By Linda Satchwell
Special to Plumas News
Plumas District Hospital (PDH) has recently informed patients and the community at large that they are struggling to keep their Obstetrics/Labor and Delivery program afloat. And, while many residents, including former maternity patients, say they can’t imagine Quincy without that life-affirming service, PDH, like most hospitals, is facing a confluence of difficult circumstances. This is the first in a series of articles to explore the complexities of maintaining PDH’s rural OB program, as well as its intrinsic value.
Rural OB – The National Picture
By 2014, fewer than half of all rural counties in the country had hospital-based obstetric care. And rural hospitals, especially rural OB programs, continue to close at an alarming rate. OB/L&D services at rural hospitals are particularly vulnerable due to low patient volumes, high costs, and a dependence on notoriously low MediCal rates. In fact, 56 percent of PDH’s OB patients are on MediCal. The problems are exacerbated in rural communities like Quincy, where the closest urban hospital is at least two hours away. Without local OB services, patients may forego important prenatal care because of distance or cost, resulting in increased risk and poorer outcomes for both mother and baby.
Also, rural communities tend to be less healthy overall. Risk factors, including obesity, advanced age, and socioeconomic disparities, are more prevalent. In addition, expecting mothers have more contributing conditions, such as hypertension and diabetes, which means they’ll likely require more specialized OB care (neonatal services for example) that a larger hospital can offer. These higher risk pregnancies, that by necessity aren’t delivered locally, combined with an aging rural population, mean that the number of births in rural areas have steadily decreased.
But, according to Dr. John Cullen, President of the American Academy of Family Physicians, who is also a family doctor in rural Valdez, AK, “For small communities like ours, if you don’t do obstetrics, you’re still going to do obstetrics,” because maternity patients often will show up in the ER if there isn’t a hospital with OB services nearby. Once a hospital has given up their OB program, however, doctors and nurses will be out of practice, especially when it comes to emergencies such as C-sections, Dr. Cullen said.
Plumas District Hospital’s OB Challenges
There is no doubt that PDH wants to keep its OB/L&D program, and it seems the community expects just that. They want the personal, compassionate care their Family/OB doctor provides. They want nurses they call friends. They expect the short, safe drive, with their family and friends close by. They want to know their community will be a safe harbor for babies and children, a vibrant community that other young people will want to call home for years to come.
Moreover without an OB program, there is what Dr. Jeff Kepple, who delivered 500 – 600 babies at PDH over a 20 year period, calls “the ripple effect . . . You may lose your general surgeon, OB docs, and anesthesia provider,” he said. With no OB program, maintaining 24/7 anesthesia coverage and emergency surgery capability becomes very expensive, especially because the number of patients served is much lower.
Hospitals often end up cutting surgery altogether. With OB, however, you improve your hospital’s ability to handle emergencies, including surgeries. “You end up improving the quality of care [throughout the hospital],” Kepple said.
Like the nation as a whole, however, the number of births at PDH has fallen – recently the hospital has delivered between 65 – 70 babies per year. PDH is an anomaly in that it has four primary care/OB doctors, one of whom is also trained to perform C-sections. They are all vibrant women who are passionate about keeping the program. Family Medicine OB Dr. Erin Barnes has been delivering babies at PDH for 11 years. “We have an amazing program,” she said. “I delivered both of my children here. I like our small, intimate personalized care program. The amount of attention we can give during prenatal visits and during labor is very different than a big facility.”
Mirroring the rest of the country, though, PDH is experiencing a severe nursing shortage. They need OB nurses and backup nurses, which are very difficult to find. Currently, the hospital is utilizing two traveling nurses, at $160/hour (including food and housing), to keep the program afloat. In fact, these nurses were set to leave with no one to replace them, but hospital CEO JoDee Read convinced them to stay with this lucrative offer. Their tenure will be up at the end of October though, and everyone agrees this way of keeping the program afloat is untenable.
The stark reality of this situation spurred Read to say PDH needs to come up with a viable plan, and soon, or else OB/L&D at PDH will come to an end. That said, with all the creative energy being put into saving the program, Read holds out hope that a solution will be found. “We want to write a different ending to our OB story than so many other hospitals have,” she said. “We want to write the story that demonstrates how OB services can be safely provided meeting quality standards in rural America.”
Historical Perspective Offers Insight
Dr. Kepple offers a long term perspective to help explain the evolution of the hospital’s current OB problem. When he started 27 years ago, there was a big movement for family doctors to do OB, because it was a difficult area to staff. Also, there was an emphasis on small town family physicians who were trained in primary care and, often, high risk OB. “Some of us even trained in C-section,” he said. But, “slowly this doctor has disappeared.” To make the problem worse, “nurses, who do a lot of the work in OB, are finding they’re being asked to work on their own without a dedicated backup. It’s very hard to find a nurse willing to do that.”
Kepple points to today’s “specialized culture.” The generalist has disappeared as the “nature of medicine has changed,” he said. “As knowledge expands, specialization increases,” so the idea of being a generalist and cross training to different departments becomes a hard sell. Nurses, understandably, want to work in the specialty they’ve trained for.
In addition, when an OB nurse is attending a birth and a second nurse is needed, a Med/Surg nurse who has cross-trained may be pulled over. If one isn’t available, an off-duty L&D nurse may be called in. Often, though, L&D Nurse Manager, Sue Brown ends up filling that role after she has worked her own shifts. “The number of hours our core OB nurses have worked over the years to staff labor and delivery is remarkable and demonstrates their commitment to care for every patient,” said Read. To help support these nurses, Read has renewed the hospital’s recruiting effort, searching for two full-time day and two full time-night L&D nurses which, given the nursing shortage, sometimes seems like a Quixotic task.
Further, Kepple notes that nurses are attending “so few births “(less than one per month on average), that they need to attend simulations and drills to keep their skills up. This, however, isn’t the same as delivering a live baby. While, again, the situation may seem bleak Kepple, like Read, is not giving up. “I’m still absolutely convinced it has to stay,” he said. “I’m presenting you with the dilemma. We have to find innovative solutions.”
Getting Creative – New Ideas . . .
Kepple and Read are working with UC Davis (which already provides PDH with 24/7 neonatal support via telemedicine) about the possibility of having some of their L&D nurses come here as backup/on call nurses. Moreover, they want to explore the reasons why some local women choose to give birth elsewhere. “In the long run,” he said, “we need to do our utmost to draw women in our community into our Women’s Health and OB services. We do that by establishing trust in the attentive and conscientious care that we provide,” Kepple said.
In other efforts, Family Medicine/OB Drs. Ali Hunt and Erin Barnes are supportive of a plan to recruit Certified Nurse Midwives who could assist with labor and delivery and also could help with the development of a birthing center program, “from the ground up,” said Hunt. Finally, there is a renewed effort to recruit both L&D nurses and Certified Nurse Midwives through internal sources and an outside recruiting firm. The hope is that this combined effort will net a few top-notch, dedicated nurses who will help keep PDH’s OB program alive. “We must come together and consider all possibilities and ideas,” Read said. “There’s no harm in trying something new, and if it doesn’t work, going back to the drawing board and trying something else. The tremendous effort of our OB nurses, and the great support from our OB doctors and community makes me believe, while this is a long road, we have the potential to succeed.”
If you know a Labor and Delivery nurse who would be interested in making a powerful difference for mothers in our rural community, please encourage them to apply here – www.pdh.org/careers/careers