OB/GYN hospitalists have mirrored the evolution of the first general hospitalists—the internal medicine and family practice physicians who focused their clinical care on the hospitalized patient in the early and mid-1990s. Wachter coined the term in an article published in August 1996¹ and the earliest form of the eventual Society of Hospitalist Medicine (SHM) met in April 1997. The SHM definition of general hospitalist was: “A physician who specializes in the practice of hospital medicine.”

Although a few isolated hospitals had OB/GYN hospitalist programs as early as 1989, it was not until Dr. Louis Weinstein published his article² and spoke at the American Congress of Obstetricians and Gynecologists (ACOG) annual clinical meeting in 2005 that the subject was extensively discussed and eventually widely implemented.

(Fig. 2-1)

We do not have precise numbers, but the spread of OB/GYN hospitalist programs mirrors the success of the general hospitalist.

(Table 2-1)

Here is a summary of the OB/GYN hospitalist movement:

• 
  

  2003

  
  
  
  
  • 
    

    The term OB/GYN hospitalist was widely embraced.

  
  
  
  
• 
  

  May 2010

  
  
  
  
  • 
    

    The first OB/GYN Hospitalist Special Interest Group meeting, ACOG, was held in San Francisco.

  
  
  
  
• 
  

  October 2010

  
  
  
  
  • 
    

    Society of OB/GYN Hospitalists (SOGH) was named.

  
  
  
  
• 
  

  July, 2010

  
  
  
  
  • 
    

    ACOG issued a Committee Opinion on OB/GYN hospitalists, which acknowledged their potential to solve or improve many of the problems and concerns addressed, stating that it “supports the continued development of the obstetric-gynecologic hospitalist model as one potential approach to achieving increased professional and patient satisfaction while maintaining safe and effective care across delivery settings.”

  
  
  
  
• 
  

  May 2011

  
  
  
  
  • 
    

    SOGH Special Interest Group meeting took place at the ACOG ACM meeting in Washington, D.C.

    
    
  • 
    

    A second Special Interest Group meeting was held at the same event, which provided the impetus and the volunteers to start organizing the society’s first ACM.

  
  
  
  
• 
  

  September 2011

  
  
  
  
  • 
    

    First SOGH Annual Clinical Meeting and First Emergency OB Simulation Workshop held in Denver, CO.

    
    
  • 
    

    With 43 enthusiastic OB/GYN hospitalists, generalists, and administrators in attendance, SOGH was officially born.

    
    
    
    
    • 
      

      The ACM was well received, as was the first-of-its-kind Obstetrical Emergency Simulation Workshop.

    
    
    
    
  • 
    

    The SOGH board of directors was elected. Volunteers signed up for four separate committees, and committee chairs were elected.

  
  
  
  
• 
  

  October 2011

  
  
  
  
  • 
    

    At the inaugural meeting of the OB/GYN Hospitalist Society, the ACOG District VIII chair, J. Joshua Kopelman, MD, gave credence to OB/GYN hospitalists as a profession, stating that “ACOG recognizes this is the new paradigm of care” and that “OB/GYN Hospitalists in this country are the wave of the future. There’s no question about it.”

  
  
  
  
• 
  

  September 2011—2013

  
  
  
  
  • 
    

    From creating a mission statement, tagline, and logo to establishing its nonprofit status and by-laws, the SOGH gained more than 100 paid founding members and launched a website. (Fig. 2-2)

  
  
  
  
• 
  

  2013

  
  
  
  
  • 
    

    Dr. Tony Vintzileos at Winthrop University Hospital establishes the first OB/GYN hospitalist fellowship.

  
  
  
  
• 
  

  2016

  
  
  
  
  • 
    

    Staffing companies developed. (Table 2-2)

  
  
  
  
• 
  

  2015/2016

  
  
  
  
  • 
    

    As OB/GYN hospitalist programs grew and spread, so did the number of hospitalists who joined the SOGH. The number of paid SOGH members surpassed 550 for the first time, and attendance at the 2015 and 2016 annual clinical meetings grew to over 150 each.

    
    
  • 
    

    In 2015, SOGH was able to purchase the website, content, and membership lists of OBGYNhospitalists.com.

    
    
  • 
    

    SOGH had paid SHM for administrative assistance between 2013 and 2016, but was able to hire their first paid executive director in 2016. The first fellowship was at NYU Winthrop in Long Island, NY. It started on July 1, 2013.

    
    
  • 
    

    A second OBGYN hospitalist fellowship started at University of California, Irvine

  
  

BACKGROUND

OB/GYNs are accustomed to managing a schedule that includes caring for patients in a variety of venues and situations. In a single day, an OB/GYN may care for patients in labor and delivery (L&D), in an operating room, in the office, and remotely via phone or computer. The labor course is usually unscheduled and unpredictable, making time management more difficult. OB/GYNs need to triage situations and prioritize their responses, which may require utilizing other resources such as their OB/GYN partners or colleagues, nurses, office staff, and now OB/GYN hospitalists. Round-the-clock coverage is essential for labor and delivery. Typically, this coverage is shared on a rotating basis within a group. Utilizing resources and time management are important in the context of ensuring patient safety and providing high-quality patient care.

PRACTICE MODELS

Hospitals providing women’s services have different needs based on the level of care that they provide and the resources that are available. There are many variations in the structures and operations of practice models in order to accomplish their common goal of providing high-quality care while ensuring patient safety.³

As part of the effort to improve quality, promote health, and reduce maternal morbidity and mortality, the ACOG and the Society of Maternal Fetal Medicine (SMFM) composed a joint statement that introduces uniform designations for the levels of care provided and service guidelines at health facilities. Please see Chapter 5 for more information about practicing within your OB/GYN system of care.

To be classified as a Subspecialty Care Hospital (Level III) or a Regional Perinatal Health Care Center, the recommendation is that an OB/GYN is always present in the hospital and a Maternal Fetal Medicine (MFM) subspecialist with inpatient privileges is available all the time. Many hospitals providing Level III and IV services meet this recommended staffing level by contracting with on-staff OB/GYNs, an OB/GYN hospitalist management company, or physician groups, or by implementing their own hospitalist service.

In-House Model

When OB/GYNs are hired to provide in-house services, they may have limited hospitalist duties because they have the additional responsibility of caring for patients in their own practices. In this model, hospital-privileged OB/GYNs are utilized, which requires a relatively small financial investment. Because these physicians have their own practices, it often takes many providers to cover the necessary shifts, which may lead to significant variations in practice patterns. There is potential for conflict of interest if the community provider is caring for his or her own patients while being paid to work a hospitalist shift. Although the ACOG/SMFM joint statement recommends a full-time OB/GYN presence in Level III and IV facilities, it is not always possible for these facilities to accomplish this with their current staffing.

These physicians may not have the advantage of resting between shifts because they also have responsibilities from their own practices, including being on call for their practice. Sleep deprivation is recognized as a patient safety issue.^5,6 Competition may be a concern between the hospitalist on duty and private practices because a patient could transfer care to the OB/GYN on duty. The hospitalist may also bill for performing a missed delivery for a competing group.

Hospital-Run/Physician-Employed Model

In most states, hospitals may employ physicians directly to perform a more comprehensive range of OB/GYN hospitalist duties. These programs may be designed so that there are no conflicts of interest or competition with OB/GYN community providers. These private OB/GYNs may bill for missed deliveries performed by the hospitalist if there is a reciprocity agreement in place. Because the hospitalist does not usually have outpatient clinic duties and is focused on inpatient care, there is an enhanced level of responsibilities and duties. Instead of a postpartum hemorrhage needing to be managed every year or two, for example, it becomes a regular occurrence for a hospitalist. Because of their concentrated focus on L&D and need to respond to all emergencies in the department, the hospitalists quickly become the more experienced providers. Further, a relatively small group of providers makes it easier to minimize practice variations and follow best practice guidelines.

The advantages of this program come at the cost of paying employee salaries, benefits, malpractice insurance, and other expenses. Some hospitals have demonstrated decreased numbers of sentinel events and malpractice payments, with a comprehensive safety program that includes hospitalists. Overall, this amounts to significant cost savings for these programs.

Management Company Model

Many hospitals contract with an OB/GYN hospitalist management company, which offers the same advantages of a hospital-run program with specialized providers, increased patient satisfaction, and rapid response. An additional advantage is the experience that the company brings to implementing and operating the program. Services provided include structuring the program, provider recruitment, billing, quality assurance, and program management. An integral component of the program may include an Obstetric Emergency Department (OBED), providing timely treatment of high-quality care with increased revenue. This type of program is also less work for hospitals to establish, but it could be more expensive. There are several OB/GYN hospitalist management groups, which include the OB Hospitalist Group (OBHG), Obstetrix, Emcare, and TeamHealth.

OB/GYN or OB Only

Approximately 40% of OB/GYN hospitalists practice only obstetrics; the remainder practice both obstetrics and gynecology.⁷ Programs whose hospitalists practice gynecology have a backup mechanism for L&D while the hospitalist is in the operating room. Programs focused solely on obstetrics do not offer services to gynecologic patients, which would affect response time and patient safety by taking the hospitalist away from L&D. Hospitalists who solely provide gynecology services are rare. Their responsibilities could include participating in consultations, performing surgery, assisting in surgery, teaching residents, and proctoring and mentoring inexperienced OB/GYNs.

OB/GYN Hospitalist or Laborist

The SOGH defined the professional terms related to the various types of work that an OB/GYN hospitalist performs (Fig. 2-3).⁸

Other than reducing confusion, a more specific definition is important for research purposes, allowing more accurate comparisons of program outcomes. Obstetricians and gynecologists contracted to cover emergencies during L&D should not be considered “OB/GYN hospitalists,” even if the physician is required to stay in the hospital.

The term laborist is not recommended because it is an inaccurate description of an obstetric hospitalist’s duties, which is not limited to the care of laboring patients. Some hospitals use hospitalists for certain specific shifts, such as nights and weekends, which may be referred to as nocturnists or weekendists, respectively. However, these programs should not be considered an OB Hospitalist program unless the shift coverage during these times is designed to fulfill the requirement for a full-time OB/GYN presence.

RESPONSIBILITIES/SERVICES

A common misperception is that OB hospitalists perform all deliveries on L&D. Actually, many hospitalists deliver fewer babies monthly than a physician in private practice. Although performing fewer deliveries, the proportion of operative vaginal deliveries and cesarean sections (C-sections) is higher. Emergency and high-risk events that OB/GYNs encounter occasionally in their practice become regular events for the OB/GYN hospitalist who responds either to manage or assist with all high-risk and emergent situations on L&D. These conditions may include hemorrhage, shoulder dystocia, fetal bradycardia, eclampsia, and breech extraction of the second twin.

Other hospitalist duties may include evaluating patients in OB triage or an OBED, providing care for MFM patients, performing deliveries, instructing residents, assisting with cesarean deliveries, providing consultation for Family Medicine physicians and midwives, and caring for high-risk patients transferred from birth centers or other, less-specialized maternal care centers (i.e. delivering Level I or II of maternal care).

Programs that include gynecologic responsibilities provide consultative service for GYN patients in the Main Emergency Department and other inpatient services. Hospitalists may provide instruction to OB/GYN and Family Medicine residents. They may also proctor inexperienced OB/GYNs and other obstetric providers. They are closely involved in patient safety, as well as quality measures that often lead to leadership roles.

In addition to utilizing OB/GYN hospitalists for specific times, duties may be focused to meet the hospital’s needs even further. Hospitalists at Northwestern Memorial Hospital in Chicago, for instance, limit their practice location to a triage unit located on a different floor from L&D. However, the hospitalists can help with L&D for imminent deliveries from triage or as a backup if L&D is overwhelmed. L&D has its own staffing model.

Brown University has a stand-alone Women & Infants Hospital that evaluates obstetric, gynecologic, and newborn patients. Its emergency department has a separate area for its obstetric evaluation unit. Programs may elect to expand evaluation to postpartum patients who may be seen for 6 to 12 weeks after delivery and postoperative patients for 4 to 8 weeks following surgery.

Programs may use a midwife as an integral part of the care team, allowing the hospitalist to manage more complicated conditions. For example, if a patient has preeclampsia with severe features, the hospitalist would comanage the patient, handling the more critical components of care such as seizure prophylaxis, blood pressure treatment, and determining the timing of interventions. The midwife manages the other aspects of labor and delivers the patient. This team approach is an efficient use of resources and optimizes the skills of each provider, allowing high-quality care and favorable patient experiences. High-volume programs may utilize midwife and hospitalist coverage as part of the practice model. There are benefits to this type of team coverage, which has been shown to increase Vaginal Birth After Cesarean (VBAC) rates and decrease C-section rates.^9,10

When Family Medicine physicians have a high-risk patient, they consult or comanage that patient with the hospitalist. It is important that the hospitalist is utilized as a resource and team member without barriers to this involvement when a patient’s clinical course becomes more complicated or risky. Guidelines and expectations for these scenarios need to be clear. Direct and timely communication is critical for effective teamwork and ensuring patient safety.

COVERAGE

Since OB hospitalists are always in the hospital, they have the ability to provide temporary coverage for OB/GYNs, Family Medicine doctors, and even midwives who need time off. They fill a gap when a call partner is unavailable, or they provide coverage so a physician can attend an important professional or family event. This service fosters a culture of collaboration and cooperation, as well as affecting patient safety. Ultimately, the volume of work determines if this is a viable option.

Maternal Fetal Medicine Collaboration

Many hospitals implement a hospitalist program to either support or facilitate the establishment of an MFM service. As mentioned previously, the joint ACOG/SMFM statement designating levels of hospital specialty care recommends that a Subspecialty Care Hospital (Level III) and a Regional Perinatal Health Care Center (Level IV) have an MFM, with inpatient privileges available, as well as an OB/GYN who is present at all times. Hospitalists also serve as MFM “extenders” by participating in the care of MFM inpatients, allowing perinatologists to continue seeing patients in their offices for consultations, supervise high-risk pregnancies, and read complex ultrasounds. In addition to making the perinatologists more productive, it enables them to stay at home more often on call, improving their work/life balance.

A hospitalist program provides an option for an MFM group to cover more than one hospital with this professionally and personally sustainable model. A common arrangement would allow MFM physicians to perform inpatient consultations, make rounds on their own patients, and perform some deliveries, especially in the more complex cases. The hospitalist admits and usually performs the inpatient duties for the perinatologist. The responsibilities may include delivering the MFM patients, depending on the details of the arrangement. The hospitalist extends the abilities of the perinatologist and ensures the safety of his or her patients as an integral part of the team. The exact responsibilities and working relationship may be designed to be mutually advantageous.

A recent article by Ranum (2011), published in the American Journal of Perinatologists, described an SMFM survey finding that “respondents were more likely to be somewhat or very comfortable with OB hospitalists providing care for all women on L&D, and specifically with OB hospitalists caring for women with complex obstetrical issues.”¹¹

Planned Out-of-Hospital Deliveries

Midwives caring for patients planning to deliver at home or in a birth center may transfer care to the hospital when a patient’s situation becomes high risk or when complications occur. State regulations and requirements for out-of-hospital births vary considerably. There are variations in defining the scope of practice and in the requirements to integrate into a heathcare system. States that have best-practice guidelines for transferring these patients to the hospital minimize barriers so that these patients can receive specialized care. Washington State has Smooth Transitions, described as “a quality improvement initiative to enhance the safety of planned out-of-hospital birth transfers,” and Oregon has held several Home Birth Consensus Summits to address many issues, including establishing best-practice guidelines for patient transfers to the hospital.

Although this work is done at a state level, OB/GYN hospitalist programs may have an impact on their local community by forming relationships with Certified Nurse Midwives (CNMs) or direct-entry midwives performing out-of-hospital births. Approaching this issue from a perspective of improving the process of timely and safe transport minimizes barriers for patients to receive specialized care when they “risk out” of an out-of-hospital birth. A smaller number of providers in a hospitalist team can make it easier to form relationships and trust, which are more difficult to establish when a rotation of all obstetric providers is used to care for these transfer patients.

Academic

Many training programs utilize hospitalists to staff L&D and help instruct resident physicians. This staffing model reduces the call burden for the nonhospitalist teaching faculty, which may help improve retention and job satisfaction. Dedication to inpatient practice may augment resident education because the hospitalist typically has experience in emergency obstetrics and low-volume, high-risk cases such as a pulmonary embolus and eclampsia. When incorporated into the teaching staff, hospitalists have an opportunity to influence the training of both OB/GYN and Family Medicine residents. Hospitalists usually do not have time constraints off the unit, such as seeing clinic patients and research, allowing them to focus on the patient safety and quality needs of the unit, and incorporating the residents into patient-care workflows.

STAFFING

Most programs staff with 24-hour shifts, followed by 12-hour shifts or a hybrid schedule. There are variations in terms of what a hospital considers “full-time.” Many programs are based on a 40-hour workweek, with 173 annual 12-hour shifts equivalent to 1.0 full-time equivalent (FTE). Vacation and continuing medical education (CME) time may be deducted from the total. A fully staffed OB/GYN hospitalist program is usually between 4.2 and 4.7 FTE. The 12- to 24-hour shift work plan provides a predictable schedule and gives people time to rest between shifts. There is a high percentage of satisfaction, both professionally and with the work/life balance, among OB/GYN hospitalists. A 2016 survey of OB/GYN hospitalists found that 91% were either “very satisfied” or “satisfied” with their work.⁷ This is in marked contrast to a 2016 Medscape survey, in which 56% of OB/GYNs reported that they were burned out.¹²

PHYSICIAN LEAD

Most programs designate a Physician Lead and/or Medical Director position, whose responsibilities include establishing and monitoring protocols, best-practice guidelines, workflows, and quality metrics. Additional duties include management of the hospitalist team and collaboration with other services such as perinatologists, midwives, Family Medicine physicians, residency programs, emergency departments, community OB/GYNs, and administrators. Some programs devote more time and resources into their Physician Lead, who may also serve as the unit’s safety officer.