Definitions of Obstetric and Gynecologic Hospitalists

Current Commentary Definitions of Obstetric and Gynecologic Hospitalists Brigid McCue, MD, PhD, Robert Fagnant, MD, Arthur Townsend, MD, MBA, Meredith Morgan, MD, Shefali Gandhi-List, MD, Tanner Colegrove, MD, Harriet Stosur, MD, Rob Olson, MD, Karenmarie Meyer, MD, Andrew Lin, MD, and Jennifer Tessmer-Tuck, MD logic practices (including hospitalist practices) should The obstetric hospitalist and the obstetric and gyneco- define inpatient coverage arrangements using these logic hospitalist evolved in response to diverse forces in standardized definitions to allow for fair conclusions medicine, including the need for leadership on labor and and comparisons between practices. delivery units, an increasing emphasis on quality and (Obstet Gynecol 2016;0:1–5) safety in obstetrics and gynecology, the changing demo- DOI: 10.1097/AOG.0000000000001235 graphics of the obstetric and gynecologic workforce, and rising liability costs. Current (although limited) research suggests that obstetric and obstetric and gynecologic he Society of Obstetric and Gynecologic Hospital- hospitalists may improve the quality and safety of Tists is a 501(c)(3) nonprofit professional organiza- obstetric care, including lower cesarean delivery rates tion established in 2011 and dedicated to enhancing and higher vaginal birth after cesarean delivery rates as the safety and quality of obstetric and gynecologic well as lower liability costs and fewer liability events. This hospital medicine by promoting excellence through research is currently hampered by the use of varied education, coordination of hospital teams, and collab- terminology. The leadership of the Society of Obstetric oration with health care delivery systems.1 Further and Gynecologic Hospitalists proposes standardized information on the Society can be obtained at www. definitions of an obstetric hospitalist, an obstetric and societyofobgynhospitalists.org. This document was gynecologic hospitalist, and obstetric and gynecologic developed by board members of the Society of hospital medicine practices to standardize communica- Obstetric and Gynecologic Hospitalists (all of whom tion and facilitate program implementation and research. are practicing obstetric hospitalists or obstetric and Clinical investigations regarding obstetric and gyneco- gynecologic hospitalists) and was endorsed at a strate- gic planning retreat of the Board and the Society in From the Beth Israel Deaconess Hospital–Plymouth, Plymouth, Massachusetts; November 2014 and reaffirmed by the Board in Octo- Intermountain Healthcare, Salt Lake City, Utah; Townsend Gyn Specialists and ber 2015. The definitions proposed describe the Soci- Integrated Physician Services, Germantown, Tennessee; Methodist Le Bonheur ety’s vision of obstetric hospitalists, obstetric and Healthcare, Memphis, and TeamHealth, Knoxville, Tennessee; the Woman’s Hospital of Texas and Houston Methodist Hospital, Houston, Texas; West gynecologic hospitalists, and obstetrics and gyneco- Valley Women’s Care and Banner Thunderbird Medical Center, Glendale, Ari- logic hospital medicine practices. The Society of zona; Northwestern Medical Group, Lake Forest, and the University of Illinois, Obstetric and Gynecologic Hospitalists is indepen- Chicago, Illinois; Providence St. Vincent Medical Center, Portland, Oregon; Peace Health, Bellingham, Washington; NorthBay Health Care, Fairfield, Cal- dent from, but has collaborative relationships with, ifornia; Meridian Specialty Hospitalist Solutions, El Dorado, California; and the Society of Hospital Medicine, the American Col- North Memorial Health Care, Robbinsdale, Minnesota. lege of Obstetricians and Gynecologists, and the Soci- The authors thank Cate Stika, MD for her editing efforts. ety for Maternal-Fetal Medicine. Corresponding author: Brigid McCue, MD, PhD, 275 Sandwich Street, Plymouth, MA 02360; e-mail: [email protected]. Financial Disclosure OBSTETRIC AND GYNECOLOGIC INPATIENT The authors are current or former board members of the Society of Obstetrics and CARE MODELS Gynecologic Hospitalists (2012–2015). Dr. Olson is a consultant for obstetric – and gynecologic hospitalist programs. Obstetrician gynecologists (ob-gyns) must provide medical care for their patients (especially obstetrics pa- © 2016 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. tients) 24 hours a day, 7 days a week. The time obstet- ISSN: 0029-7844/16 rics–gynecologic physicians dedicate to inpatient care VOL. 0, NO. 0, MONTH 2016 OBSTETRICS & GYNECOLOGY 1 Copyright Ó by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. is often referred to as “call” time or being “on-call.” A and take responsibility for obstetric emergencies if solo obstetrics–gynecologic physician is “on-call” for there is no other ob-gyn available, or while the pa- his or her patients continuously and juggles hospital tient’s ob-gyn is en route, the in-hospital ob-gyn may and office responsibilities, often leaving a busy office to simultaneously care for patients from his or her own perform hospital-based surgeries or deliveries. Given the practice and may or may not cover hospital unas- burden of this call coverage, solo obstetrics–gynecologic signed patients, the emergency department, or pro- physicians often seek call or coverage assistance from vide surgical or emergency assistance to colleagues. colleagues through reciprocal billing agreements or pay-for-coverage contracts. LIMITATIONS OF CURRENT MODELS In response to the competing demands of solo The designation of a dedicated in-hospital ob-gyn obstetrics and gynecology practices and the difficulties provides a measure of safety in obstetrics, but can of a single individual sustaining 24–7 availability, result in conflict between physicians over clinical group models currently predominate in obstetrics priorities (especially when covering both hospital and gynecology. In these practices, hospital inpatient and private call responsibilities for their own group’s coverage is usually assigned on a rotating basis to an patients), competition for patients (if asked to cover “on-call” ob-gyn from the group. This physician is urgently or emergently for patients who are otherwise typically assigned to care for the entire group’s hospi- enrolled with a competing obstetrics and gynecology talized patients for a limited and defined time period group), and possibly resentment over increased (such as 24 hours or one weekend). During the as- responsibilities and liability with perceived inade- signed call shift, he or she may or may not have quate compensation. reduced office responsibilities to accommodate the The triage of obstetric outpatients is another assigned hospital tasks. Depending on the practice, problematic process for hospitals. It is commonplace the on-call physician may cover multiple hospitals in the United States for pregnant patients who present and may take call from home, although larger and to an obstetric triage unit (regardless of complaint) to busier groups may require their on-call physician to be evaluated and treated by a registered labor nurse remain in the hospital for their call shift. and discharged to home or admitted to the hospital The primary responsibility of an “on-call” ob-gyn after phone consultation with the managing physician. is to care for the hospitalized patients who are In fact, the obstetric triage unit is the only acute enrolled in their own practice. Broader hospital patient care area of the hospital in which patients are responsibilities such as coverage of another physi- not routinely examined and managed by physicians cian’s labor and delivery emergencies, unassigned pa- or advanced practitioners such as certified nurse tients who present to the hospital or emergency midwives.2 This registered labor nurse triage and treat department and inpatient obstetric or gynecologic model is incongruous with a culture of improved qual- consultations are often secondary. Generally, hospi- ity and safety of obstetric care in the hospital setting tals make arrangements through the medical staff for (including outpatient areas within the hospital such as rotating obstetrics and gynecology coverage of these the emergency department or the obstetric triage responsibilities (voluntary or paid). These coverage unit). arrangements may be contentious and stressful in to- Finally, the Joint Commission expects certified day’s environment when hospital margins are tight hospitals to make changes such as adoption of and physician time is at a premium. Hospitals that evidence-based practice protocols, use of standardized recognize these conflicts as well as the potential for team-oriented communication tools, and simulation to sudden catastrophic changes in the clinical status of maximize a coordinated response to patient emergen- obstetric patients often arrange and pay for in-hospital cies.3 Hospital and physician reimbursement is obstetrics–gynecologic coverage. increasingly tied to quality metrics such as appropriate A 24–7 in-hospital, contracted obstetrics and use of prophylactic preoperative antibiotics and gynecology coverage model (voluntary or paid) en- venous thromboembolism prevention. Furthermore, sures that an ob-gyn is immediately available for low-volume, high-stress skill sets such as operative obstetric emergencies, thus allaying hospital concerns vaginal delivery, vaginal delivery of twins,

Load more