Susan Mann, M.D., Kimberlee McKay, M.D., and Haywood Brown, M.D.
N Engl J Med 2017; 376:1304-1305April 6, 2017DOI: 10.1056/NEJMp1700485
In a rural Minnesota town with fewer than 5000 residents, an 18-year-old woman with a term pregnancy goes into labor in a hospital that performs about 75 deliveries per year. Her pregnancy has been uncomplicated, but chorioamnionitis develops during labor and she undergoes a primary cesarean delivery for arrest of descent during the second stage of labor. Her low-risk pregnancy has become high risk — a common story for intrapartum obstetrical care in any hospital, but one that can have deadly consequences in a hospital with fewer resources, including a small staff and limited blood-bank capacity. The woman has a severe postpartum hemorrhage and loses more than 2 liters of blood. She is given the usual uterotonic medications and surgical intervention with B-Lynch suture placement, but they prove ineffective.
The lone obstetrician in the hospital is about to perform a hysterectomy when she recalls a conversation she had 2 weeks earlier with the obstetrical medical director of her hospital system about a program for team training and simulation for obstetrical emergencies that was being offered at her hospital. The director encouraged the obstetrician to reach out regarding safety concerns and left a card with her cell-phone number. Running low on options, the obstetrician contacts the director, who recommends giving the patient a transfusion from the hospital’s very limited blood supply. The director then facilitates consultation with Avera eCARE, a telehealth service that provides real-time specialty expertise to lower-resource care settings.
The teams at Avera arrange transport by helicopter to a tertiary care hospital in Sioux Falls, South Dakota, a 20-minute flight. The patient arrives 2 hours after the initial call was placed, and the telehealth specialists support both the transporting-hospital care team in stabilizing the patient for transport and the receiving care teams in intensive care and interventional radiology. The patient, who was about to have a life-altering and possibly life-threatening hysterectomy, instead undergoes a uterine artery embolization and further stabilization in the intensive care unit (ICU) and is discharged 3 days later.
More than 60% of U.S. hospitals that provide obstetrical care perform fewer than 1000 deliveries per year, or fewer than 3 a day. A review of obstetrical outcomes in 600 rural U.S. hospitals and low-volume, nonteaching hospitals — lower-resource hospitals — revealed that they had higher maternal morbidity than teaching hospitals. The possible issues identified in the lower-resource settings included maintenance of competencies and recruitment of staff.1
In the United States from 1998 to 2008, delivery and postpartum hospitalizations that resulted in maternal mortality and severe maternal morbidity increased by 66% and 75%, respectively.2 The Centers for Disease Control and Prevention and state departments of health have recognized the difficulty of obtaining accurate data pertaining to severe maternal complications and pregnancy-related deaths owing to varied definitions and reporting requirements. Even less information is available regarding the setting in which these cases occurred — urban versus rural and academic centers versus community hospitals. Rural health care centers have been essential for patients, but many of these smaller hospitals have shut down their maternity services.3 For a patient in a rural setting, frequent severe weather and long distances may impede access to a larger hospital. Is it reasonable for these women to drive for hours to get to a larger medical center, or can we do more to support obstetrical practitioners in remote settings?
We believe that Avera’s approach can provide a model for other parts of the country, where a Maternal Health Compact could be created linking lower-resource hospitals with tertiary care hospitals, with the goal of transporting patients to the appropriate facility when possible and making care as safe as possible locally when transport is not an option. Telehealth services in obstetrics can help to bridge the gap in three ways: facilitating transport of patients, supporting care provided remotely, and assisting in local quality-improvement activities.
Under a Maternal Health Compact, a tertiary care hospital provides services to its referring lower-resource hospitals for high-risk patients. Smaller hospitals also benefit from increased collaborations in which, for instance, the tertiary care hospital runs simulations of obstetrical emergencies and assists with quality-improvement activities such as implementation of hemorrhage-treatment algorithms. Such collaborative work can be done in person or through telemedicine connections.
National efforts at improving obstetrical care have stopped short of addressing rare emergencies that can occur in a lower-resource hospital. In 2015, for example, the American Congress of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine released the Obstetric Care Consensus on Levels of Maternal Care, which delineates criteria for identifying women at considerable health risk (such as those with placenta previa, placenta accreta, or preeclampsia with severe features) who should be cared for at a hospital with appropriate staffing and resources to avert obstetrical complications and related deaths.4 Unfortunately, the consensus statement does not address the situation of an 18-year-old with an unexpected severe hemorrhage. Yet with better preparation and planning through a Maternal Health Compact, hospitals could be ready for these crises.
Telehealth is already used in many disciplines in which there is a mismatch between patient needs and specialty expertise, such as dermatology, geriatrics, and mental health, but to our knowledge, there has been no telehealth model for obstetrical care for an acutely high-risk pregnant woman in a lower-resource hospital. In the case of the Minnesota patient, a coordinated telehealth team intervened quickly and effectively; they worked with the rural hospital to stabilize the patient, arranged transport, and prepared the tertiary care hospital.
Through a Maternal Health Compact, physicians and nurses made available to lower-resource hospitals through a video link can help manage on-site obstetrical emergencies. Physicians make recommendations regarding care, while nurses support the nurse in the field by documenting the patient’s course and care in the medical record and facilitating communication with the local pharmacy to obtain necessary medications. The telehealth program developed at Avera, for example, houses under one roof a variety of medical departments — ICU, pharmacy, emergency, and others — to provide continual specialty care to partner care facilities. This kind of coordination is invaluable to patients.
The development and implementation of national standards supports the consistency of obstetrical care. The National Partnership for Maternal Safety, an initiative aimed at reducing maternal morbidity and mortality, released a Consensus Bundle on Obstetric Hemorrhage, in conjunction with the Alliance for Innovation in Maternal Heath (AIM), which recommended that all hospitals that provide obstetrical care develop a standard treatment protocol for postpartum hemorrhage.5 The challenge for the smaller, often rural, hospital has been to determine what the protocol should be for a massive transfusion when their blood bank carries only a fraction of the blood products considered essential for most hemorrhage-treatment protocols. Lower-resource hospitals need site-specific protocols for managing the care of patients with massive hemorrhage. The tertiary care physicians who accept transfers of such patients should help identify resources available at the referring hospitals and partner with them to create such site-specific algorithms, including use of emergency-release blood, fresh frozen plasma, shock garments, and tranexamic acid. The workflow for patients requiring transport should be as efficient and seamless as possible.
Pregnant woman in rural communities cannot afford to lose access to local hospitals; rather, we need to make the care they receive as safe as possible. Team training and simulation of emergencies are common tools of the patient-safety movement, and electronic connectivity and broad implementation of a Maternal Health Compact are the next logical steps for improving patient care, retaining rural care facilities, and recruiting and supporting practitioners in the field.
Disclosure forms provided by the authors are available at NEJM.org.
This article was updated on April 6, 2017, at NEJM.org.
From the Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston (S.M.); the Obstetric Service Line, Avera Health, Sioux Falls, SD (K.M.); the American College of Obstetrics and Gynecology, Washington, DC (H.B.); and the Duke University School of Medicine, Durham, NC (H.B.).