Number 657 (Replaces Committee Opinion Number 459, July 2010)
Committee on Patient Safety and Quality Improvement
Committee on Obstetric Practice
The Society for Maternal–Fetal Medicine and the Society of OB/GYN Hospitalists endorse this document. This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Patient Safety and Quality Improvement and the Committee on Obstetric Practice. Member contributors included Jeffrey Ecker, MD and John Keats, MD. This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.
ABSTRACT: The term “hospitalist” refers to physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities may include patient care, teaching, research, and inpatient leadership. The American College of Obstetricians and Gynecologists supports the continued development and study of the obstetric and gynecologic (ob-gyn) hospitalist model as one potential approach to improve patient safety and professional satisfaction across delivery settings. Effective patient handoffs, updates on progress, and clear follow-up instructions between ob-gyn hospitalists and patients, nurses, and other health care providers are vital to maintaining patient safety. Hospitals and other health care organizations should ensure that candidates for positions as ob-gyn hospitalists are drawn from those with documented training and experience appropriate for the management of the acute and potentially emergent clinical circumstances that may be encountered in obstetric care.
The American College of Obstetricians and Gynecologists supports the continued development and study of the obstetric and gynecologic (ob-gyn) hospitalist model as one potential approach to improve patient safety and professional satisfaction across delivery settings. Standardization of medical care has been shown to lead to improved outcomes, and ob-gyn hospitalists can serve as a driving force behind the implementation of these protocols in labor units.
Effective patient handoffs, updates on progress, and clear follow-up instructions between ob-gyn hospitalists and patients, nurses, and other health care providers are vital to maintaining patient safety.
Hospitals and other health care organizations should ensure that candidates for positions as ob-gyn hospitalists are drawn from those with documented training and experience appropriate for the management of the acute and potentially emergent clinical circumstances that may be encountered in obstetric care.
Additional outcomes research is needed to determine the effect of the ob-gyn hospitalist model on the safety and quality of care and to determine the economic feasibility of various models.
The ob-gyn hospitalist concept emerged from the hospitalist movement of the 1990s. The term “hospitalist,” coined in 1996 by Wachter and Goldman 1, refers to physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities may include patient care, teaching, research, and inpatient leadership. Hospitalists help manage the continuum of patient care in the hospital, often seeing patients in the emergency department, monitoring them into the critical care unit, and organizing postacute care 2. According to the Society of Hospital Medicine, in 2014 there were more than 44,000 practicing hospitalists functioning in 80% or more of hospitals in the United States 3.
The Obstetric and Gynecologic Hospitalist Concept
The application of the hospitalist concept to the practice of obstetrics and gynecology was first suggested in 2002 4. Although not universally standardized, the term “obstetric and gynecologic (ob-gyn) hospitalist” (which is consistent with the term used by the Society of OB/GYN Hospitalists) most commonly refers to an obstetrician–gynecologist who has minimal outpatient and elective surgical responsibilities, and whose primary role is to care for hospitalized obstetric patients and to help manage obstetric emergencies that occur in the hospital 2. An ob-gyn hospitalist also may provide urgent gynecologic care and consultation to the emergency department or hospital inpatient services. Some use the term “obstetric hospitalist” to distinguish an obstetric hospitalist provider who defers all gynecologic responsibility to focus solely on obstetric care. Although recognizing that some facilities may use the term “obstetric hospitalist” or “laborist,” the term “ob-gyn hospitalist” will be used throughout this document. Consistent use of standardized terminology, like the term ob-gyn hospitalist, with standardized definitions will facilitate data collection to determine the efficacy and outcomes for patients cared for by these physicians.
In contrast to internal medicine hospitalists who have essentially replaced their practice-based colleagues in the hospital, ob-gyn hospitalists may replace, but also can assist and complement, their colleagues. Responsibilities may be broad or narrow in focus, ranging from only providing triage and care for unassigned patients, to admitting and providing the full spectrum of labor and delivery and postpartum care for some or all obstetric patients. Depending on the hospital, ob-gyn hospitalists may directly supervise and teach residents and students; provide surgical and consultative support to certified nurse–midwives, certified midwives, and family physicians; or manage unassigned patients in the emergency department or medical floors. Other responsibilities may include assisting in cesarean or multiples’ deliveries, providing coverage for precipitous births, managing obstetric emergencies such as postpartum hemorrhage, and providing coverage for obstetrician–gynecologists during scheduled clinic hours. The ob-gyn hospitalists also may provide assistance for scheduled operative cases and could support fatigued ob-gyn physicians. The ob-gyn hospitalists also may work with nursing leadership to ensure effective resource use and to monitor quality metrics, such as elective delivery before 39 weeks of gestation. It is estimated that, in 2014, there were more than 1,700 ob-gyn hospitalists working at more than 243 hospitals in the United States, which represents approximately 10% of hospitals that offer obstetric services 5, though penetration of the model may vary by region. A recent study demonstrated that 24% of community hospitals in California used ob-gyn hospitalists 6.
Various Practice Models
Currently, there is great variety among ob-gyn hospitalist practice models 7. Ob-gyn hospitalists may be independently contracted for their services or may be employed by hospitals, physician groups, or national staffing companies. Ob-gyn hospitalists’ shifts range in length, although 12-hour and 24-hour shifts are most typical. Ob-gyn hospitalist programs are active across a wide spectrum of delivery volumes, and hospitalists practice in settings ranging from small community hospitals to large academic medical centers. Compared with the overall demographics for U.S. obstetrician–gynecologists, hospitalists tend to be younger and to have completed their residency training more recently 8 9.
In contrast to those physicians who serve only as ob-gyn hospitalists, members of a department, practice, or call group often cooperate to function as their own “hospitalist” support. In lieu of office hours, obstetrician–gynecologists take turns covering the labor ward and hospital floors on a rotating schedule that includes day, night, and weekend shifts. Recognizing the benefits of the 24-hour presence of an obstetrician on labor and delivery, in some systems, hospitals often reimburse obstetrician–gynecologists to remain present in the facility as the day’s “on call” physician. A variety of models exist in which continuous presence of a covering obstetrician–gynecologist can be achieved.
Training and Certifications
Most practicing ob-gyn hospitalists have achieved board certification in obstetrics and gynecology. There are several fellowship programs available for those seeking additional training as an ob-gyn hospitalist; however, there is no subspecialty certification recognized by the Accreditation Council on Graduate Medical Education or the American Board of Obstetrics and Gynecology. Ob–gyn hospitalist staffing companies may require participating physicians to achieve and maintain expertise in electronic fetal monitoring, neonatal resuscitation, basic and advanced cardiac life support, accurate billing, and risk management. Hospitals and other health care organizations should ensure that candidates for positions as ob-gyn hospitalists are drawn from those with documented training and experience appropriate for the management of the acute and potentially emergent clinical circumstances that may be encountered in obstetric care.
The ob-gyn hospitalist model is one method hospitals can employ to improve the quality and safety of their obstetric–gynecologic services and reduce the incidence of adverse events. Although it has been difficult to gather direct evidence of the extent to which these programs improve patient safety, outcomes data regarding ob-gyn hospitalist programs are emerging 10. In one study, a dedicated ob-gyn hospitalist service was associated with a 27% reduction in the cesarean delivery rate as compared with the traditional model of care 11. Another study also associated a significant reduction in the cesarean delivery rate with care managed by ob-gyn hospitalists in conjunction with certified nurse–midwives versus a traditional ob-gyn care model 12 13. The design of these studies does not allow for the measurement of improvements attributable to hospitalists. Recognizing this, more studies are needed to demonstrate the effect of care provided by ob-gyn hospitalists on patient outcomes.
Sleep deprivation of caregivers is increasingly recognized as a potential issue for patient safety in obstetrics 14 15 16 17 18 19. Effects of fatigue on health care outcomes remains an area of ongoing study with very little data on actual outcome at the moment. However, depending on its design, a hospitalist model may have the potential to reduce risks associated with health care provider fatigue based on defined work schedules and the potential avoidance of extended shifts. Groups and departments, including ob-gyn hospitalist programs—particularly those including coverage of cases in the emergency department—should require a well-defined back-up system so that a fatigued or overwhelmed physician can call for assistance 14.
Standardization of medical care has been shown to lead to improved outcomes 20, and ob-gyn hospitalists can serve as a driving force behind the implementation of these protocols in labor units 21. Ob-gyn hospitalist programs can involve staffing the labor triage area as an obstetric emergency department, where all patients can be evaluated by a physician or other qualified clinician before disposition is decided. Such standardization of a program in which patient care is decided by a qualified health care provider could theoretically avoid potential adverse outcomes or unrecognized complications.
Obstetrician–gynecologists may use an ob-gyn hospitalist to care for patients requiring inpatient evaluation while they are assigned to office duties or other activities outside of the hospital. The ob-gyn hospitalist also may ease the responsibilities of on-call obligations, which commonly extend beyond 24 hours 15. An ob-gyn hospitalist program may afford office-based physicians greater autonomy over their personal lives by responding to obstetric emergencies and urgent needs as well as providing coverage for the physician’s laboring patients if they are unavailable, cannot get to the hospital, are in the middle of busy office hours, or have scheduled operative cases.
In addition to benefits for obstetrician–gynecologists, patients, and facilities, a hospitalist model may appeal to particular individual hospitalist providers, who may have specific career goals and practice desires. Focusing practice uniquely on inpatient obstetrics promotes maintenance of skills such as forceps-assisted delivery, delivery of the second twin, and response to postpartum hemorrhage. Practicing solely in the hospital setting removes activities related to office practice that some may find unappealing, such as the financial and business implications associated with managing a solo or group practice. Other possible benefits include more predictable schedules, fewer unanticipated clinical responsibilities outside of assigned shift times, competitive compensation, paid benefits, and guaranteed time off that may or may not be available in other practice models.
Challenges to Implementing a Hospitalist Model
One challenge of the ob-gyn hospitalist model is maintenance of obstetric and gynecologic privileges by hospitalists and office-based obstetrician–gynecologists. If hospital administrations and governing bodies require physicians to perform a minimum number of procedures to retain their privileges, ob-gyn hospitalists may have difficulty maintaining competency in major gynecologic surgeries. In some cases, it could be difficult for office-based physicians who use a hospitalist model to perform the majority of obstetric procedures to demonstrate continued competence in certain aspects of obstetric care, particularly those less-common procedures such as operative delivery. These potentially unintended consequences will need to be considered in the adoption of hospitalist-based models to ensure that all obstetrician–gynecologists involved have access to maintenance of competency.
Although concerns about the effect of a hospitalist model on patient satisfaction have been raised, one study found that patient satisfaction does not appear to be affected adversely by initiation of the ob-gyn hospitalist model, but did note that additional research is needed to fully understand the implications of the model 22. Health care providers should inform their patients if ob-gyn hospitalists are a part of the health care team that may provide their care.
Other concerns for hospitals to explore when considering an ob-gyn hospitalist program include operating costs, maintaining manageable volume for ob-gyn hospitalists, ensuring that non-ob-gyn hospitalists maintain their qualifications, and ensuring that obstetrician–gynecologists are sufficiently trained and experienced because this is a younger, less-experienced cohort, as mentioned earlier.
A key element for instituting an ob-gyn hospitalist program is the establishment of clear communication methods between ob-gyn hospitalists and primary ob-gyn health care providers, including ready access to the patients’ ambulatory records. Effective patient handoffs, updates on progress, and clear follow-up instructions between ob-gyn hospitalists and patients, nurses, and other health care providers are vital to maintaining patient safety 23 24. It also is important that hospitals with ob-gyn hospitalist programs use standardized protocols and management techniques agreed on by obstetric care providers. These may vary between institutions depending on local resources.
The ob-gyn hospitalist model has the potential to achieve benefits for obstetric patients, obstetric providers, and hospitals. Additional outcomes research is needed to determine the effect of the ob-gyn hospitalist model on the safety and quality of care and to determine the economic feasibility of various models. For the reasons outlined in this Committee Opinion, the American College of Obstetricians and Gynecologists supports the continued development and study of the ob-gyn hospitalist model as one potential approach to improve patient safety and professional satisfaction across delivery settings.
For More Information
These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s web site, or the content of the resource. The resources may change without notice.
ACOG has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/ObGynHospitalist.