Is a level 2 hospital's policy of transferring patients under 30 weeks with threatened preterm labor an example of a risk management strategy because it identifies, segregates, and transfers the risk?

Risk Management in Preterm Labor: Transfer Policy Analysis

A level 2 hospital's policy of transferring patients under 30 weeks with threatened preterm labor is primarily an example of a risk management strategy because it transfers the risk to a higher level facility that is better equipped to handle very premature infants.

Understanding Hospital Levels and Risk Management

Level 2 hospitals (specialty care facilities) are designed to care for:

• Moderately ill newborn infants born at ≥32 weeks' gestation
• Infants weighing ≥1500g at birth with problems expected to resolve rapidly
• Patients not anticipated to need subspecialty services urgently 1

These facilities have limitations:

• Can provide assisted ventilation only on an interim basis
• Can deliver continuous positive airway pressure
• Can provide mechanical ventilation for less than 24 hours
• Must refer to higher levels of care for pediatric surgical or medical subspecialty intervention 1

Evidence Supporting Transfer as Risk Management

The American Academy of Pediatrics guidelines clearly state that infants born at <32 weeks' gestation or weighing <1500g should be cared for at a level III facility 1. This recommendation is based on evidence showing improved outcomes when very premature infants receive care at facilities with appropriate resources.

When a level 2 hospital establishes a policy to transfer patients under 30 weeks with threatened preterm labor, they are:

1. Transferring the risk: Moving the responsibility of care to a facility better equipped to handle the potential complications of extreme prematurity 2

2. Identifying the risk: Recognizing that these patients require specialized care beyond their capabilities

3. Segregating the risk: Separating high-risk patients from those the facility can safely manage

Clinical Guidelines Supporting Transfer

The American College of Obstetricians and Gynecologists (ACOG) recommends that:

• Hospitals without optimal resources should have established protocols for timely transport 2
• The primary goal of tocolytic therapy in preterm labor is to delay delivery long enough for safe maternal transfer 2
• Delivery should occur in a facility with appropriate maternal and neonatal care capabilities 2

A 2022 Finnish study found that successful centralization of very preterm deliveries is achieved through rapid and active antenatal transfers, with most hospitals transferring women despite regular contractions or cervical dilation up to 4 cm 3.

Benefits of Transfer as Risk Management

The transfer policy provides several benefits:

• Ensures delivery occurs in a facility with appropriate maternal-fetal and neonatal care capabilities 2
• Allows time for administration of interventions that improve neonatal outcomes, such as antenatal corticosteroids 2
• Reduces potential morbidity and mortality associated with very preterm birth 4

Implementation Considerations

For effective implementation of this risk transfer strategy:

• Transfer should be arranged quickly (ideally within 2 hours) 3
• Tocolytic therapy may be used to delay delivery for 48-72 hours to facilitate transfer 2
• Clear communication between referring and receiving facilities is essential 1

Common Pitfalls to Avoid

1. Delaying transfer: Waiting too long to initiate transfer may result in delivery occurring during transport or at the level 2 facility
2. Inadequate stabilization: Failing to properly stabilize the patient before transfer
3. Poor communication: Not providing complete information to the receiving facility
4. Neglecting maternal anxiety: Women experiencing threatened preterm labor report high levels of anxiety that can be exacerbated by transfer 5

In conclusion, while a level 2 hospital's transfer policy for patients under 30 weeks with threatened preterm labor does involve identifying and segregating risk, its primary function is transferring risk to a facility better equipped to manage these high-risk cases, making risk transfer the most accurate characterization of this risk management strategy.