwood Falls and Sleepy Eye, so there are a total of four cesarean section providers in the area. In 2011, there were 29 births total (equal to the 5-year average). In January 2012, there were six births total. The hospital used to do 15-20 births per month, so the number of local deliveries is going down. Renville County Hospital covers 25% of the obstetrics market in the service area with others going to Willmar. The hospital has two labor and delivery suites that include electronic monitoring and a jacuzzi tub. One physician participated in an underwater birth last spring, but it does not happen too often.

Standard staffing for a birth includes a physician, two nurses and a CRNA. For cesarean sections, there is a general surgeon, CRNA, second physician and two nurses. The second physician is required for routine and high-risk cesarean section procedures. Mid-level providers are not involved in prenatal care or deliveries at this hospital. With 75% of obstetric patients going to Willmar, do local family practice physicians participate in pre-natal care and then refer to a physician in Willmar for the birth? This arrangement is not formal, but there might be a high-risk pregnancy that is reassigned to Willmar.

How does the hospital train new nurses for obstetrics, or does the hospital count on limited staff turnover? This question gets at core of providing obstetric services in rural areas. Staff resources are important. The hospital is fortunate to experience little turnover with several senior nurses sharing a lot of experience. Obstetric nurses are required to have neonatal resuscitation program (NRP) training and a fetal monitoring class. Nurses have shadowing opportunities with North Memorial and CentraCare hospitals. When nurses show a strong interest in obstetrics, they will get to participate in births. There is reluctance to offer hands on training, but they are happy to shadow other nurses. When training at other facilities and in other states, staff is careful with malpractice coverage and licensure issues.

Swift County-Benson (Benson, MN) – This Critical Access Hospital, located in the middle of five towns in central Minnesota, serves about 8000 people. The hospital captures 85% of residents in the primary service area. Staff includes three physicians, two nurse practitioners, an orthopedic surgeon, an optomologist, physical therapy, occupational therapy, speech, home health and ambulance services. The average patient census is 3.4 people. About 65% of the patient mix is Medicare covered.

Swift County-Benson Hospital discontinued their obstetrics program in 2008. An interesting situation occurred when an insurance audit questioned the hospital’s ability to meet American Congress of Obstetricians and Gynecologists (ACOG) guidelines. They did not like the hospital’s plan to transfer obstetric patients to Willmar which is 32 miles and three communities away. It would be difficult to meet the requirement limiting time to 30 minutes from decision to incision for cesarean sections.

Swift County-Benson Hospital may now have an opportunity to restart their obstetrics program. A Rural Physician Associate Program (RPAP) student who is interested in returning to the Benson area is training in a year-long fellowship program concentrating on cesarean sections. When this physician completes the training, if no obstetrics program is developed at the hospital in Benson, he will go elsewhere. A second medical student from the Benson area has indicated an interest in obstetrics and would be willing to return to an established obstetrics program. The hospital is focused on restarting the obstetrics program from a staff recruitment and retention standpoint versus the need for obstetric services.

Hospital administrators are gathering information on costs to restart an obstetrics program. Retraining staff is costly and involves sending nurses to Willmar for training. Younger nurses are interested in an obstetrics training opportunity. Hospital administrators are looking at the potential number of deliveries. The 10-year average had been 11.7 births per year and ranged from 2-18 births per year. High-risk obstetric patients would be referred to another hospital. Newspaper articles about reinstating obstetrics at the local hospital have been a “mixed bag”. There has been some positive community comments and engagement, but some pregnant women are fine with travelling to Willmar.

Sanford Thief River Falls Medical Center –
This relatively larger Critical Access Hospital has a primary population of 8500. The entire service area includes 16,000-20,000 people. The obstetrics program is staffed by two OB/GYNs. (A third OB/GYN recently left the organization.) Only two family practice physicians are trained to do deliveries out of 30 family practice physicians. Mid-levels do primary care, but are not used on obstetric teams. A general surgeon was recruited with experience in surgery and obstetrics. Call coverage is a challenge with providers on call every third weekend.  

Currently, all of the obstetric providers are male. The hospital does not look at obstetrics as a profitable program, but they understand that women make many of the health care decisions for their families. They want to provide options to encourage women and their families to seek local health care services. To this end, they are looking at adding a female certified nurse midwife to the obstetrics team. The hospital performs 250-300 deliveries per year.

One challenge for the obstetric program is maintaining the obstetric team’s skillset. Sanford offers nursing training and credentialing at the Fargo location. The training requires ten deliveries, but some providers cannot make that number. Nurses choose to do obstetrics with medical-surgical nursing or obstetrics with critical care nursing. About 45% are currently cross-trained for deliveries. It takes obstetric nurses up to 6-8 months to get trained. The nurse compact for training in another state also requires licensure in that state.

Another challenge for the obstetric program is geographic isolation. Patient transfers are a nerve racking situation because they cannot get to Grand Forks in less than one hour. It is far enough away women will schedule an elective cesarean section. Other women will choose to receive all their obstetric care in Grand Forks, although they lose a lot of work time traveling to appointments. There was talk in the community that the hospital has a high cesarean section rate (28%), although it is within the norm when compared to other remote areas of the state. The hospital has focused on this issue and the Medical Assistance (MA) rule limiting inductions to patients at 39 weeks gestation has helped. With current staffing levels, the hospital has plenty of capability to do cesarean sections.

Saint Elizabeth’s Medical Center (Wabasha, MN) – Saint Elizabeth’s Medical Center has partnered with a sister hospital for obstetric training purposes. Staff is oriented to obstetrics for three weeks in a larger hospital doing hands on work in labor and delivery. They are in the process of rolling out the training program and younger nurses seem excited about it.

Saint Elizabeth’s Medical Center has high percentage of Medicaid patients utilizing obstetric services. State legislators have reduced payment to physicians through Medicaid, paying as little as $500 for care throughout an entire pregnancy (including pre-natal visits and labor/delivery). The uninsured or underinsured patient population is the most likely to use local obstetric services regardless of local obstetric capacity. Social workers attempt to get people enrolled in public coverage for the health care they receive.

Discussion

Number of births per year to maintain a rural obstetrics program - One question this work group has tried to answer is the number of births per year required to sustain a rural hospital obstetrics program. This answer takes into account financial considerations as well as the number of births per full-time obstetric provider needs to maintain his or her competencies. The answer is not clear in the medical literature or in practice. Once a provider is experienced in obstetric procedures, they could do fewer deliveries to maintain their competencies. Newer physicians need the support of experienced physicians for consult purposes, but to give an exact number of births needed to develop or maintain competencies does not seem possible. Some have tried to answer this question specifically for rural family practice physicians, but it is not easy to do. These are fluid concepts that depend a lot on individuals (e.g. experience, comfort level, how they work in teams). More important than a magic number is composite obstetric capacity at the rural hospital level.

Rural hospitals want to “be all we can be” for patients. They want a full complement of services to be available and enable local people to not have to travel, especially the elderly. They want patients to receive care near friends and family for support. When rural pregnant women go elsewhere for obstetric care, she might continue to go there for follow-up and child care, and pretty soon the whole family is travelling for health care. It is not so much about the economics of rural obstetric programs; rather it is about having a full range of services available locally.

Even if a rural hospital chooses to shut down their obstetrics program, they may still see patients in labor in the emergency room. Not having any obstetric staff capacity makes this a very difficult scenario. The hospital in Ely operates at a loss with their obstetrics program, but they are not comfortable taking away the service. They would rather have minimal practice and services than cut it out entirely because of geographic isolation. The family practice physician in Ely does not do other surgeries and it has been 16 months since the last cesarean section procedure. The worst-case scenario is high-risk deliveries presenting in the emergency room because these cannot be anticipated ahead of time.

Nurse training – It takes 6-8 months to get new nurses trained and feeling competent to provide obstetric services. Hospitals are financially not able to have nurses that solely do obstetrics. There are issues with cross-training nurses to do obstetrics with medical-surgical or critical care nursing. Culturally, it has been difficult to change the mentality of nurses to work in more than one area and be comfortable being the first nurse on. It is important to get nurses experience working with a mix of providers including midwives, CRNAs, OB/GYNs, general surgeons and family practice physicians.  

Training is costly, but it is good to have cross-training for obstetrical care for a large portion of rural hospital-based nurses. Training costs for nurses are estimated to be $2000 per nurse for a five week training course. They are paid for their time as well as other costs (mileage, housing, etc.) while other nurses must cover the hospital schedule.
Training costs, cross state licensing requirements, and hesitancy to engage in hands on training due to liability issues are preventative to rural obstetrical nurse training.

Liability, risk management and malpractice insurance – Benson has looked into legal issues when considering start-up costs of an obstetrics program. Insurance will not be preventative because it is based on service volume. If a lawsuit did occur, it would likely raise their premium. The topic of liability in obstetrics was big in the 1980’s. Currently in states like Montana, Wyoming and Minnesota, the insurance climate is not expensive. Some states like Ohio have experienced vanishing obstetric programs because of courts and the liability structure, but it is nearly a non-issue in Minnesota.

When the hospital in Thief River Falls was independent, they looked at risk management for obstetric services. Pregnant moms would need to be monitored closely because the operating room was located a distance from the birthing rooms. With fetal monitoring, moms are never off the monitor and are less mobile. This can be a sad part of the story with difficult consequences, but hospitals are held to specific standards of care. When risk management audits are performed, fetal monitoring is one of first areas they look at for potential issues. In the past, giving birth was more natural even in a hospital setting. Now it is complicated with many inductions and medical interventions. Obstetric providers were glad to see the state policy limiting MA patient inductions to after 39 weeks gestation. Patients will often request inductions on a specific date so they can plan their birth schedule.

It is a tough situation for a rural hospital to be involved in legal cases. There is substantial risk in the private practice world for physicians not associated with systems. These physicians have a break-even point of 15-20 deliveries per year to cover malpractice insurance costs before they can make a profit. It is worth educating medical residents about these figures as they make decisions about their future practice. They can see the business side of obstetric care and learn the trade-offs on the profit sheet which can be substantial. A hospital-based obstetric practice takes care of this issue for physicians as the hospital pays for the malpractice insurance, but for independent obstetric providers, it is still a big consideration.

Technology (EHRs, monitoring, consults, training, effect on referrals, costs) – It is helpful when a single electronic health record (HER) system allows pre-natal information to be shared with obstetric providers and across health care settings. Obstetric providers can do fetal monitoring remotely to cut down on in-hospital time for obstetric providers with on call responsibilities. Some hospitals are set up with telemedicine relays between the emergency room and remote locations, including OB/GYNs or family practice physician’s homes. Small rural hospital emergency rooms can connect to larger regional emergency departments for consultation purposes. Remote monitoring also allows nurses to have more bedside time instead of paperwork. Health systems are looking at the potential uses of telemedicine for obstetrics, but these services are still in their infancy.

Quality Measurement – Initial approaches to quality included measurement of patient volume. That is not an appropriate quality measure for rural obstetrics programs. Obstetrics requires adequate amounts of time and consciences application and providers cannot be too thorough.

Recruitment of family practice physicians willing to do obstetrics - Rural hospitals are experiencing a downward trend in family practice physicians interested in obstetrics. They are considered a “rare breed” and it makes for a difficult search and recruitment. Health systems may go to extreme measures to recruit these individuals. They can work anywhere in the U.S., so rural systems and hospitals have to get very creative with loan forgiveness, sign on bonuses, and promises about limited call schedules.

Trends have gotten worse in last 5-10 years. When a family practice physician doing obstetrics comes to a community, they are fine to do obstetrics for the first 5-7 years. After that, maintaining their willingness to do obstetrics is a challenge. Many female family practice physicians consider a full family practice as including obstetrics and deliveries. Yet it is very difficult to recruit female family practice physicians with obstetric experience. In more remote areas of the state, most family practice physicians doing obstetrics are international medical graduates (IMGs), specifically J-1 visa recruits, because of isolation and inability to attract other physicians to the region.

The thirty-two hospitals in southwest Minnesota affiliated with MediSota are not seeing RPAP students from the University of Minnesota or University of Minnesota-Duluth in their area. They have more availability for placement than can get students to fill. RPAP is a great resource for training rural physicians. However, to recruit these providers, rural hospitals need retention and follow-up plans and to make a concerted effort to keep in contact. Often times the candidates want to move back to an area their family is from, or females physicians will get married and may go where the partner wants to live. We need to match family geographic preferences to the location of the RPAP experience.

Aging family practice physicians and early retirements - If we look at which providers are doing cesarean section rates across a region, it will indicate generational trends. We are losing family practice physicians able to do cesarean sections to early retirements (55+). Younger physicians are hard to recruit, but there is usually someone who wants exactly what a small rural facility has to offer. Even when facilities pay a stipend to surgical residents for training, they will not be available for five years. Within Mayo system, deliveries are not done in small hospitals. Obstetric providers in the system understand family practice physicians will do pre-natal care and delivery will be referred to a larger system facility. It is difficult to get into the mindset of rural sites to engage in an earlier recruiting process to cultivate students and get them to stay in the area.

Recommendations

  1. Minnesota could adapt an interstate compact (especially with WI, ND and SD) for licensing nurses or family practice physicians for rural obstetric training purposes. There is potential for policies to have exceptions or reciprocity. The nurse compact issue has been introduced in state legislation. Twenty-four states have adopted this policy and many rural hospital administrators would welcome the change. Currently there is support from the Minnesota Hospital Association (MHA) and potentially good legislative support, but there is opposition from the Governor and Minnesota Nursing Association.
  2. State-level support is needed to cover training costs for current or new family practice physicians willing to do obstetrics. Costs may include 5-6 weeks of training, salary and travel/living expenses, meetings to develop partnerships and inter-facility agreements, and physician time for curriculum development and teaching. This training is critical for rural hospitals for obstetrics programs as well as other workforce shortage areas. State leaders need to be forward thinking around meeting future needs for training and practice. A similar approach has been used with state EMS services, so it is possible to push ahead in this area.
  3. Analysis is needed on the impact of legislation to reduce Medicaid payments legislation on Critical Access Hospitals. Legislators may not understand cause and effect for small rural hospitals. Legislators have been successful in creating other options such as promoting midwifery and home births for public program patients. It may be interesting to look into these changes, including the number and geographic distribution of women using these policy-driven delivery options as these offerings may be limited in rural areas.
  4. To properly educate medical residents, it may be necessary to revisit newly imposed federal work hour restrictions. Residents are now getting less experience overall. There is an inability to get case volume or delivery volume due to ACGME work hour restrictions. Regarding obstetrics, they have experienced a drop off in the number of deliveries they participate in over the course of their residency program. These types of unintended consequences also affect general surgical training. Ten years ago, surgical training included around 1500 surgeries. With current federal work hour restrictions, residents are participating in 750 surgeries. It is a new enough policy restriction, so it will take time to see the cause and effect of these changes. A statewide study of unintended consequences may be a good first step.

Next Steps

The next workgroup meeting will be via webinar on Thursday, March 15, 2012 from 1:30-3:30 p.m. The topic is rural obstetric patient and community issues: access to prenatal care, premature births, cesarean deliveries, support for high-risk pregnancies, costs and travel, community awareness of services, local competition or collaboration, care coordination across systems.

Adjourn

The webinar adjourned at 11:00 a.m.

Updated Wednesday, 04-Apr-2012 10:53:15 CDT