Over the last 5 years, a new obstetric-gynecologic hospitalist model has emerged rapidly, the primary focus of which is the care and safety of the laboring patient. The need for this type of practitioner has been driven by a number of factors: various types of patient safety programs that require a champion and organizer; the realization that bad outcomes and malpractice lawsuits often result from the lack of immediate availability of a physician in the labor and delivery suite; the desire for many younger practicing physicians to seek a balance between their personal and professional lives; the appeal of shift work as opposed to running a busy private practice; the waning amount of training that new residency graduates receive in critical skills that are needed on labor and delivery; the void in critical care of the laboring patient that is created by the outpatient focus of many physicians in maternal-fetal medicine; the need for hospitals to have a group of physicians to implement protocols and policies on the unit, and the need for teaching in all hospitals, not just academic centers. By having a dedicated group of physicians whose practice is limited mostly to the care of the labor and delivery aspects of patient care, there is great potential to address many of these needs. There are currently 164 known obstetrician/gynecologist hospitalist programs across the United States, with 2 more coming on each month; the newly formed Society of Obstetrician/Gynecologist Hospitalists currently has >80 individual members. This article addresses the advantages, challenges, and variety of Hospitalist models and will suggest that what may be considered an emerging trend is actually a sustainable model for improved patient care and safety.
Labor and delivery can be a place of unanticipated crises that require the immediate response of the skilled practitioner for life-threatening complications. It is also an area of immense medical legal liability. In many private hospitals, practitioners care for patients remotely, either from busy offices or from home. Many physicians desire a better balance between personal and professional life without the burden of night and weekend call. In other areas of the hospital, hospitalists have emerged as a solution to these and other issues and have become a rapidly growing trend throughout the United States. The obstetrician/gynecologist (OB/GYN) hospitalist is a 24-hour a day/7-day a week physician who assists with or assumes the care of laboring patients, obstetric triage, and gynecologic emergencies and has resulted in a rapidly growing new model of OB/GYN care.
History of hospital medicine
The field of “hospitalist medicine” and the practitioner descriptor “hospitalist” have their origins in internal medicine. The terms were coined by 2 internists, Wachter and Goldman in a 1996 New England Journal of Medicine article “The emerging role of ‘Hospitalists’ in the American Health Care System.” The initial goal for the adoption of the hospital medicine model was to “increase hospital efficiency by reducing length of stay and care-related costs.” As the field has grown and evolved, so have the rationales for adoption of the model, which include the ability to provide care for “no doc” patients and the request for hospitalists’ services from primary care physicians. In 2006, the American Board of Internal Medicine announced that it would begin the development of focused recognition for hospital medicine as part of the American Board of Internal Medicine’s Maintenance of Certification process, which gave internal medicine hospitalists a formal credential and officially recognized hospital medicine as a distinct field.
“Fifteen years ago, hospital medicine was [only] an emerging idea catalyzed by individuals sharing their experiences,” says Society of Hospital Medicine cofounder John Nelson. Today, hospital medicine is the fastest growing subspecialty in the history of modern medicine, with >30,000 hospitalists practicing in 4 of 5 large hospitals in the United States ( Figure 1 ). This growth is due to several factors that include the changing role of primary-care physicians and the growing research and data that supports the value of hospital medicine. Peter J. Pronovost, MD, PhD, Medical Director of the Center for Innovation in Quality Patient Care and director of the Quality and Safety Research Group at Johns Hopkins University in Baltimore believes that “hospitalists are better positioned than many other physicians to play a key role in the drive toward efficiency while also improving health care quality and safety” and predicts that “hospitalists’ roles are going to go up dramatically” in the future.
Potential for improving OB/GYN hospital care
In 2003, Weinstein proposed the idea of hospital-based obstetricians primarily to improve patient safety. He states “This is the salvation of this profession and the biggest thing we can do to improve patient safety.” In July 2010, the American College of Obstetricians and Gynecologists’ (ACOG) Committee on Patient Safety and Quality Improvement stated 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.”
Potential for improving OB/GYN hospital care
In 2003, Weinstein proposed the idea of hospital-based obstetricians primarily to improve patient safety. He states “This is the salvation of this profession and the biggest thing we can do to improve patient safety.” In July 2010, the American College of Obstetricians and Gynecologists’ (ACOG) Committee on Patient Safety and Quality Improvement stated 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.”
What is driving the need for this new approach?
Care of laboring patients needs to be more efficient. Instead of several physicians caring for a few laboring patients at 1 time, a hospitalist physician alone usually can manage the situation instead. For medical malpractice cases, the most common areas of alleged negligence are delayed response of the physician who is treating the laboring patient and issues of communication between the labor and delivery nurse and a remote physician.
The 2008 study “Reducing obstetric litigation through alterations in practice patterns” concluded that a hospital could halve its litigation costs 4 ways, the first of which is to have “a facility with 24-hour in-house obstetric coverage.” Emphasis on patient safety has become a recent theme; safety is, or at least should be, the primary driver for the increased demand for OB/GYN hospitalist programs. The management of critical emergencies that are handled by trained hospitalists based on labor and delivery has the real potential to improve the quality of care and standardization of processes and to yield a better outcome.
The issue of waning experience in operative deliveries and other critical skills among recent residency graduates is also a concern. A hospitalist program potentionally can also address physician fatigue. A survey of Wisconsin obstetricians revealed that, on average, obstetricians cover for 5 physicians while on-call, and call duration averages 24 hours. Only 26% facilities had provisions for reduced work hours after being on-call, and just 18% of the physicians restricted themselves from major surgery the next day. An accompanying editorial by Weinstein and Garite called for obstetricians to make changes to avoid such dangerous sleep deprivation and advocated that hospitalists be one of the solutions. Instituting a hospitalist program means that, unlike with private practioners, OB/GYN hospitalists come to the shift rested and can rest or nap during their shift; once the shift is over they hand-over their responsibilities to another rested hospitalist. The OB/GYN hospitalists can become a valuable resource in implementing new policies or technologies.
A recent experience at Good Samaritan Hospital in San Jose, CA, illustrates this point. When a new uterine tamponade balloon device was introduced, several training sessions were offered to all Obstetric Department physicians. Relatively few private practice physicians attended, whereas all of the hospitalists did; many of those who attended have now become device experts and have placed more of these balloons than all the private obstetricians combined. Also, it is easier to coordinate patient safety program changes by partnering hospitalist physicians with nurses, pediatricians, neonatologists, anesthesiologists, and hospital administrators to create change. The evolution of the Maternal Fetal Medicine (MFM) specialty to outpatient care means that most MFM specialists now spend less time in the inpatient setting and have less ongoing experience with critical maternal care; thus, a void in the critical care of the patient has reemerged.
Hospitalists also address other important issues. There is an increasing desire to create a better balance between personal and professional life. The newest generation of physician differs from more established physicians in their desire to put personal priorities at least on an equal footing with professional life. It is also not economical to employ a new partner just for additional night and weekend call. The hospitalist model provides an alternative for night and weekend coverage for the busy practitioner and/or practice.
Models for OB/GYN hospitalist care
The evolving models for exactly what care OB/GYN hospitalists provide and how they fit into the care of private physicians’ patients, supervising resident care, or caring for emergencies or “drop in” patients are illustrated by the failure to even agree on the exact title for this role: it is referred to as OB or OB/GYN hospitalists, a laborist, or even, with tongue in cheek, a nocturnist or weekendist. The terms hospitalists and laborists are used interchangeably and do not seem to imply differences in job approaches. Regardless of its title, it is clear that this job description requires a great deal of flexibility to fit the needs of the position, a willingness to accept the change, and the logistics of each new hospital to implement these professionals. It is also clear that the role will evolve over time as hospitalists prove their value and reveal they are not a threat to private practitioners.
One way of describing the role of the hospitalist is with the authors’ perceptions of the ideal: a model that few hospitals actually have used but that is perhaps the best way to understand the potential and then modify it according to individual hospitals’ realities. Consider this first model on one end of the spectrum; on the other end of the spectrum is an in-house obstetrician who is available only for emergencies, such as umbilical cord prolapse, unattended deliveries, and for patients with no prenatal care who drop in for delivery.
Full-service hospitalist
What marks the difference between a true labor-and-delivery hospitalist and a physician who is available for unexpected emergencies is someone who is present immediately to manage labor, not just attend deliveries. This is an individual who, along with his or her colleagues, provides 24-hour a day/7-day a week in-house coverage. The following duties are included: signs out all triage patients and personally evaluates them as needed; evaluates all admitted patients; writes an admitting note or history and physical examination and initial orders; orders all nonroutine laboratory and other tests; and monitors every patient’s labor progress, complications, need for anesthesia, and need for amniotomy. This hospitalist works jointly with the patient’s private physician and performs all of the aforementioned duties, unless the patient’s physician is in-house and otherwise not occupied with other duties, such as surgery. The private physician is called for deliveries and any major decision regarding patient treatment. The hospitalist decides on and implements all labor interventions (eg, pitocin or amnioinfusion), reviews all fetal monitor strips on a regular basis (especially when any abnormality or concern is noted by the nurse and any time any nonsurgical intervention is required), decides on the need for internal monitoring, and is available for emergent deliveries or deliveries for which the primary physician is unable or prefers not to.
In addition, the hospitalist is available to assist on operative deliveries, twins, or other procedures that need a second hand. They can be used as the on-call OB/GYN for the general emergency room, can provide ongoing nursing and physician education, are available for neonatal resuscitation in unanticipated situations, can evaluate and manage postpartum complications, can check on hospitalized antepartum patients, and can perform emergent gynecologic surgery on emergency patients for cases such as ectopics or incomplete abortion curettage. Many programs have elected not to have the hospitalist participate in gynecologic surgery and/or emergency room call because it takes away from the potential of rapid response for labor and delivery emergencies, but others have elected to do one or both because of the revenue that these services generate or to make the program more attractive to the private attendings who benefit from the hospitalist providing these services.
The obvious question with this model is how does the private physician interact with the hospitalist and vice versa? In this particular model, the primary doctor has the option of performing any of the preceding duties instead of the hospitalist if, and only if, the primary doctor does these promptly and in person. In virtually all situations, for the primary doctor to override the hospitalist, they will have to perform the same function on-site themselves. More often this will be a team effort for which the primary doctor will have the option of discussing all evaluations and participating in treatment decisions. At any time, the primary doctor has the option of turning over all treatment of the patient to the hospitalist. When the hospitalist is too busy to manage the duties described, there is an emergency backup system in place. To keep this system running well and deal with unanticipated issues or conflicts, a committee is needed to monitor and constantly improve the manner in which interactions take place. Data collection is also essential to prove the program’s relevancy and success.
The reality
In most situations, except in the military, many teaching hospitals, or in models such as Kaiser Permanente, the full-service hospitalist model is an ideal, with hospitalists performing the aforementioned duties on some (perhaps few at first), but not all, of the patients in labor and delivery. However, the reality is that some private physicians will prefer not to involve the hospitalist at all in the care of their patients; others will only use hospitalists for specific requests or when they are too busy to care for the patient. Hospitals have discovered that the hospitalists start primarily as an emergency back-up physician and, gradually, over time take on more of the duties of the ideal hospitalist role for some of the physicians, increasing over time to involve more of the physicians. In many hospitals, other models are tailored to their own wants and needs and will continue to evolve.
As an example of a different hospitalist model, at Good Samaritan Hospital in San Jose, CA, the OB/GYN hospitalists (general OB/GYNs) are part of the MFM practice and, in addition to serving as an obstetrician hospitalist, are involved with the MFM service and all of the perinatal patients. In this model, most patients of the MFM group, except for scheduled cesarean section deliveries, are treated by the hospitalists; most maternal transports are admitted by the hospitalists, and the hospitalists are available to treat or assist with the patients of the private generalists as well. The MFM serves as the obstetrician hospitalist back up, and there is an MFM physician available at all times. There are carefully written and monitored protocols for when the MFM physician needs to come in and evaluate and/or deliver certain types of patients or situations. The MFMs do the actual consultations for the private physicians when requested, and MFMs and hospitalists make rounds together every morning on high-risk antepartum and postpartum patients. This is a cost-effective model that allows the MFM physicians to attend to their office duties and avoids hiring new MFMs solely to handle the burden of night and weekend call.
Teaching hospitals also differ from the ideal model
OB/GYN hospitalists may perform the dual role of both the required in-house resident supervisor and treat or assist with the private physicians’ patients. The hospitalist has the potential to differ from the more traditional attending of the night or weekend in that he/she is less distracted by issues or patients on the attending’s own service and less likely to be tired and to spend the time in the call room but rather have the skills and interests that are particular to the labor and delivery area and be more available to teach house staff and students.
Clearly different models evolve to meet individual hospitals’ needs, but all must be flexible enough to meet the demands of the private OB/GYNs, the hospital administration, and the medical staff and the volume and logistics of the hospital, nurses, presence or absence of a teaching services, hospital type, and other variables.
There are other benefits that go beyond improving patient safety.
For the patient
The hospitalist will serve to reduce waiting times for clinical decisions, can aid in communication regarding the clinical plans of care, and is available immediately to assist with operative procedures, ultrasound scans, labor procedures, and triage evaluations.
For nursing staff
The hospitalist provides immediate evaluation of patients, which reduces the amount of contact needed with offsite attending, reduces the time that is involved in contacting physicians, aids in communication with attending physician and patients, provides a source of expertise and advice, assists in interpreting fetal monitor tracings and unanticipated clinical situations that may arise, is a source for interpretation of and adherence to hospital protocols and procedures, and provides immediate and ongoing continuing education.
For hospital administration
The presence of a hospitalist program has the potential to result in reduced malpractice premiums; can be a tool for improved marketing and patient attraction; can be a recruiting tool for bringing new young physicians and retaining older physicians on staff who are attracted by the opportunities for less weekend and night call; may give the hospital more control over physicians practices; allows easier implementation of care paths and protocols; improves nursing job satisfaction, retention and recruiting; provides better supervision of house staff where applicable; may make it easier for administration and physician problem-solving, and can reduce the difficulty of finding physicians to do emergency room call.
Another significant driver for hospital administration to consider
How do OB/GYN hospitalist programs relate to current Emergency Medical Treatment and Active Labor Act (EMTALA) regulations? With increasing enforcement and refinement of EMTALA regulations, hospitals must now accept unscheduled patients who arrive to labor and delivery as Emergency Department patients and extend to them all of the policies and requirements of an Emergency Department patient. Qualified labor nurses traditionally have been able to perform obstetric triage and notify an obstetric attending who could make the determination to admit or discharge without ever seeing the patient. However, EMTALA policies plainly state that a qualified nurse may perform only a medical screening examination to determine the presence or absence of labor and that any other medical conditions or complaints must be seen by a physician in a timely manner. Compliance with this regulation is extremely difficult in an obstetrics department that does not have obstetrician hospitalists.
Program cost and how to pay for it
To staff a full-time OB/GYN hospitalist program requires at least 4-4.5 full-time equivalent hospitalists. Most hospitals choose to hire physicians who do not have a private practice, thus reducing any fear that a private doctor may have of losing a patient by turning over his or her patients for care in labor and delivery. Salaries, benefits, and malpractice premiums for these physicians make up the vast majority of the cost of such a program. Overall, these direct costs will be in the range of $1.25–1.5 million.
Covering other physicians’ deliveries and their cesarean section deliveries are the primary ways of recovering costs and facility and physician fees from the obstetric triage area. An American Board of Obstetrics and Gynecology (ABOG) statement provides guidance on how these fees can be recovered: “Each component of the OB package can be billed and reported separately. That is, report the antepartum care (59425 or 59426), delivery of the placenta (59414), episiotomy repair if appropriate (59300), and the postpartum care (59430).” Thus, if the hospitalist provides the delivery, he/she can bill for it separately. Or with a signed agreement between the hospitalist and the private physician, the private physician can choose to bill for the global total obstetric care and then pay an agreed upon fee to the hospitalist for covering the delivery. Separate fees may also be charged for procedures that the hospitalists performs, which include triage, evaluation of discharged patients, ultrasound scanning, assisting on operative procedures, external version, labor induction initiation (inserting intracervical balloon catheters or medications).
There can be savings for the hospital in reduced fees to private physicians for emergency room calls and administrative work, and there may be reduced malpractice premiums or reduced malpractice “set asides,” which has already occurred in some hospitals. At least initially, the hospital administration will need to subsidize a large portion of the hospitalist program; however, this will decrease over time, and many of the benefits previously described, both financial and otherwise, will more than compensate for this in the long term.
The model for who hires and manages these physicians varies; several private staffing companies contract with the hospital to hire, pay, and manage OB/GYN hospitalists. The hospital may choose to run the program itself with the hospitalists as their employees; hospitalists can be part of a general OB/GYN or MFM group practice or even a multispecialty group practice; hospitalists may choose to be a group of independent contractors, much like many radiologists, pathologists, or emergency department physicians, or they could be a hybrid of any of the these possibilities.
Such a drastic change in the model of practice does not come about without some difficulties. Besides the usual problems of hiring and scheduling and dealing with turn over, unexpected absences, and variation in the quality of the individual’s performance, there are other potential problems. Acceptance by private physicians is usually the first hurdle because they fear loss of control and that their patients will not accept this model. The latter fear has proved to be largely unfounded because patients are often cared for by physicians who provide on-call coverage anyway and will not have met the patient before the day of delivery. Patient surveys have been positive because patients particularly like having someone immediately available to answer questions and to provide care and to have the individual who actually performs their delivery whom they have met well before the time of the actual delivery (written communication, Daniel O’Keeffe, MD, Good Samaritan Hospital, Phoenix, AZ; written communication, Alan Fishman, MD, Good Samaritan Hospital, San Jose, CA).
Malpractice insurance is a concern because the hospitalist is exposed to a larger volume of patients than a private physician in the high-risk labor and delivery area. If the hospitalists can be covered by the hospital’s umbrella policy, this can solve this problem because of the potential for an overall reduction in malpractice claims may be realized.
A significant problem occurs when new resident graduates apply for this position. This individual will not have the gynecologic experience that they would have in a typical practice, missing out on ambulatory and surgical gynecology. This creates a problem for their participation in emergency gynecologic surgery and getting the required cases for their Board examinations. Recently graduated obstetricians do have the option of using cases from the senior year of their residency for gynecology and/or office practice. It is recommended that they refer to the ABOG’s bulletin for the examinations on this point. ABOG is currently evaluating options for how this affects individuals who become hospitalists (written communication, L. Gilstrap, MD, ABOG).
A 2011 employment survey of ObGynHospitalist.com –registered members yielded 7 additional issues that respondents stated were their biggest issues. They were scheduling difficilities, pay, and benefits, having too many responsibilities, problems with hospital and nursing management, billing issues, fatigue and burn out, and lack of gynecology cases posing skill maintainance issues.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
