The Impact of Hospitalists on Gynecologic Emergencies

Up to now, I have been commenting mainly on ob.gyn. hospitalists’ impact on labor and delivery, but our surveys show that the majority (64%) of ob.gyn. hospitalists also have responsibility for seeing gynecologic patients in the main emergency department as well as inpatient consultation.

Most gynecologic emergencies are as you would suspect: threatened miscarriage, ectopic pregnancy, pelvic inflammatory disease, and, to a lesser extent, torsion of benign tumors as well as the occasional malignancy, and the common vague abdominal pain syndromes. Ob.gyn. hospitalists provide the main emergency department with the type of service that they provide in labor and delivery (L&D) triage or the obstetric ED: immediate or at least rapid response, expert clinical care, and the ability to work with the team in the ED or with other team members such as surgeons in the case of major trauma involving either pregnancy or gynecologic organs. This rapid response results in increased patient satisfaction as well as a more efficient ED.

However, having an ob.gyn. hospitalist cover the ED comes at a cost, as it physically takes him or her away from covering potential emergencies in the L&D area. Some hospitals get around this problem by allowing the ob.gyn. hospitalist to only go to the ED when they’re unoccupied; or if they make a diagnosis requiring surgery, they will call the on-call gynecologic surgeon so that the ob.gyn. hospitalist is not in the operating room with a case just when they’re needed for a shoulder dystocia or prolapsed cord in L&D.

This compromise of allowing diagnosis but not surgical treatment is a good one because even though the main ED is frequently geographically separate from L&D, the ob.gyn. hospitalists can usually rapidly leave the main ED to respond, while they could not provide the same response if they were in the middle of a surgical case. Having a backup gynecologic surgeon on call also provides a mechanism for outpatient follow-up for a medically treated gynecologic emergency patient.

Well-run programs also have an obstetric physician on backup call for follow-up of unassigned outpatient obstetric patients who need to be seen after triage or obstetric ED visits. More importantly, these programs have a backup physician if the ob.gyn. hospitalist gets either too busy or too fatigued. However, our most recent ob.gyn. hospitalist.com employment survey shows that between 35% and 45% of programs do not have an adequate emergency backup system in place to cover the hospitalists (www.obgynhospitalist.com) [now obgynhospitalistconsulting.com].

Rapid and easily obtained gynecologic consultation also helps with improved patient care, diagnosis, treatment, and turnover of inpatient beds. With in-house ob.gyn. hospitalists, the days of internists, family practitioners, and traditional hospitalists having to wait until after office hours for a gynecologist to see an inpatient are over. Traditionally, that consultation would take place at 6 p.m. or 7 p.m., and then additional ordered diagnostic imaging might not take place until the next day, adding unnecessary delays in diagnosis and causing longer hospital stays than necessary.

Gynecologic responsibilities add to the body of knowledge that ob.gyn. hospitalists need to be skilled at, especially with diagnosis and medical treatment. However, requiring hospitalists to provide gynecologic coverage also emphasizes the potential challenge of how to maintain superb gynecologic surgical technique. This is difficult with low volumes of surgical cases. Once again, this problem can be eliminated if there’s a gynecologic surgeon to do the work in the operating room. This is also an area that is of particular interest to the Society of OB/GYN Hospitalists as they discuss and decide which skills and competencies hospitalists must possess and maintain.

Originally posted FEBRUARY 14, 2013 on ehospitalistnews.com

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