Monday, May 19, 2014
NORTHAMPTON — Interviews with Cooley Dickinson Hospital Childbirth Center staff contained in a state report paint a disturbing picture of an at-times short-handed unit. An obstetrician said he’d been on call every other night from October to early February — and he was tired. A nurse said that because of her patient assignment, she was unable to leave the nursery to help with the problematic delivery of one of the babies who died. Help was summoned from other areas of the hospital to care for other patients.
And the surveyor’s description of an interview with the obstetric department chair included this: “The OB department chair said that it has been a hard three months due to short-staffing and the maternal and newborn deaths.”
In the wake of six problematic incidents that included the deaths of two babies and a mother that prompted a state investigation, Cooley Dickinson Hospital has made protocol, policy, and staffing changes — and is engaged in its own internal soul-searching,
“Things are very different in the Childbirth Center. It’s been completely revamped, the mood is improving, people are confident,” said Dr. Mark Novotny, chief medical and patient safety officer at CDH. “We hope the public appreciates our openness and knows that we’ve taken all of this very seriously. The work is not done. It is a continuous process of improvement.”
The staffing problems believed to have contributed to the “system failures” that led to the deaths on the childbirth unit include resignations of longtime doctors — four of the nine obstetricians in the unit left to take other jobs and a fifth went on maternity leave between October and December 2013. Exacerbating those departures is a time-consuming recruitment process to hire new providers that means it can take many, many months to hire replacements. Another contributing factor is a practice that seeks to reduce nursing staff during slow periods.
Meanwhile, three temporary physicians started work on Dec. 25, Feb. 3, and March 1, according to CDH spokeswoman Dianne Cutillo. A permanent obstetrician started April 1 and another starts work Aug. 14. In addition, physicians from Massachusetts General Hospital are covering some shifts. The hospital is recruiting for a seventh obstetrician and a new midwife now, she said, and will soon start recruiting to replace providers who plan to retire in the next few years. And Cutillo noted that the Department of Public Health notified the hospital Thursday that recent inspections of the Childbirth Center turned up no deficiencies. That means the DPH has informed the Centers for Medicare & Medicaid Services that Cooley Dickinson is in compliance with federal law.
The state report notes that the departures between October and December of four obstetricians — and another who went on maternity leave — meant the four remaining physicians took on additional workloads and on-call shifts.
An obstetric consultant the hospital hired Jan. 28 to evaluate the unit told state surveyors Feb. 3 that given that situation, “he did not know how the obstetric providers could not be fatigued.”
During that time, the Perinatal Safety Committee tasked with oversight of safety in the unit ceased to meet because the obstetricians on it had too much work.
Novotny said the fact that there were “less than optimal staffing levels” in the Childbirth Center for months was not for lack of trying to hire replacements.
The hospital has been recruiting for both temporary and permanent replacements since July 2013, when officials first learned an obstetrician was leaving, he said. “But it takes on average eight to 12 months to hire an obstetrician,” he said. Even finding temporary replacements can take months.
Cutillo said the national recruitment market is highly competitive because there are not enough new obstetricians being trained to keep up with those retiring or cutting back their hours.
Novotny said determining how to staff a hospital is never easy, particularly in the hospital’s Childbirth Center. Patients can’t call a week ahead to inform staff when they plan to deliver, and it is rarely known how complicated a delivery might be.
“We staff according to the need,” he said, but “there are so many variables in any hospital.”
Hospital leaders have stopped short of saying they agree with the findings of the investigation conducted by the Department of Public Health on behalf of the Centers for Medicare & Medicaid Services.
The state report focuses on the period between October and January, although hospital officials have declined to confirm that is when the deaths occurred. In late 2013, a baby died in the birth canal when it could not be removed by cesarean section, and a mother died after delivering her baby when she suffered a stroke caused by high blood pressure. Then, in January, an infant was born without a heartbeat.
The report cited numerous other contributing factors, including lack of board oversight, poor communication among staff, and failure to properly report or respond to warning signs before delivery.
Novotny said Cooley Dickinson’s internal investigation agreed with most of the state findings, with the exception of its charge that the hospital failed to provide adequate staffing levels to ensure patient care and prevent fatigue. He said the hospital investigation did not find nurses’ workloads or physician fatigue to be contributing factors in the deaths, though he called the staffing levels at the time “less than optimal.”
Nevertheless, Cooley Dickinson has made sweeping changes, he said, not just in the Childbirth Center, but in the whole hospital.
“It’s been a time for stepping back and looking at how we do things,” he said. “It’s much more than just staffing.”
Staff have been undergoing new and refresher training and implementing new policies, including some to promote better communication and the reporting of patient safety concerns.
In terms of the staffing issues in the Childbirth Center, he said, new obstetricians have been hired and their on-call shifts have been limited in an effort to reduce fatigue. A practice where nurse staffing levels were reduced if the Childbirth Center was not busy has been temporarily discontinued. There has been a renewed effort to keep charge nurses, who are meant to be free to assist with any patients, from being burdened with patient assignments.
In the wake of the report, Novotny said the hospital has hired replacement obstetricians and reduced their on-call shifts. The medical staff office coordinator now notifies the chief of obstetrics and Novotny when the schedule requires an obstetrician to work more than one night shift in a four-day period.
Cutillo said that starting in December, the goal for the Childbirth Center’s schedule was for obstetricians to work no more than one night shift in four nights, and now that ratio is one in five nights. The doctors can sleep in a bed on the unit when things are quiet, she said.
Doctors are on “second call” one in five nights, Cutillo said, and would be called in if a cesarean section was needed or multiple patients were having complicated deliveries.
The hospital hopes to eventually get back to the one in six nights ratio it had before October by having highly trained midwives take all the overnight shifts, with obstetricians only being called in second or third, Novotny said.
“It might take two years,” he said. “Midwives could be managing the normal labors and working with physicians on call to manage the more complicated ones.”
Nursing staff levels
In two of the three deaths the state report investigated, charge nurses on the shift said they were not free to assist the other staff with the deliveries because they were assigned patients to care for. The Association of Women’s Health, Obstetricians and Neonatal Nurses recommends that a charge nurse “ideally” not be given patient assignments.
“The charge nurse should never have an assignment because the role of the charge nurse is to help in an emergency,” said Roland Goff, director of strategic campaigns at the Massachusetts Nurses Association, the union that represents Cooley Dickinson nurses. “If they have a full load, they can’t be that extra person when something goes wrong.”
David Schildmeier, the union’s public relations director, said the union has tried unsuccessfully to get Cooley Dickinson to limit or eliminate assignments for charge nurses.
“Unfortunately, it had to get to a tragedy for it to happen,” Schildmeier said.
Novotny said the goal instead is to have Childbirth Center charge nurses free of assignments 80 percent of the time. “We’re moving toward that, but we’re not there yet,” he said. He hopes that recruiting several new nurses will help achieve that goal.
While state investigators did not mention it in the report, Cooley Dickinson trustees have temporarily discontinued a common scheduling practice called “flexing down” in the Childbirth Center.
“Flexing down” nursing levels means sending nurses home or asking them not to come to work when the unit is not busy. Goff said the practice is risky — just because a unit is quiet does not mean it will stay that way.
“Then all of a sudden, something occurs — something goes wrong — and there isn’t enough staff there to deal with it,” Goff said. “It is becoming more prevalent everywhere as hospitals look at ways to cut costs, but they’re looking in the wrong place.”
Novotny said that Cooley Dickinson has been flexing down nursing levels throughout the hospital since the money-saving method became a national trend a few years ago. He said it is due to the need to keep health care costs low for patients. “We’re obligated to carefully control costs, and most of the expenses in health care is people,” he said.
Despite that, he said the hospital it is now prepared to take a financial hit to keep Childbirth Center’s nursing shifts fully staffed while the plan of correction is implemented. “The board of trustees is committed to spending that extra money in the Childbirth Center,” he said.
But he does not expect it to continue forever. “In the future, if everything is going the way we expect, will the board talk about flexing down again? Probably,” he said.
While Goff and Schildmeier feel that the resuming the practice would put the hospital at risk for another tragedy, Novotny disagrees.
“No hospital can afford to carry expenses that are not directly related to providing patient care,” he said. “As we’ve seen with the hospital in North Adams, having expenses that are not covered by revenues can have very serious consequences.”
Rebecca Everett can be reached at firstname.lastname@example.org.