OB Emergencies Pose Patient Safety, Legal Risks
January 1, 2024
By Stacey Kusterbeck
Patients with pregnancy complications presenting to EDs with little or no obstetric services may require transfer to another facility. This situation poses multiple risks for emergency physicians (EPs), according to Bryan Baskin, DO, FACEP, vice chair of Safety, Quality and Experience in the Department of Emergency Medicine at Cleveland Clinic and assistant professor at Cleveland Clinic Lerner College of Medicine. In Baskin’s experience, EDs may have these key areas of risk:
• ED providers may fail to recognize the risk of hypertension in pregnant patients.
Patients may present to the ED with elevated blood pressure and symptoms such as headache or dizziness. If discharged home without treatment, some develop preeclampsia. “It’s a more subtle risk that gets underestimated and can cause a lot of disability to pregnant patients,” says Baskin.
• Some EDs have an inefficient transfer process for obstetric emergencies.
EDs need appropriate transfer algorithms if the hospital does not have in-house OB/GYN. If the patient delivers in the ED, there are potentially two patients involved, and one or both may require transfer. “There are a lot of moving parts happening in these cases. Having the transfer process standardized and ready to go is critical,” says Baskin. EPs also might need to document reasons for delays in transfer that were outside the control of the ED and what was done in response.
“If you have a patient who is hemorrhaging, or having a pre- and postpartum emergency, or an actual delivery and a neonate who is not doing well, the ED physician can’t really spend the time — especially if it’s a single coverage site — to try to figure out how to move the patient, who is going to move them, and where,” says Baskin. Ideally, EDs have robust systems in place to transfer obstetric patients fast and efficiently. “Having a system or process in place before the patient arrives with an emergency to move the patient quickly is good for everyone involved — most importantly, the patient. Any delay can be really devastating,” says Baskin.
• EDs may be unprepared for pregnant patients who present with hemorrhage, either pre- or post-delivery.
“There is a lot of compliance around OB hemorrhage, and what needs to be in the ED, and not everyone is compliant with those requirements sometimes,” observes Baskin. EDs need the right equipment and medications to treat the patient in the ED. Having a dedicated area of OB hemorrhage supplies (such as a cart located alongside neonatal resuscitation equipment) is ideal.
• There may be delays in obtaining OB consultations.
If the consult is delayed, document it without placing blame on a colleague, says Baskin. Some ED charts contain statements such as “The consultant refused to show up. Delayed transfer,” or “Paged Dr. Smith repeatedly but he never called back, so I am now paging him again.”
“That just inflates risk for everyone — most notably, the person who is writing it, because they are the attending of record, usually,” says Baskin. A better approach: Allow electronic health record timestamps to tell the story. The ED chart will reflect that the OB consultant was paged at 4:00 and again at 4:30, for instance.
Sometimes, it is just not possible for the EP to obtain the OB consult. If the EP determines that an emergency consultation is needed, transfer may be necessary. Having a point of contact at the receiving facility can be helpful to facilitate those cases. “Maybe it’s not a formal consultation, but reaching out to an OB center is a way to discuss the case and determine whether or not the patient needs to be emergently transferred,” says Baskin.
• EPs may give incomplete information about the case to the OB consultant at the institution, or to an OB provider at the receiving facility.
“Be clear on what you are asking, what you have in front of you, and what you think needs to happen next. Sometimes, from the consultant’s point of view, they don’t get the right story told to them. They were giving advice on what they heard the question was,” says Baskin. The consultant might give the EP the “wrong” recommendation, but in retrospect, it becomes apparent that the consultant did not understand the critical nature of the pregnant patient. The consultant might be getting the call walking out of the OR, or in the middle of the night. Their recommendation might have been appropriate for the question that the EP asked. “They may not understand there is a different concern if the EP doesn’t explain it correctly or doesn’t give the right information,” says Baskin.
Patients with pregnancy complications presenting to EDs with little or no obstetric services may require transfer to another facility. This situation poses multiple risks for emergency physicians.
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