In Praise of Level One Hospitals

Recently I received a comment from Ruralnrs, extolling the benefits of her workplace, a small, rural hospital. In her comments, she spoke of the low rates of intervention that occur to mothers giving birth at her facility, as well as the level of personalized care that would be difficult to match in a large metropolitan hospital. She spoke of the benefits of fewer "personalities" that (and here I paraphrase liberally), contribute to the multiple interpretations of policies that can "get in the way" of a mother's attempt to achieve a non-interventive birth in hospital. She also pointed out that the success of her unit in achieving a high level of non-intervention, as well as patient satisfaction, lies in the fact that, since the unit is not equipped to (routinely) handle high risk labors and births, they do not want to risk making a labor high risk by engaging in the administration of interventions thay may actually produce the risk! Oh, the exquisiteness of common sense!

Ruralnurs's comments were timely ones. Recently in a community not far from the large metropolitan area where I work, a tragedy occurred to two women, within 24 hours of each other, at the same small L&D unit of a small Level One hospital. Both women received epidural analgesia. Both delivered healthy babies; and both women, the day after giving birth, began experiencing complications that were first attributed to the epidural but which became progressively worse. Each woman was soon transferred... first to that hospital's ICU, and shortly thereafter to another large hospital in the city in which I practice. One of these women subsequently died. Of course an investigation is underway, the public has been "assured" that the cause of the illness, bacterial meningitis, is not communicable, and that everything possible is being done to both determine the cause of the tragedy, and to prevent it from occurring in the future.

Thanks to the "gag" order that has almost certainly been issued by attorneys to the grieving families, pending the inevitable malpractice investigation, we may never know the final outcome of the research into the incidents; of course, in the birthing community, suspicion immediately turned to the administration process during which each woman received her epidural.

Regardless of the cause, a woman has died, a family has been denied a loved one's continued presence in their lives, a child is motherless, and another family's anticipation of one the happiest times of their lives has changed from joy to horror as they gather to support the surviving mother in her journey back to health; and while I can't...could not possibly trump the tragedy being experienced by these two families, incidents like this place all of us in peril in a way, because they feed the usually incorrect perception that care at a smaller, usually rural, Level One hospital is "not as good" as care given in large metropolitan hospitals. Indeed, the continuing survival of this hospital, and many others like it, could be considered at risk due to this type of thinking, and unfortunately, when tragedies like this happen, that risk increases.

Don't quote me here...because I haven't taken the time to gather the research to bolster my words... but I've heard statistics that upwards of 50 percent...in some states, 80 percent...of babies are born in Level One hospitals. A Level One hospital is likely to be located in a rural area or a small town. If it does provide care to birthing women, often the services provided take place in small L & D units...two to four labor rooms as opposed to the dozen-plus common in metropolitan hospitals. There may be only one surgical suite, no Neonatal Intensive Care Unit (NICU), and only a handful of practitioners...Obstetricians and Midwives, usually Nurse Midwives. Access to anesthesia is often readily available only during daytime hours, and on an "on call" basis at night. In some Level One hospitals, access to surgical services...even emergency surgeries...depends on an "on call" staff that has to come in from home should a patient require unscheduled surgery during the night...hence ACOG's prohibitive stance on VBAC (Vaginal Birth After Cesarean) birth in Level One hospitals; they don't believe it is "safe" for a woman to labor on a scarred uterus in an institution of this size and limitation.

I beg to differ, both with the perceived public view in general, and with ACOG's stance in particular. These hospitals serve a huge portion of the population of the United States, and as such, are a critically important part of our country's health care system. To deny low risk pregnant women served by these hospitals access to the full spectrum of birth-related services endangers not only those women, but the overall health of our country, as well as our national economy.

Although I currently work in a large university medical center, I live about 30 minutes from my previous employer, a Level One hospital. It too has a small L&D unit, and it too has seen it's share of tragedies; but poor outcomes happen everywhere...the size of an institution is not indicative of the skill of its' practitioners. Indeed, the physicians at a Level One hospital need to be particularly skilled, in that in time of crisis, they are the point of access to care for the individual(s) involved, unlike in a larger hospital where there may be several (or many). These folks need to "know their stuff"... have exceptional critical thinking skills, and the confidence to put put those skills into action quickly; not that these attributes aren't necessary in a larger institution where there are more practitioners...of course they are...but in a smaller hospital, fewer hands can mean more responsibility on those hands. I can only speak for this one particular hospital...but if a woman I loved were to need care, I would have total confidence if she were admitted there. The skill and care given to women at this particular institution rivals that given where I work any day. No, they don't have a special care unit for infants; but the nurses were well trained to support even tiny preemies until transport from the nearest NICU could arrive. During my employment at that particular hospital I saw hemorrhages, fetal demises, preterm labors and births, even one uterine rupture...all handled expertly by the well-trained and skilled nursing and medical staff, and all with the healthy survival of both mother and infant. Until ACOG's edict limiting VBACs to basically only large tertiary care centers, that unit also saw it's share of successful VBACs.

Health care dollars being limited, resources are going to have to be distributed where they are likely to be used the most; hence Level One hospitals, particularly those few that remain independent of larger healthcare "systems" such as Humana, will rarely be the ones to have the newest and latest of the technology; JCAHO standards should provide that a reasonable standard of care in terms of technological resources will be available at any hospital. Should a patient require more, resources for adequate support should be available until a transfer can be arranged; but for initial access to care, particularly for low risk situations such as normal labor, a community based hospital is the most cost-effective and appropriate level of entry to care (actually, I really believe that home is the most appropriate level of entry to care for laboring women, but my topic being levels of medical care for laboring women, and our culture being what it is, that statement will have to suffice...for this post at least).

I think level of entry and access are the core issues here. A healthy woman experiencing a normal labor does not need all the "bells and whistles" of a unit like the one I work on; she needs care that is accessible...in her community. One of most ridiculous misuse of resources I've ever seen occurred, ironically, in the same community as the hospital that I just praised so highly. The health department in this community contracted its prenatal care to the residency staff of a larger city hospital over 35 miles away! When the women cared for at the public clinic went into labor, they were expected to travel into the city. Not all of them had the resources to get there however. Those that did not have transportation to get from their homes in the town ended up...of course...at the local Level One hospital, where the only access we had to their prenatal information was via fax...and that was if we could track the information down, and if we had time to get the information faxed to us before the mother gave birth. It made absolutely no sense, when right there in the woman's home town a perfectly good medicaid eligible clinic was available to her, within the very hospital that she would ultimately give birth in...attended by physicians she was familiar with.

It can be difficult enough to get access to health care in our country. Even in the city where I work, there are more than a few mothers who get little or no prenatal care because they cannot manage the bus fare to get to clinic; or they do not live near public transportation. How much more of a burden do we place on women in sub-suburban communities we close down the L&D unit in the local community hospital, forcing them to travel, if they have the means, to the next town or city over? Often the woman cannot meet that burden, and she goes without prenatal care, possibly setting off a sequela of events that turn a healthy, low-risk pregnancy into a high-risk situation...and a high cost situation ensues, should that mother and or her infant end up requiring a level of care that may have been avoidable had she had access to good prenatal care. How much of a burden do we place on a woman when we prevent her access to VBAC based on the perceived level of care at a hospital that may have a proven record of successful VBAC births, forcing her instead to travel out of her community, adding yet another expense on top of the considerable (and avoidable) expense ( as well as the increased risks and discomfort) of a scheduled cesarean? Neither situation can be considered a good outcome for either mother and infant...and it can't bode well for a health care system that is already crumbling under the weight of not enough financial resources to provide access to all of its citizens. Prenatal care is, more often than not, preventative care...head the high risk situations (those that we can) off, and prevent the huge expense (and increased potential for morbidity and mortality) of an unnecessary surgical delivery...or of a mother or infant in intensive care.

Our culture has collectively "forgotten" that there is an entire world of medical care independent of the big, dramatic city hospital we see on primetime television with it's depiction of exotic diseases and traumatic occurences that seem to happen every day and require the highest and most expensive level of technology to treat. We forget that when we use resources appropriately to maintain our health, that this level of drama and expense is the exception, not the norm. Of course the tragedy that occurred in the Level One L&D that I depicted in the beginning of this post was just that...a tragedy (and likely a very avoidable tragedy); but with appropriate investigation into the cause, and corrective intervention taken (albeit after the fact), the hospital involved can reduce dramatically the likelihood of a reoccurrence. It would be an even larger tragedy to close the unit, and reduce access to the pregnant women of the community served by the hospital.

I love what I do...I love where I work...but my family continues to utilize the same health care providers that we did when I worked for my previous employer. I've found, both as a patient and as an employee that the care is both cost, and health effective. Level One care can be, and often is the very best care.