Health Facility Committee Meeting Minutes

 Health Facilities Committee
Sub-committee on Rule changes for Birthing Centers
Members: Jeanette Drews, Chair; Keith Tintle; Tracy Stocking; Paul Clayton
Three major issues have been brought to the Health Facilities Committee for
consideration of proposed modification. The sub-committee has taken public input and
gathered documentation both in support of these proposals and counter-point discussion
in response.
The purpose of this document is to present a summary of the key issues to the subcommittee
in order to reach a consensus of recommendations to present to the full
membership of the Health Facilities Committee in February, 2009.
Issue #1: Transfer Agreements
Rule 432-550-11. Contracts and Agreements.
Segment in debate: “written transfer agreements with one or more general
hospitals within 30 minutes travel distance of the birthing center”
Birthing Center Representatives’ proposed change: “a transfer plan to ensure
safe transfer of patients to the hospital when circumstances require it.”
Utah Hospital Association has proposed the following changes to existing rules:
R434-550-11: Contracts and Agreements (italics=new language)
(3): The licensee shall maintain transfer agreements for the
(a) admitting obstetrical privileges….
(b) Written transfer agreement with one or more general hospitals
within 30 minutes travel distance of birthing center;
(c) Written transport agreement with a local ambulance;
(d) Written transport agreement to identify neonatal-specific
transportation services.
(4) The general hospital transfer agreement shall include provisions for
(a) transfer of information needed for proper care and
treatment of the individual transferred;
(b) security and accountability of the personal effects of the
individual being transferred.
(5) Annual assessments of the transportation services and transfer
protocols shall be made and documented.
(6) Documentation that a general liability insurance policy is
presented to include current coverage dates, provider name,
address and limits of coverage. Minimum coverage is $1million
occurrence/#3 million aggregate.
Sub-committee member, Tracy Stocking, has submitted the following options as
possible means of addressing this proposed rule change.
1. Leave the rule as written and continue to require a written transfer
2. Accept the proposed changes from the Birthing Center
Representatives and allow a written plan, notifying hospitals but
not requiring them to sign-off on the plan.
3. Create a compromise position, assuming there is a middle ground.
Ask if there are other requirements that could accomplish
the same safety net as transfer agreement, e.g. the patient’s
OB has privileges at the hospital that can serve as a
transfer agreement.
Tracy has also cautioned against unintentionally reducing safety-related rules for
the purpose of starting or expanding a business.
Issue #2: Expanding the Provider Pool
Rule 432-550-15 Clinical Staff and Personnel
Birthing Center Representatives propose expansion of the definition of clinical
staff to allow all licensed obstetrical or midwifery providers to attend deliveries in
birthing centers, specifically allowing Licensed Direct-Entry Midwives (LDEMs)
to deliver in birthing centers.
Utah Hospital Association proposes the following modifications to R432-550-15:
Clinical Staff and Personnel
(1) A physician applying for privileges at the birthing center must
maintain admitting obstetrical privileges at a general hospital
within 30 minutes travel distance of the birthing center.
(2) A certified nurse-midwife applying for privileges must provide
evidence of, and maintain, a collaborative relationship with a backup
physician to include at least a written and signed agreement
approved by the clinical director. Written agreements a certified
nurse midwife establishes with a back-up physician at least the
a. Documentation that back-up physician agrees to accept
consultation calls and referrals from the certified nurse midwife
24 hours a day
b. Documentation that the back-up physician has admitting
obstetrical privileges at a general acute hospital within 30
minutes of the birthing center;
c. Provisions to ensure adequate and timely services by the backup
(3) No changes recommended in points 3-5
(4) …no change
(5) …no change
(6) A second employee who is licensed registered nurse [strike or
certified to give] with adult and infant cardiopulmonary
resuscitation shall be present at each birth.
(7) A certified nurse midwife or registered nurse shall be present in
the birthing center at times when mother(s) are in the postpartum
period, and a registered nurse shall be present if more than one
mother is in labor.
(8) No change (formerly item #7)
(9) Meetings of the professional staff shall be held monthly to discuss,
review and evaluate patient care. Written minutes of these
meetings shall be maintained and distributed to staff.
(10) All personnel shall receive in-service education at least semiannually
which shall include, but not be limited to, infection
control, fire and safety procedures. Written minutes of these
meetings shall be maintained and distributed to the staff.
Sub-committee response from Keith Tintle states that “as long as they [licensed
professionals] act within the scope of their licensure, and in a setting that is
approved and governed by rule, we should be comfortable. … The issue at hand
seems to be the rules that dictate the appropriate setting, support entities, and
relationships with potential hospitals that they may need to refer to, [are there] to
protect the optimum safety of the patient.
Issue #3: Rule 432-550-29(4)(i): Vaginal Birth after Caesarean (VBAC)
Birthing Center Representatives propose changing the rule cited from restricting
“previous caesarean section or major uterine wall surgery or obstetrical
complications likely to recur” to restricting “previous caesarean sections as
described in 58-77-204 which would prohibit attendance by a licensed direct
entry mid-wife.” These restrictions require mandatory transfer upon evidence of:
R58-77-204(4)(b) reads:
(v) more than two prior c-sections, unless restricted by the division by
(vi) prior c-section with a known classical or inverted-T or J incision;
(vii) prior c-section without an ultrasound that rules out placental
implantation over the uterine scar;
(viii) prior c-section without a signed informed consent document
detailing the risks of vaginal birth after caesarean;
(ix) prior c-section with a gestation greater than 42 weeks;
The Birthing Center Representatives also promote a new policy similar to that
designed by the Commission of Accreditation Standards for Birth Centers
(CABC) offering indications of when VBACs in Birthing Centers will be
The new CABC policy states:
VBACs in birthing centers will be appropriate if:
1. A client has had only one prior caesarean sections
2. Client has a documented low transverse incision
3. Ultrasound demonstrates placental location is not anterior and low lying
(i.e. not over old scar)
4. Client has signed a VBAC-specific informed consent
5. Client has had one or more successful prior VBACs
6. Client meets all other risk criteria of the birth center
For birth centers desiring to do primary, or first-time VBACs, the CABC will
evaluate on a case-by-case basis and will grant accreditation based on meeting
items 1,2,3,4,and 6 above, plus:
1. Center must document ability to transfer care to a facility with 24/7
availability of anesthesia and obstetrical attendance.
2. Center must be located in close proximity to the transfer facility.
The Utah Hospital Association has not proposed written changes to the VBAC
rule. However, there has been discussion in sub-committee meetings that indicate
hospitals consider VBACs high risk which would eliminate them as candidates
for delivery in licensed birthing centers.

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