In recent years, more OB units in rural areas have experienced closures and maternity care deserts have grown. In response, many rural healthcare organizations are exploring creative approaches in their efforts to maintain OB and gynecology (OB/GYN) services for their patients. The National Rural Health Association describes some of the approaches hospitals and policy makers have taken to try to maintain OB services, such as addressing costs of maternity care, increasing staffing levels, and consolidating health systems.
Combining units and going "on diversion" may also be considered creative approaches to addressing staffing issues in OB units, but such efforts raise potential risks.
OB Merging with Medical-Surgical Unit
Combining a medical-surgical unit with an OB/GYN unit does not appear to be a typical solution to an understaffed OB department. Although there are instances in which OB services from multiple locations combined into one, particularly during the height of the COVID-19 pandemic, merging similar departments from different locations is significantly different from merging different departments with different responsibilities.
There are several aspects the organization must consider before implementing this merger, including but not limited to the following:
Putting the OB Department "On Diversion"
Diversion is typically a term applied to the emergency department (ED). EMTALA laws require hospitals that do not provide maternity services or who are short on OB staff to provide emergency screening for pregnancy-related issues as well as life-saving care. State laws and regulations may also apply, like in this case, in which an Oregon hospital that planned to divert pregnant women to another hospital faced sanctions from the Oregon Health Authority.
Therefore, even if a hospital requests to go on L&D diversion, if a patient's condition is unstable and the hospital requesting diversion is the closest/most appropriate hospital for the patient, they are required to care for the patient. Hospitals can screen and stabilize the patient in the ED and then transfer the patient to another facility if they cannot provide services, but the referral facility must be notified and must agree to accept the patient.
If the organization is concerned about not having enough OB staff on hand to meet patient needs, it may want to consider partnering with local emergency medical services (EMS) and other hospitals in the region to ensure that they can provide OB care to patients. It should also ensure that referral agreements are up to date.
In addition, the organization should consult its legal/compliance department to ensure that any policies they are considering do not violate EMTALA laws. This issue can be particularly difficult to navigate since the Dobbs v. Jackson Women's Supreme Court decision has resulted in more conflicts between state and federal laws and greater confusion related to emergency abortion access. Such situations are complex and rapidly changing, and the organization's legal, compliance, and risk management staff will need to keep abreast of any related laws and regulations.
The organization should consider convening a meeting with executive and clinical leadership (e.g., ED director, chief nursing officer, chief medical officer) and the legal, risk management, and compliance departments to coordinate a plan. The organization should also consider reaching out to their state hospital association; state medical, nursing, and EMS boards; and state chapters of relevant professional organizations (e.g., ACOG, AWHONN, Emergency Nurses Association, American College of Emergency Physicians, American College of Healthcare Executives) to see if state-level efforts are being coordinated.
Additional resources that may be helpful include the following:
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