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Smooth Transitions: Enhancing the Safety of Planned Out-of-Hospital
Birth TransfersA Quality Improvement Initiative
of the WA State Perinatal Collaborative
Disclosures
The speakers have no conflicts of interest to disclose
Learning Objectives
At the conclusion of this presentation, participants will be able to:
Describe the categories of midwives recognized in WA State
Describe the scope of practice of Licensed Midwives in WA
Understand the benefits of a quality improvement program that addresses transfers from planned out-of-hospital births
Understand how to engage in such a program at their hospital
The Issues
Out-of-hospital (OOH) birth is chosen by a small but growing number of families
Physician and hospital services will be needed
Lack of systemic supports for smooth transfer of care
Context
AWHONN Position Statement on Midwifery:
AWHONN supports a woman’s right to choose and have access to a full range of providers and settings for pregnancy, birth and women’s health care.
It is critical that each health care professional recognize and respect the scope of practice and state and/or provincial licensure parameters of each collegial health care professional. Research suggests that lack of teamwork is associated with less optimal patient outcomes. Effective communication between all types of health care professionals is essential to provide safe and effective care of women and newborns and is especially critical when the patient’s care occurs in more than one care setting.
The Context
ACOG Statement on Home Birth:
Although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery. Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth. Importantly, women should be informed that the appropriate selection of candidates for home birth; the availability of a certified nurse–midwife, certified midwife, or physician practicing within an integrated and regulated health system; ready access to consultation; and assurance of safe and timely transport to nearby hospitals are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes.
Published in 2011; reaffirmed in 2013
The Context
Home Birth Consensus Summit, October 2011
Statement on Collaboration:
We believe that collaboration within an integrated maternity care system is essential for optimal mother-baby outcomes.
All women and families planning a home or birth center birth have a right to respectful, safe, and seamless consultation, referral, transport and transfer of care when necessary. When ongoing inter-professional dialogue and cooperation occur, everyone benefits.
The Context
Home Birth Consensus Summit
Collaboration Workgroup
Best Practice Guidelines: Transfer from Planned Home
Birth to Hospital
May 2014
2013 WA BirthsTotal Births 86,431
Hospitals 84,053 97.2%
Birth Centers 1,161 1.3%
Home 1,753 2.0%
Other 65 .07%
MD/DO 74,994 86.7%
CNM 7,832 9.1%
LM 2,804 3.2%
Other or unknown 629 0.7%
Out-of-Hospital Births in Washington
State In 2013 3.2% of Washington’s births occurred in an out-
of-hospital setting (N=2,914) ; up from 1.9% in 2006
60% at home40% in licensed freestanding birth centers
Washington’s home birth rate is more than twice the national rate; birth center rate is more than triple the national rate
Majority (94% of OOH births) attended by Licensed Midwives (LMs)
There are currently about 120 LMs in the state and 16 licensed freestanding birth centers
Midwives in Washington
Lay (unlicensed) midwives
Certified Nurse Midwives (CNMs)
Licensed Midwives (LMs)• LMs may also hold a national
credential of Certified Professional Midwife (CPM)
Licensed Midwives Complete 3 year education from a Washington State approved
school, including attendance at a minimum of 100 births
OR
Graduate from an equivalent program from another state or country
OR
Present documentation of completion of “equivalent subject matter...and number of clinical managements under a (qualified) preceptor.”
AND
Pass an examination provided to the state by the North American Registry of Midwives (NARM)
Licensed Midwives
• Regulated and disciplined by the Department of Health, in accordance with RCW 18.50, with assistance from a Midwifery Advisory Committee
• Most LMs work in independent practices, attending births in homes and licensed freestanding birth centers
LM Scope of Practice
Washington law (RCW 18.50)
defines the scope of practice for LMs as providing care during the prenatal, intrapartum, and postpartum stages
requires the midwife to consult with a physician whenever there are significant deviations from normal in either the mother or the infant.
LM Scope of Practice
Legend Drugs and Devices
LMs do not have prescriptive authority but are authorized to obtain and administer:
Prophylactic ophthalmic medication
Postpartum uterotonics
Vitamin K
Rho immune globulin
Local anesthetic
IV fluids
MMR, Hepatitis vaccine & HBIG
IV Antibiotics for GBS prophylaxis
Legend Drugs and Devices
In addition, the Midwifery Advisory Committee has established protocols for use of:
Epinephrine for use in allergic reactions
Magnesium Sulfate in cases of preeclampsia
Terbutaline for non-reassuring FHR
ALL PENDING TRANSPORT
LMs may also “administer such other drugs or medications as prescribed by a physician”
LM Practice in WA
• LMs are trained in both neonatal resuscitation and CPR and required to renew every 2 years
• LMs carry oxygen to births and are trained in the use of laryngeal mask airways and pulse oximeters
LM Practice in Washington
LMs contract with a variety of health insurance plans, including Medicaid
Liability insurance 89 of the 120 LMs in Washington have
liability coverage through a state-mandated Joint Underwriting Association (JUA); malpractice insurance is also now available through an out-of-state company
All 16 of the licensed freestanding birth centers in the state have liability coverage, all but one through the JUA
Professional Association
Midwives’ Association of Washington State (MAWS)
www.washingtonmidwives.org
Professional Association
MAWS establishes standards of practice, provides continuing education, advocacy, and legislative support
There are currently 116 professional MAWS members,100 LMs and 16 CNMs
MAWS maintains a Quality Management Program (QMP) with state-protected, confidential peer review and incident review; all professional MAWS members are required to participate in the QMP
QMP Incident Review
Midwives are required to self-report sentinel events within 14 days
Anyone may submit a report (patient, family members, other healthcare providers).
Review includes recommendations and may include report to the Department of Health, pursuant to state law
Intrapartum Hospital Transfers
Intrapartum transfer rates range from 10.9% – 20% (about 580 transfers/year from OOH births in Washington)
Intrapartum transfer rate for primips=22.9%; rate for multips= 7.5%
96.5% are non-urgent
55.9% of IP transfers for prolonged labor, exhaustion, or maternal request for pain relief; 56.1% receive epidurals; 22% receive oxytocin augmentation
53.2% deliver vaginally; overall c-section rate = 5.2%
Sources: Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Melissa Cheyney PhD, CPM, LDM, Marit Bovbjerg PhD, MS, Courtney Everson MA, Wendy Gordon MPH, CPM, LM, Darcy Hannibal PhD and Saraswathi Vedam CNM, MSN, RM. Journal of Midwifery. January 2014. Jane Hutcheson, Group Health, and Thomas Benedetti, MD, Personal communications.
Intrapartum Hospital Transfers
1.5% mothers were transferred immediately postpartum, primarily for hemorrhage and retained placenta
0.9% newborns were transferred after birth, primarily for respiratory problems
Source: Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Melissa Cheyney PhD, CPM, LDM, Marit Bovbjerg PhD, MS, Courtney Everson MA, Wendy Gordon MPH, CPM, LM, Darcy Hannibal PhD and Saraswathi Vedam CNM, MSN, RM. Journal of Midwifery. January 2014.
Historically, intrapartum hospital transfers have not always gone well…
Both “sides” have a role in ensuring efficient transfers of care
Intrapartum Hospital Transfers
Obstacles reported by hospital-based providers:Belief that home birth is unsafeBurden of assuming care of
unknown patient with elevated risk
Working with “difficult” patients or “difficult” midwives
Intrapartum Hospital Transfers
Obstacles reported by midwives:Lack of awareness among
hospital-based providers of OOH research supporting safety
Defense of co-negotiated assessment of risk
Feeling judged by the “exception rather than rule”
The midwife assesses the status of the woman, fetus, and newborn throughout the maternity care cycle to determine if a transfer will be necessary.
The midwife notifies the receiving provider or hospital of the incoming transfer, reason for transfer, brief relevant clinical history, planned mode of transport, and expected time of arrival.
The midwife continues to provide routine or urgent care en route in coordination with any emergency services personnel and addresses the psychosocial needs of the woman during the change of birth setting.
Model practices for the midwife
Model Practices for the Midwife
Upon arrival at the hospital, the midwife provides a verbal report, including details on current health status and need for urgent care. The midwife also provides a legible copy of relevant prenatal and labor medical records.
The midwife may continue in a primary role as appropriate to her scope of practice and privileges at the hospital. Otherwise the midwife transfers clinical responsibility to the hospital provider.
The midwife promotes good communication by ensuring that the woman understands the hospital provider’s plan of care and the hospital provider understands the woman’s need for information regarding care options.
Model practices for the midwife
Model Practices for the Midwife
Model practices for the hospital provider and staff
Hospital providers and staff are sensitive to the
psychosocial needs of the woman that result from
the change of birth setting.
Hospital providers and staff communicate directly with the midwife to obtain
clinical information in addition to the information
provided by the woman.
Timely access to maternity and newborn care
providers may be best accomplished by direct
admission to the labor and delivery or pediatric unit.
Whenever possible, the woman and her newborn are kept together during
the transfer and after admission to the hospital.
Model practices for the hospital provider and staff
Hospital providers and staff participate in a shared
decision-making process with the woman to create an
ongoing plan of care that incorporates the values,
beliefs, and preferences of the woman.
If the woman chooses, hospital personnel will
accommodate the presence of the midwife as
well as the woman’s primary support person during assessments and
procedures.
The hospital provider and the midwife coordinate follow up care for the
woman and newborn, and care may revert to the
midwife upon discharge.
Relevant medical records, such as a discharge
summary, are sent to the referring midwife.
MD/LM Workgroup
Convened in September 2005 as a subcommittee of the Department of Health’s Perinatal Advisory Committee
Charge: To study and improve the process of transferring women and their babies from a planned home or birth center location to an acute-care hospital when a higher level of care becomes necessary
Smooth Transitions
A Quality Improvement Initiative of the WA State Perinatal Collaborative
www.waperinatal.org
Smooth Transitions
A voluntary, free, customizable program to help hospitals improve the efficiency of planned
out-of-hospital birth transportsenhance patient safetydecrease liabilitypromote greater satisfaction for all
parties involved
Smooth Transitions
GOALS:
Build greater understanding between OOH birth midwives and hospital personnel
Improve interactions between providers when intrapartum transfers occur
Increase probability of safe and satisfying care for mothers and babies
Smooth TransitionsGetting Started
Download the materials from the website: www.waperinatal.org
Identify a project lead at your facility
Contact the Project Coordinator to arrange a pre-project interview
Smooth TransitionsNext Steps
Form a Planned OOH Birth Transfer Committee• Local Licensed Midwives• Obstetricians, Family Physicians, CNMs• Emergency Department Physician & Nursing
Leadership• Obstetrics Nurse Manager• Obstetrics Charge Nurses• Hospital Administration Representatives
(including risk management department)• EMS personnel
Smooth TransitionsNext Steps
Committee develops a transfer process • Sample on the website
MD/LM Workgroup is working on a survey tool• Sample on the website• All perspectives: patient, midwife, OB
provider, labor and delivery nurse • Ideally would be electronic• Must be secure, confidential
Smooth Transitions Follow-up
Planned OOH Birth Transfer Committee meets 2 – 3 times/year to review transfers
Share successes and identify areas that need improvement
Submit an annual summary to the MD/LM Workgroup
Smooth Transitions
Seven (7) hospitals have had initial presentations:• University of WA Medical Center, Seattle• Evergreen Health, Kirkland• Providence Health and Services, Everett• PeaceHealth St. Joseph, Bellingham• Jefferson Healthcare, Port Townsend• Yakima Valley Memorial Hospital, Yakima• Kittitas Valley Healthcare, Ellensburg
Three (3) other hospitals have expressed interest in the QI project:• St. Joseph Medical Center, Tacoma• Providence St. Peter Hospital, Olympia• Valley Medical Center, Renton
These 10 hospitals account for over 30% of the births in WA State
A model that works
Legacy Emanuel Hospital in Portland, OR
In 2006, Dr. Duncan Neilson, Chief of Women’s Health Services, began to implement “wholesale structural and cultural changes” designed to make all five hospitals in the Legacy system “more appealing to women who start delivering at home and to the midwives who help them—thus providing a safe and welcoming alternative when problems arise."
A model that works
OB hospitalist program
Midwife to midwife transfers of care for clinical situations that are not high-risk or emergent
Waterbirth
Staff training
A model that works
“We used to have these horrible [home-birth] disasters show up at the ER. And we do not see
those disasters now. They have just about gone away.”
Smooth Transitions
THANK YOU!
Smooth Transitions Project Coordinator: Audrey Levine
(360) 709-0888
