N E W S L E T T E R J u n e 2 0 1 6 E d i t i o n

SOGH is dedicated to enhancing the safety and quality of OB/GYN Hospital Medicine by promoting excellence through education, coordination of hospital teams, and

collaboration with healthcare delivery systems.

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SOGH Newsletter 6.2016

Practice Matters-

Saint Thomas Midtown

Nashville, Tennessee

Philip Bressman, MD

May 27, 2016

I am old, 63 years old. I was trained as a generalist and I practiced as a generalist for 30 years.

My practice started as a 3 physician group and grew to include 30 physicians. I had been

president of the group for 10 years when I walked away in 2013. My departure was not an easy

decision but I had overlapped the last 5 years as an Ob hospitalist. Starting with a part time

position as an Ob hospitalist, I was able to transition into a very rewarding, but nontraditional,

career path that includes full time hospitalist duties, directorship of the obstetric simulation

program, and a core faculty position with the UT Nashville OBGYN residency program.

Saint Thomas Midtown Hospital, with 7000 deliveries per year, has the largest labor and

delivery unit in Tennessee. The unit includes 30 LDR’s, 6 OR’s, an adjacent antepartum unit, and

a Level III NICU. The unit is perfectly located just above the hospital’s laboratory facility and

only 2 blocks away from the Nashville Red Cross with access to the entire blood supply for

middle Tennessee. Staff includes over one hundred nurses and techs, a very involved MFM

group, and a veritable army of in-house anesthesia personnel. This facility is an Ob hospitalist’s

dream.

The hospital has a strong hospitalist service for intensive care, internal medicine, surgery, and

neurology. It also employs a large portion of the medical staff under the umbrella of Saint

Thomas Medical Partners. With most of this infrastructure already in place Saint Thomas

Midtown established its own Ob hospitalist service in 2008. In prior years, backup obstetric

coverage was provided on nights and weekends by a pool of prn private physicians working in

12 hour shifts. This was a safety initiative funded by the hospital. The new Ob hospitalist

service was structured to maintain this culture of safety even though it was anticipated to be

revenue negative for the hospital.

Our Ob hospitalist service consists of three core Ob hospitalist, each working 13 to 14 twelve

hour shifts per month. None of the core group has a private practice. The remaining shifts are

filled from a prn pool of select private physicians, each working 1 to 4 shifts per month.

Monthly, the core group selects their shifts prior to the prn pool signup. Shifts may be selected

in 12 or 24 hour blocks.

SOGH Newsletter 6.2016

Ob hospitalist compensation is calculated per shift with the core Ob hospitalist and the prn

pool receiving the same reimbursement per shift. An incentive bonus is paid quarterly. The

amount of incentive is based on several unit metrics and individual quality performance

surveys. There is no financially based incentive parameter.

The core Ob hospitalist are considered full time employees of the hospital. We receive a full

benefits package consisting of health insurance, disability and life insurance, and access to the

Saint Thomas retirement savings program. We also receive full malpractice insurance coverage.

There is no paid vacation or sick time. Therefore, missed shifts must be made up and there is a

fair amount of last minute schedule juggling as there is in any group practice.

The current contract requires all Ob hospitalist to commit to ongoing education and training.

ACLS certification is required and funded by the hospital. Shoulder dystocia management and

EFM review are provided as online educational modules and completion is required every two

years. Obstetric simulation exercises are required yearly.

Duties of the Ob hospitalist are entirely obstetrical. We manage all unassigned patients that

arrive in the ED with a viable pregnancy. Thus, any pregnant patient after 16 weeks that is not

admitted to a private attending is managed by the Ob hospitalist service. Pregnant patients

with non-obstetric problems are co-managed by the Ob hospitalist and other appropriate

hospitalists. Unassigned hyperemesis patients are admitted to the Ob hospitalist while missed

abortions and ectopic pregnancies are managed by the ED gynecology call system.

On labor and delivery, the Ob hospitalist is available for emergencies, evaluation of fetal

monitoring tracings, intrapartum consults, and operative assistance for c/sections and operative

vaginal deliveries. Occasionally we co-manage labors or cover for private attendings who are

out of the hospital. We are often the physicians who are immediately available for a patient

attempting a vaginal birth after c/section (VBAC). Our Ob hospitalist service also accepts

maternal transports from middle Tennessee and southern Kentucky. These patients are usually

co-managed with the MFM service.

Saint Thomas is a Catholic based nonprofit hospital, and as part of its mission serves a large

population of uninsured and underinsured women. The hospital is affiliated with many

community clinics that offer prenatal care. These clinics have in house obstetric providers for

prenatal care, but the patients are admitted to the Ob hospitalist service for delivery. In

contrast, prenatal care through the Vine Hill Clinic is administered by certified midwives. The

Ob hospitalists and midwives work in a collaborative practice to attend and deliver these

patients in the hospital. One of t Ob hospitalist serves as medical consultant to Vine Hill and

visits the clinic regularly

SOGH Newsletter 6.2016

Ob hospitalists serve as educators and leaders in the hospital. We have a large role in teaching

medical students and residents in the University of Tennessee OBGYN residency program on

the Nashville campus. Since 2007 there has been a strong obstetric simulation program at

Saint Thomas. All nurses and all physicians and midwives are required to participate on a

regular basis. Ob hospitalists are involved in both the planning and administration of this

program. Besides the simulation committee, Ob hospitalist serve on the perinatal, obstetric

executive, women’s health steering, hospital safety, obstetric adverse events, and OB/

pediatrics High Reliability Organization (HRO) committees.

To sum up the Ob hospitalists services at Saint Thomas Midtown was conceived as a quality

initiative and is staffed by seasoned and respected practitioners dedicated to improving the

quality of pregnancy care. As such we have a central and indispensable position in the strong

safety culture of Saint Thomas Health System.

SOGH Newsletter 6.2016

Sim Corner UmbilicalCordProlapse

byVajiDharmasena,MDandNgoziWexler,MDMPHMay10,2016SOGHiscommittedtosupportingitsmembersinacquiringthetools needed to run a successfulOb/GynHospitalist program.Simulationprovidesapowerfulopportunity for teambuilding,education, and identification of unit-specific challenges. SimCornerwillprovidescenarios,checklists,anddebriefstoassistyouinyourfacilitationofsimulations.Thismonthwebringyouthebasictoolsforsimulationofprolapsedumbilicalcord.IEWCaseSummary:Length:15-20minutesPatientwithgestationaldiabetesandpolyhydramniosexperiencesasuddenspontaneousruptureofmembranes(SROM)withclearfluid,followedbyacordprolapse.ProlapseresultinginaSTATcesareansection-Endpointisdeliveryofinfant

SOGH Newsletter 6.2016

Targetgroup:Obstetricians,Midwives,PediatriciansTeamMembersfortheScenario:1. Obstetrician2. Midwife3. AnesthesiaProvider4. Neonatalteam5. PrimaryRN6. SecondaryRN7. ScrubTech8. Patient9. Familymember

PotentialSystemsexplored•Maternalandfetalassessmentprocess•ActivationofemergencyresponsesystemPERINATALSCENARIO4PAGE1EARNINGOBJECTIVESGeneralLearningObjectives•Communicateeffectivelywithpatient/family•Communicateeffectivelywithteamusingcrisisresourcemanagementskills•Demonstratesafetyinitiativesincludingmedicationsafetypractices•Demonstratesafetyinitiativesincludingworkplacesafetypractices•Maintaininfectioncontrolstandards

SOGH Newsletter 6.2016

ScenarioSpecificObjectives•Demonstratefocusedlaboranddeliveryassessment•Identifyumbilicalcordprolapse•Relievepressureofbaby’sheadonthecord•Prioritizecareofpatientwithprolapsedumbilicalcord•MonitorthefetusDebriefingOverview•Reviewlearningobjectives•Demonstratefocusedlaboranddeliveryassessmentandprioritizecare•Identifyumbilicalcordprolapseanddemonstrateappropriatemanagement•Reviewteamworkskills•ReviewcommunicationskillsincludinguseofSBAR•Whatwentwell?•Whatmighthavebeendonedifferently/better?•Sharekeyassessmentsandinterventions/events•Whatwaslearnedthatcanbetakenbacktotherealworkplace?PERINATALSCENARIO4PAGE2

SOGH Newsletter 6.2016

Briefing(patientstory):This32-year-oldG4P3presentedat37weeksEGA.ShewasadmittedtoL&D4hoursagoinearlylabor.CurrentFetalHeartRate(FHR)is140bpm(CategoryI).Shehasgestationaldiabetes,nowdietcontrolled.At34weeks,itwasnotedfetalsizewasgreaterthandates.Anultrasoundconfirmedfetalgrowthandanatomywaswithinnormallimits.Heramnioticfluidindex(AFI)was29,andadiagnosisofpolyhydramnioswasmade.Currently,thepatientisrestinginbedinsemi-fowler’spositionwithuterinedisplacementtotheleft.Sheishavingcontractionsevery2-4minutes,lasting60-90seconds.Herfamilyispresent.Acervicalexam10minsagowas7cm/90%/-2withbulgingbagofwaters(BBOW).Noepiduralispresent.Additionalinformation,MedicalHistory•Allergies:NKDA•Medications:PNV•OBHistory:G4P3,GestationalDiabetes,Polyhydramniosdiagnosedat34weeks.Shehad3priorvaginaldeliverieswithoutanycomplications.•Ht5’5”•Wt290lbs•EFW:3.41kg,7lbs6oz•PSHnegative

SOGH Newsletter 6.2016

•VSHR90;RR22;BP128/78;T37.2(98.7);•FHTs140(CategoryI)•Abnormal1hrGlucola,3GTT-2readingsabnormal•Hgb/Hctnormal,Plt150,WBC10•GBSherpes,HIV,VDRLallnegative•SocialHistory:MarriedwithstrongsupportsystemProlapsedUmbilicalCordEQUIPMENTLIST:�Urinarycatheter�IVsupplies�IVfluids�Fetalheartratemonitor�Bedpan�Medications(OBandAnesthesiaMeds)�Pitocin�Laborroom�OR�Setupforcesareansection�Hybridsimulation:standardizedpatientdressedinhospitalgownandPROMPTsimulator�SimMan3G:inORwithbabywrappedinsimulateduterusforcesareansection

SOGH Newsletter 6.2016

�IVinrightarmat125ml/hr�BluepadsunderthePROMPTbirthingsimulator-saturatedwithclearwaterOBSERVERCHECKLIST:

�Focusedassessment�Identifyprolapsedumbilicalcord�Callforhelp�Demonstratemaneuverstorelievepressureonprolapsedcord�Communicateeffectivelywithpatient/family�Communicateeffectivelywithteam�MonitorFHR�Applyoxygentomother�Positionpatientleftlateral�Positionpatientonbedpan�Positionpatientintrendelenberg�TransfertoORforSTATcesareansection�Inductionoranesthesia�Assistwith/performcesareansectionPERINATALSCENARIO4PAGE5PERINATALSCENARIO4PAGE6

SOGH Newsletter 6.2016

SOGH Newsletter 6.2016

Brief Review of Key Points: Prolapsed Cord

Incidence: 0.17-0.18 percent of live born deliveries Diagnosis: prolapsed cord palpated or visualized, fetal heart rate changes. Approach: Call for help, perform intrauterine resuscitation, minimize cord manipulation, minimize cord exposure to cold/ambient temperature, prepare for emergency delivery. Debrief: How well did communication and systems work? VajiDharmesana,MDFACOGisanObHospitalistwithKaiserSanJose,California.SheisanadjunctclinicalprofessorofOBGYNatBostonUniversitySchoolofmedicine.Sheisco-chairoftheSOGHSimulationCommitteeandhadheldthatpositionforthepast2years.SheisalsothesimulationleadforKaiserSanJose.NgoziWexler,MDMPH,FACOGisDirectorofOBGYNHospitalistProgramatMedstarSouthernMarylandHospitalCenterinClinton,MD.Sheisalsoco-chairoftheSOGHSimulationCommitteeandhasheldthatpositionforthepast2years.Reference:UmbilicalCordProlapse,MelisssaBush,MD,etal,Uptodate,Jan29,2016.

QuestionsorfeedbackonSimCorner?Contactusat:newsletter@societyofobgynhospitalists.com