Springfield hospital cited for lapses in treating high-risk pregnant patients

The woman admitted to Mercy Medical Center to give birth earlier this year exhibited clear warning signs for complications. Overweight and a smoker, she suffered from
high blood pressure and a dangerous condition known as preeclampsia.

Yet when her condition rapidly deteriorated, the Springfield community hospital did not transfer her to a medical center specialized in treating complex maternity patients, even though Mercy is not designated by the state to care for high-risk pregnancies.

Hours after undergoing a caesarean section, the woman suffered a fatal cardiac arrest.

After an investigation in April turned up another mishandled case involving a high-risk obstetrics patient, regulators deemed the hospital as in “immediate jeopardy’’ of harming patients. That is a serious designation that required urgent changes or the hospital would lose its right to participate in the federal Medicare program.

The immediate jeopardy designation was lifted in May, after Mercy improved its procedures. But the lapses are an extreme example of what can go wrong when pregnant women are not cared for in the most appropriate facility, an issue with which hospitals nationwide are grappling. The Massachusetts Health and Hospital Association said a group of hospitals, public health officials, and medical professionals will make specific statewide recommendations on levels of maternity care in the coming months.

In a statement to the Globe, Mercy executives said they “took decisive and effective action’’ after the problems, bringing in national perinatal experts from its corporate office to recommend improvements. The changes included identifying obstetrics patients in its doctors’ practices who should be referred to high-risk practices and hospitals, and adopting an “early warning’’ system for maternity patients at Mercy who are at risk for developing life-threatening complications.

Executives said they could not say how many high-risk patients, if any, Mercy had transferred to other practices since the inspection.

“Safety and quality of care are our top priorities at Mercy Medical Center,’’ the hospital said in its statement. “It is important to note that women in labor can develop complications abruptly and without sufficient warning to initiate a safe inter-facility transfer.’’

The state Department of Public Health licenses hospital maternal and newborn services, designating them as between level 1, able to care for uncomplicated patients, and level 3, able to handle the most involved cases. Mercy is a level 1A service, while Baystate Medical Center, also in Springfield, is a level 3 hospital.

But several obstetricians who care for women with high-risk pregnancies said that the rules are geared toward the baby’s health, and that the state needs clearer, more detailed standards for when hospitals should send mothers to higher-level facilities, especially those patients with heart conditions.

Public health officials and medical organizations have been raising alarms about the issue nationally as well, amid concerns over rising maternal deaths. The United States ranks 60th in the world for its maternal death rate, according to the American College of Obstetricians and Gynecologists, in part due to growing rates of obesity, high blood pressure, and diabetes among women.

Dr. Julian Robinson, chief of obstetrics at Brigham and Women’s Hospital, said Massachusetts safety data indicate most pregnant women in the state are giving birth at an appropriate facility, but a small number may not be. New rules would improve care for those women, he said.

Several states, including Arizona and Texas, have adopted detailed standards for maternal levels of care, and public health leaders in Massachusetts have been discussing similar measures for several months, said Dr. Ronald Iverson, vice chairman of obstetrics at Boston Medical Center. “We are trying to get everyone around the table,’’ he said.

Robinson and Iverson said they could not comment on the problems at Mercy, which is owned by Trinity Health of New England, based in Hartford, Conn.

But according to the investigators’ report, there seemed to be confusion about whether the hospital could care for complicated pregnant patients.

Despite the state’s designation, one staff member from the corporate quality department told investigators that the hospital “delivers high-risk obstetrics patients.’’ But a nurse said “we usually do not take care of patients as complex’’ as the woman who died.

The report said the hospital did not have guidelines for determining which patients were high risk.

The patient who died is identified only as “patient #1’’ in the report to protect her privacy. She was admitted to the hospital on the morning of Feb. 12 to induce labor. By 11 a.m., she was having difficulty breathing and felt pressure in her chest.

But doctors did not perform a cardiac assessment to rule out a heart attack, the report said, despite a family history of heart disease and diabetes.

Following a caesarean section the next day, the patient’s condition quickly worsened, and included heavy bleeding and vomiting.

“I am having a hard time breathing,’’ she told staff. Despite a policy for transferring maternal patients to nearby Baystate Medical Center, there was no indication she was evaluated for transfer, investigators said.

The state and federal investigation also found that on the same day as the patient’s death, doctors did not recommend transferring another high-risk obstetrics patient to a hospital with more expertise until more than 20 hours after a scan showed her heart was dangerously enlarged, according to the investigators’ report.

A cardiologist advised that she might need mechanical support for her failing heart. By that time, she was already having trouble breathing and in Mercy’s intensive care unit. The report does not say whether she ultimately recovered, though hospital executives said she was transferred in stable condition.

She was also overweight and suffered from high blood pressure and preeclampsia.

The report does not address the health of the patients’ newborns.

The lapses also seemed to result in several staff firings or resignations at the hospital, including that of an obstetrician “who demonstrated unprofessional behavior,’’ according to the hospital’s correction plan submitted to the state.

The hospital declined to comment further, citing privacy considerations.

“Mercy is not alone in dealing with these challenges,’’ the hospital said in its statement. “Mercy is among a group of level 1 obstetrical centers that have worked to improve the transition of care to level 3 centers.’’