NEWSLETTER. June 2016 Edition

Transcription

1 NEWSLETTER June 2016 Edition 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. Newsletter articles and content Society of OB/GYN Hospitalists Broadway, Suite 2743 Pearland, TX Twitter &

2 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 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 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.

3 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

4 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.

5 Sim Corner Umbilical Cord Prolapse by Vaji Dharmasena, MD and Ngozi Wexler, MD MPH May 10, 2016 SOGH is committed to supporting its members in acquiring the tools needed to run a successful Ob/Gyn Hospitalist program. Simulation provides a powerful opportunity for team building, education, and identification of unit-specific challenges. Sim Corner will provide scenarios, checklists, and debriefs to assist you in your facilitation of simulations. This month we bring you the basic tools for simulation of prolapsed umbilical cord. IEW Case Summary: Length: minutes Patient with gestational diabetes and polyhydramnios experiences a sudden spontaneous rupture of membranes (SROM) with clear fluid, followed by a cord prolapse. Prolapse resulting in a STAT cesarean section - End point is delivery of infant

6 Target group: Obstetricians, Midwives, Pediatricians Team Members for the Scenario: 1. Obstetrician 2. Midwife 3. Anesthesia Provider 4. Neonatal team 5. Primary RN 6. Secondary RN 7. Scrub Tech 8. Patient 9. Family member Potential Systems explored Maternal and fetal assessment process Activation of emergency response system PERINATAL SCENARIO 4 PAGE 1EARNING OBJECTIVES General Learning Objectives Communicate effectively with patient/family Communicate effectively with team using crisis resource management skills Demonstrate safety initiatives including medication safety practices Demonstrate safety initiatives including workplace safety practices Maintain infection control standards

7 Scenario Specific Objectives Demonstrate focused labor and delivery assessment Identify umbilical cord prolapse Relieve pressure of baby s head on the cord Prioritize care of patient with prolapsed umbilical cord Monitor the fetus Debriefing Overview Review learning objectives Demonstrate focused labor and delivery assessment and prioritize care Identify umbilical cord prolapse and demonstrate appropriate management Review teamwork skills Review communication skills including use of SBAR What went well? What might have been done differently/better? Share key assessments and interventions/events What was learned that can be taken back to the real workplace? PERINATAL SCENARIO 4 PAGE 2

8 Briefing (patient story): This 32-year-old G4 P3 presented at 37 weeks EGA. She was admitted to L&D 4 hours ago in early labor. Current Fetal Heart Rate (FHR) is 140 bpm (Category I). She has gestational diabetes, now diet controlled. At 34 weeks, it was noted fetal size was greater than dates. An ultrasound confirmed fetal growth and anatomy was within normal limits. Her amniotic fluid index (AFI) was 29,and a diagnosis of polyhydramnios was made. Currently, the patient is resting in bed in semi-fowler s position with uterine displacement to the left. She is having contractions every 2-4 minutes, lasting seconds. Her family is present. A cervical exam 10mins ago was 7 cm/90%/ -2 with bulging bag of waters (BBOW). No epidural is present. Additional information, Medical History Allergies: NKDA Medications: PNV OB History: G4 P3, Gestational Diabetes, Polyhydramnios diagnosed at 34 weeks. She had 3 prior vaginal deliveries without any complications. Ht 5 5 Wt 290 lbs EFW: 3.41 kg, 7lbs 6oz PSH negative

9 VS HR 90; RR 22; BP 128/78; T 37.2 (98.7); FHTs 140 (Category I) Abnormal 1 hr Glucola, 3 GTT-2 readings abnormal Hgb/Hct normal, Plt 150, WBC 10 GBS herpes, HIV, VDRL all negative Social History: Married with strong support system Prolapsed Umbilical Cord EQUIPMENT LIST: Urinary catheter IV supplies IV fluids Fetal heart rate monitor Bedpan Medications (OB and Anesthesia Meds) Pitocin Labor room OR Set up for cesarean section Hybrid simulation: standardized patient dressed in hospital gown and PROMPT simulator SimMan 3G: in OR with baby wrapped in simulated uterus for cesarean section

10 IV in right arm at 125 ml/hr Blue pads under the PROMPT birthing simulator - saturated with clear water OBSERVER CHECK LIST: Focused assessment Identify prolapsed umbilical cord Call for help Demonstrate maneuvers to relieve pressure on prolapsed cord Communicate effectively with patient/family Communicate effectively with team Monitor FHR Apply oxygen to mother Position patient left lateral Position patient on bedpan Position patient in trendelenberg Transfer to OR for STAT cesarean section Induction or anesthesia Assist with/perform cesarean section PERINATAL SCENARIO 4 PAGE 5 PERINATAL SCENARIO 4 PAGE 6

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12 Brief Review of Key Points: Prolapsed Cord Incidence: 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? Vaji Dharmesana, MD FACOG is an Ob Hospitalist with Kaiser San Jose, California. She is an adjunct clinical professor of OBGYN at Boston University School of medicine. She is co-chair of the SOGH Simulation Committee and had held that position for the past 2 years. She is also the simulation lead for Kaiser San Jose. Ngozi Wexler, MD MPH, FACOG is Director of OBGYN Hospitalist Program at Medstar Southern Maryland Hospital Center in Clinton, MD. She is also co-chair of the SOGH Simulation Committee and has held that position for the past 2 years. Reference: Umbilical Cord Prolapse, Melisssa Bush, MD, et al, Uptodate, Jan 29, Questions or feedback on Sim Corner? Contact us at: newsletter@societyofobgynhospitalists.com