Consider risk of allowing new mothers and babies to stay an extra day
Tips to ensure that good PR doesn't increase liability
Stay-an-extra-day programs for new mothers can be good for hospital public relations. But if not planned correctly, these maternity ward policies can be a risk management headache.
As both fee-for-service and managed care payers continue to pressure doctors and hospitals to shorten the length of stay for maternity patients -- in most cases to 24 hours after a normal vaginal delivery and 72 hours after a normal cesarean -- many health care providers are scrambling to develop policies that would allow women and infants to stay in the hospital longer.
The so-called stay-an-extra-day programs have been one response to the controversy over "drive-through" deliveries, and they are growing in popularity at hospitals across the country. The programs typically allow maternity patients and their infants to stay in the hospital for an additional day or two -- regardless of reimbursement from insurers -- to allow extra time for the patient to recover and for the medical staff to educate the mother and monitor the infant.
While the idea behind the longer stay is the same everywhere, various hospitals have implemented the program differently. Some are allowing the mother and infant to stay in the maternity ward as patients for an extra day of care, while others have created separate wards where mothers and infants stay while convalescing. (See a related story on new state laws about maternity lengths of stay, p. 19.)
If your hospital implements such a policy, the risk implications depend on how your program is set up, experts caution. Following are seven questions you should address as risk manager when developing stay-an-extra-day policies at your hospital:
1. Should the new mother and baby still have "patient" status?
As risk manager, you should help determine whether the new mother and infant will retain patient status in the hospital. This depends on the services the maternity patient will be provided while remaining in the hospital.
At Grand View Hospital in Sellersville, PA, for example, maternity patients are discharged before they enter the hospital's residential care program for new mothers, since they no longer meet the criteria of being a patient and do not receive the same services, says Kathleen Strunk, RN, risk manager.
At Tampa (FL) General Hospital, new mothers and infants are moved into an extended-care area of the hospital called "family suites," for up to two days at no cost. Like the patients at Grand View, these mothers and infants are discharged as patients from the hospital before moving into the family suites, says Paula Bradlee, RN, CHRM, director of risk management for Tampa General.
The mothers and infants are discharged as patients because they are receiving different services, Bradlee explains. In the suites, which are designed to have a hotel-like feeling, mothers can receive education and assistance from nurses and staff in areas such as parenting, infant care, and breast feeding, Bradlee explains. Hospital staff are available for daily maternal and infant physical assessments.
Clarifying expectations
To protect itself, the hospital must be clear about the services it is offering to the mother and infant while in the extended care facility, Bradlee says. Tampa General gives patients brochures about its family suites program before they are ready to be discharged, to help clarify the differences in care.
2. Should you obtain a separate consent?
When a nonpatient is allowed to stay in the hospital, a separate consent should be used. At Tampa General, the new mother is asked to sign a separate consent form that states what services the hospital is and is not providing, Bradlee says.
Similarly, at Grand View, "We make it clear the differences they can expect," Strunk says. Grand View's consent form is accompanied by a list of items the new mother is expected to provide for herself and her child while in the hospital, including supplies and medications.
If new mothers are not discharged as patients from the hospital, a separate consent may not be needed, suggests John Sward, director of risk management at Saint Joseph Medical Center in Joliet, IL.
New mothers at Saint Joseph can choose to stay on as patients in the maternity ward for an extra day at no additional cost. The consent form maternity patients sign at admission covers the patient's extended stay because the services remain the same, Sward says.
3. Should you move the patients?
Some hospitals move the maternity patient to another bed or ward of the hospital under these stay-an-extra-day programs. If you do, set policies on moving the patients and infants, Bradlee advises. The policies should address whether the mother and child should be allowed to move themselves and their possessions physically or whether the hospital staff will transfer them into a new location.
Bradlee also cautions risk managers to consult infection control staff if they plan to move the mother and child into a different ward of the hospital, since such moves can also make patients susceptible to infection.
Out of the hospital is not out of the woods
4. How should the hospital identify and handle needed treatment?
Medical and nursing care often are reduced or terminated under the stay-an-extra-day programs. Risk managers should make sure the program has trained hospital personnel monitoring the new mothers and infants, in the event that treatment is needed, Bradlee advises.
The maternity patients and their infants in Tampa General's family suites are monitored by trained staff who can bring in a nurse if medical treatment is required.
The location of the ward for the stay-an-extra-day program is important, in the event a mother or infant needs treatment, says Bradlee. For that reason, the family suites at Tampa General are located in proximity to the maternity ward.
5. How should security be assured?
Maternity ward security measures should remain in place for patients and infants staying for extra days, no matter where they stay in the hospital, risk managers advise. Newborns remain in the hospital's nursery at Saint Joseph as a security measure, Sward says.
Bradlee advises risk managers not to overlook security for personal property. In Tampa General's family suites program, all of the room doors and furniture can be locked so patients can keep their valuables and other personal property with them. The locking doors and drawers also help to protect the hospital from liability for theft.
6. Have promotional pieces been reviewed for risk?
Although few hospitals are willing to say they are using the stay-an-extra-day programs as marketing tools, several do advertise them in local newspapers. Review any advertisements or marketing brochures about the program to make sure they do not overstate the services provided, Bradlee suggests. Overstatements could subject the hospital to increased risk, she cautions.
7. Will the benefits outweigh the costs? Would a less intensive program be a better option?
While the stay-an-extra-day programs could potentially increase market share for hospitals, they can be costly because of the increased use of beds, staff, and services. For that reason, it is important for risk managers to make sure the program's goals are being met, Sward says.
"Make sure the extra time in the hospital is really worthwhile for the patient," he advises. For example, make sure the patient teaching takes place.
Offer home health, instead?
Recognizing that the stay-an-extra-day programs can be a financial strain, other hospitals have developed less intensive programs designed to meet the same goals.
"The key is adequate education, good training on signs and symptoms, and having access back to the patient if anything starts looking strange," says Jane Bryant, MHSA, FASHRM, director of risk management for Greenville (SC) Hospital System.
Greenville Hospital System sends home health care nurses to the homes of early-discharge maternity patients and their babies, for an extra day of monitoring. She advises other risk managers to be creative when designing policies to meet the concerns over shortened maternity stays.
"Risk managers are going to have to weigh the cost outcome factors and understand if the clinical indicators say this patient should not be discharged," Bryant says. "You could have an organizational philosophy that says the patient goes when the patient is ready, and there can be creative ways of handling that, like monitoring with home health aides. You'd like to be able to keep them in the hospital for another day, but if you are not authorized for that, you can get them authorized for something else that will at least meet the doctor's concerns." *
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