The Doctor’s Advocate | First Quarter 2013
An Ounce of Prevention
Changing Times, Changing Practices
In this article, Dr. Dunnavant describes a hospitalist model designed to enhance patient safety, reduce malpractice risk, and improve physician quality of life.
—Robin Diamond, JD, RN; AHA Fellow–Patient Safety Leadership; Chief Patient Safety Officer, Department of Patient Safety
In October 2008, OB Hospitalists, Inc. (OHI) started the first OB hospitalist program in central Virginia at Henrico Doctors’ Hospital (HDH). The program—three years in the making—is a product of many doctors’ dining room conversations, research on sleep data, malpractice risk reviews, and negotiations with Hospital Corporation of America (HCA).
The concept, which is in keeping with the principles of HCA’s Perinatal Safety Initiative, was a huge cultural shift for the community. OHI’s OB hospitalist program, unique in the hospitalist world, is designed for a private practice community.
The OB hospitalists would be in labor and delivery from 8:00 PM to 8:00 AM daily to cover all obstetric and gynecologic calls. It was presumed that this is the time period when the greatest risk for patient injury could occur—when physicians are generally off-site, and there is a possibility of impaired judgment from sleep deprivation. The program structure is based on three tenets: enhancing patient safety, reducing malpractice risk, and improving physician quality of life.
One review stated that babies born at night were 12 percent more likely to die.1 Another study reported that babies born between 9:00 PM and 7:00 AM were twice as likely to die in the first week of life. Doctor fatigue was referenced as one of the causes.2, 3, 4
The standard of care in obstetrics cites 30 minutes as the time in which a delivery must be accomplished after the onset of an emergency. Physicians who are off site when covering calls risk delaying this window when emergencies arise. OHI believed that patient safety would be positively affected by having a well-rested OB hospitalist on site.
Besides the identified nighttime risk, evidence shows that after 16 hours of being continuously awake, a person begins to suffer from decreased mental acuity. This data helped persuade doctors that the way we had always practiced actually increased risk that could result in a bad outcome.5 Ob/gyns have the longest workweek of any specialty. Quantifying the demands of the OB call schedule further convinced physicians that having relief at night had value to both decrease risk and improve quality of life.6
Engaging physician support for the endeavor was perhaps the biggest hurdle. The physician-patient relationship is an imperative component of a successful ob/gyn practice. As doctors began to consider the program, they made it clear that they wanted night coverage only so they could care for their patients during the day. Based on the sleep data, we wanted our OB hospitalists working no longer than 12 contiguous hours. The mutual desire for 12-hour shifts was helpful in designing the program and engaging physician support. After we proved its value to doctors, we proposed the program to HDH. HDH was willing to take a chance on the program’s cost for the resulting benefits of patient safety, reduced risk, and doctor satisfaction.
When OHI began coverage at HDH, four board certified ob/gyns were employed, each having at least five years of practice experience. Additionally, there is one doctor in-house and one readily available on backup for every shift. On weekends, OHI covers 12-hour shifts from 8:00 PM Friday until 8:00 AM Monday.
The 12-hour coverage system resulted in continuity challenges. Because the OB hospitalist starts three hours after the offices close, there were forgotten sign-outs, leaving the OB hospitalist to find the doctor or muddle through with the information on the chart. To facilitate sign-out, there is a 24-hour call line where doctors can leave messages if they can’t sign out in person. In the morning, the OB hospitalist signs out reports of laboring or delivered patients, consults, surgery, admissions, or ER visits.
At times, some of the private doctors continued to oversee their patients’ care even after signing out. They would call to check on their patients and to speak with the patient’s nurse, making suggestions or giving orders. The OB hospitalist would be unaware of these interventions. It became an area of conflict and risk. This issue was resolved by getting everyone together and making a commitment to have only physician-to-physician conversations.
OHI had to find ways to accommodate the natural variations between the clinical management styles of the private doctors and the OB hospitalists. Working together required surrendering some autonomy on both sides.
To clarify expectations and clearly communicate practice standards, OHI published a handbook of best practices that the OB hospitalists would follow. These standards, consistent with safety initiatives the OB department had already developed, were reviewed and vetted by the HDH perinatologists. Creating consistency in practice patterns, expectations, and communication eventually facilitated a cultural shift, and everyone adapted well.
Patient satisfaction was a concern for many doctors because they believed their patients would object to receiving care from unfamiliar doctors. In fact, patients were quick to recognize the safety improvement and to embrace the program with a high level of satisfaction. Patients were already aware that a practice partner they might not know could deliver their baby. Shifting to an unfamiliar but well-rested doctor who could review all labor data was an easier transition than expected. Additionally, the OB hospitalists participate in hospital antepartum classes to meet as many patients as possible.
Although HDH had a very low historical incidence of malpractice claims, by the third year of the program, the rate had fallen by half. It’s hard to say what part of that drop is related to OHI; there have been ongoing safety initiatives to reduce risk. However, there is a long list of amazing response times during emergent situations. Several patients who required emergent cesareans for placental abruption, cord prolapse, fetal distress, and uterine rupture had delivery of the infant completed within six to 10 minutes of arrival to the unit or after the onset of the concerning fetal heart rate tracing. Having well-rested, in-house board certified ob/gyns ensured the highest possible standard of care.
Patient safety has always been the preeminent goal of the program. OHI covers for emergencies—regardless of whether the patient’s physician participates in the program—thereby reducing risk of remote care for all doctors and patients. In fact, many of the emergent interventions have been for patients of nonparticipating physicians who were at home or en route to the hospital during the emergency.
This OB hospitalist program has been cited by several doctors and a large practice as an important reason they have relocated to our hospital from a competitor. While deliveries nationwide and in our community are down, they are up at HDH. Participating doctors frequently remark, “I don’t know what I would do if the OB hospitalists weren’t here.”
When the program was started, OHI identified three clients who needed to be served in order to ensure success—patients, doctors, and the hospital. We identified the obstacles to patient safety that occur in traditional obstetric practices and developed a program to correct for remote care and sleep deprivation.
Outcomes at least partially attributable to the program include exceeding the standard of care based on time to delivery in emergency situations, decreasing malpractice cases, achieving excellent patient satisfaction, increasing delivery volume, and attaining excellent physician satisfaction and increased participation in the program.