Several audience members voiced discomfort about leaving the labor and delivery area to take on emergency department gynecologic surgical cases because it distracts from the primary hospitalist focus of saving babies. Dr. McCue responded that the answer is to negotiate boundaries.
“What most of the hospitalist programs are coming to is making a deal with the privates,” she explained. “You say, 'I am doing the vast majority of your nighttime work by covering the labor floor for you and covering the first calls for you. All that I ask is that you be available on an emergency basis for the ER overload that I can't handle. I am happy to get the ectopics and incompletes started for you, but if I call that's because I need you to be there to cover.'”
Conference attendees heard best-practice updates from authorities on obstetric triage and evidence-based cesarean section techniques. They also began planning SOGH's future course. Dr. Bob Fagnant circulated a rough draft of proposed core competencies defining what ob.gyn. hospitalists need to be able to do. (See box.)
The society will eventually have to formally settle on a group of core competencies, a program for attaining them, and a means of tracking them to attain subspecialty status from the American Board of Obstetrics and Gynecology. The board will want to see evidence that being an ob.gyn. hospitalist requires a special set of skills not taught to physicians who graduate residency as general ob.gyns., explained Dr. Fagnant, an ob.gyn. hospitalist at Intermountain Health Care in St. George, Utah, who is also vice chair of the ACOG Committee on Ambulatory Practice.
The SOGH leadership believes simulation training will play a key role in demonstrating ob.gyn. hospitalist competencies. Toward that end, SOGH's first annual meeting featured a half-day of participation in a three-station obstetrical emergency simulation workshop focused on management of obstetric hemorrhage, maneuvers and techniques to relieve shoulder dystocia, and operative deliveries.
Dr. Arthur Townsend, medical director of the ob.gyn. hospitalist program at Methodist Le-Bonheur Hospital in Germantown, Tenn., stressed that hospitalists are “perfectly positioned” to support the quality initiatives hospitals take on to improve outcomes, decrease liability, attract patients, and meet the requirements of outside national organizations that report on quality indicators, such as the National Perinatal Information Center/Quality Analytic Services.
A significant part of what he and his hospitalist colleagues do is gather statistics. These include hospital-wide cesarean rates, vaginal births after cesarean, incidence of episiotomy, third- and fourth-degree laceration rates, postpartum hemorrhage, vaginal deliveries with shoulder dystocia, and a host of others.
He and his fellow hospitalists also carefully track their own performance. They file a detailed online report at a secure website upon completing every shift. These shift reports are compiled into monthly reports totaling the number of deliveries the hospitalists have performed, assists provided at cesarean and vaginal deliveries, the emergencies hospitalists responded to, the number of gynecologic surgeries performed, unassigned patients they've seen, and nurse and physician satisfaction survey results. These reports go to the hospital CEO, the board of directors, and the hospital risk management and quality committees.
“We've got some data to show that we really make a difference. What we do in these reports is tell how we save people. Everyone wants to know how many patients we're saving,” he explained.
The hospitalists track and submit individual physician-level statistics. When the data point to a problem physician – for example, an ob.gyn. who doesn't return phone calls from a nighttime nurse in timely fashion or who regularly scores poorly in patient satisfaction – Dr. Townsend leaves it to the hospital quality committee to do something about it. “I don't want to be the sheriff,” he explained.
These data-filled reports document the progress the hospital has made in achieving safety. This in turn has led to a reduction in the cost of the hospital's risk insurance. Moreover, when Dr. Townsend made a presentation to the hospital's risk underwriter, the company was so favorably impressed by what ob.gyn. hospitalists do that it provided them with a $60,000 grant to purchase obstetrical emergency simulators.
Dr. Townsend asked audience members to think about which hospitalist quality measures they consider to be most important yet practical for hospitalist practices to routinely collect at the national level. This is an issue where SOGH would like to be able to provide recommendations.
Dr. Suneet P. Chauhan, a non-hospitalist guest speaker at the conference, recommended focusing initially on two key statistics where he believes ob.gyn. hospitalists could make an impact with maximum “wow” factor: time to cesarean section for nonreassuring fetal heart rate tracings, and time spent in obstetric triage for preterm labor.