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Are you OK admitting this patient?

January 2011

Published in the January 2011 issue of Today’s Hospitalist

While he didn’t announce it at the time to his hospitalist colleagues, Eric McFarling, MD, allowed a pregnant patient on his roster this fall. He did so despite his group’s hard-and-fast rule against admitting any pregnant patient for medical issues.

The woman was particularly ill: diabetic, suffering from a rare blood disorder and frequent infections, early in her pregnancy and possibly miscarrying. In hindsight, it all worked out, but his decision to admit her “will probably come back to haunt me,” Dr. McFarling says, in terms of hospital and group politics.

“Absolutely no pregnant patients” is one of the few firm positions his group of 22 hospitalists ” who work at St. Cloud Hospital in St. Cloud, Minn., part of the CentraCare Health System “is sticking to, despite a number of “uncomfortable meetings” with the hospital’s OBs, who are pressing for more hospitalist help.

Of course, that line in the sand has been blurred many times with other specialties. “We used to say, ‘No dialysis patients,’ and we are admitting them,” Dr. McFarling points out. “We used to say, ‘No head bleeds,’ but that has gone by the wayside. As we have taken on duties for everybody else, our OB group has asked, ‘Why can’t we have you service our people too?’ ”

In response, the hospitalists have said that hospitalists trained in internal medicine have no business being the primary physician for a pregnant patient, no matter what the problem is or how early it may be in the pregnancy. Dr. McFarling, a co-leader of the group, mostly agrees, but he also thinks he made the right decision for the patient with cyclic neutropenia. By admitting her, he provided the fastest possible care, instead of waiting for obstetrics to admit her and then call him for a consultation.

The debate over whether hospitalists should admit pregnant patients is splitting some medical staffs and hospitalist groups, and not just in St. Cloud. Across the country, mission creep has meant that hospitalists are being asked to admit patients they may never have seen before, from hip fractures to cerebral hemorrhages. Pregnancy, in many hospitals, is the next frontier.

When confronted with these patients “usually from the emergency department in the middle of the night when in-house hospitalists are the easiest physicians to reach “hospitalist groups are reacting differently. Some are concluding that they can’t admit pregnant patients for any reason. Others are negotiating policies with obstetricians and administrators to admit some pregnant patients, but not all. But in other hospitals, like Dr. McFarling’s, compromise remains elusive, with both hospitalists and obstetricians standing pat “and feeling unfairly put upon.

Possible delays in care
While hospitalists are being asked to perform all kinds of duties that they didn’t learn during training, pregnancy is of a different magnitude. Continuing education, many say, isn’t enough. Not only do internal medicine residents learn no obstetrics, but the presence of OB residents and specialists at the academic hospitals where internists train means that most don’t even have accidental exposure to caring for pregnant patients with medical concerns.

In St. Cloud, Dr. McFarling says that the pressure on hospitalists to admit some pregnant patients has come not only from the OBs but also from the leaders of the multispecialty group that employs the hospitalists. For now, group leadership has backed the hospitalists’ ability to say no.

Because the hospitalists’ pay is based on productivity, he points out, it’s very rare that they turn down any new service line. Fortunately, Dr. McFarling adds, the dispute over who actually is the admitting physician may in many cases be simply a matter of semantics.

“Both the hospitalists and the OBs are going to see these patients and, hopefully, very quickly,” he says. “The work is getting done, but there are hurt feelings.”

But according to Maria J. Hoertz, DO, a hospitalist in Arizona, the distinction of who’s the attending can be very relevant.

OBs at home or in their office are going to be tempted to stay there when they know that the hospitalist is in-house, she points out. And if a pregnant patient who’s been admitted to the hospitalist service for an asthma exacerbation and placed on a general medical floor starts bleeding or having contractions in the middle of the night, “the nurses are going to call the admitting physician,” Dr. Hoertz says. “There will be a delay in care because the nurses are not OB nurses, the patient is not on an OB floor, and while the hospitalist will of course evaluate the patient, the patient needs an OB.”

Because she trained in family medicine, Dr. Hoertz adds that she’s frequently asked by both hospital administrators and OBs to admit their patients “requests that she turns down. “None of my partners who trained in internal medicine want to touch OB, so I can’t,” she says. “My partners can’t cover for me because they do not have the training.”

Financial pressures
From her perspective working over the last five years in hospitals from Mississippi and Maine to California and Arizona, Dr. Hoertz now believes that a big reason there’s growing pressure to admit pregnant patients in community hospitals has more to do with money than medical care.

“OBs are harder to recruit to the community than hospitalists, so the hospital tells a prospective OB, ‘We have a group of hospitalists who will do your admissions for you,’ ” she says. Hospitalists in these communities, she adds, feel they can’t say no, in part because that’s the ethos of hospital medicine.

Hospitalists may also go along “even if they don’t want to “because hospitals are subsidizing their salaries, says Dr. Hoertz. In addition, many hospitalists in small community hospitals come from foreign counties. “They do anything the hospital says,” Dr. Hoertz says, “or they lose their visa.”

Absent those political pressures, some hospitals say that hospitalists will only consult on OB patients ” never admit, no matter what the diagnosis.

That’s the policy in effect at York Hospital in York, Pa., says William A. “Tex” Landis, MD, director of WellSpan Hospitalists there. After it became clear that OBs and hospitalists might have different expectations in terms of admissions, hospital leadership a year and a half ago negotiated a policy whereby all pregnant patients are admitted by the OBs to labor-and-delivery floors staffed with OB nurses.

“When we look at the number of patients we are going to be asked to admit who are pregnant, it’s a pretty small number,” Dr. Landis says. “You spread out that experience ” or lack thereof “over 20 physicians and 10 midlevels, and you start to question whether that is in the patient’s best interest, just in terms of skills.”

He includes himself in that assessment. At one time, Dr. Landis continues, he had an interest in medical complications in pregnancy, “so I saw a fair number of those patients.” He has not, however, kept up that expertise. “Now, if I’m being asked to do that again on rare occasions, I don’t think that’s the best thing for the patient.”

Setting ground rules
There are, however, hospitalist groups that feel comfortable being more flexible. That’s the case at White River Medical Center in Batesville, Ark. Thomas Cummins, MD, director of hospital medicine, says that it tends to be young hospitalists, newly out of internal medicine training, who are most worried about admitting pregnant patients. Their concern is partly their own inexperience, but also the fear of being sued.

“My new guys always ask about that, but I maintain that if you have a consulting OB helping you, your liability is no higher if you are the admitting doctor vs. the consultant,” Dr. Cummins notes. Even if the hospitalist acts only as a consultant, “your name is going to be all over the paperwork” anyway, he reasons, and lawyers will sue everyone “primaries and consultants ” associated with an obstetrical case gone bad.

In his 200-bed hospital, the hospitalists occasionally admit pregnant women on a case-by-case basis, if their pregnancy is less than 23 weeks. That’s as long as the primary reason for the admission is not the pregnancy but another condition.

The hospitalists with Martha Jefferson Inpatient Services in Charlottesville, Va., go even further. Although “it always strikes fear in the group when you have to go down to see a pregnant patient because you never know what you are going to find, “says Paul Tesoriere, MD, the group director, “the more you treat pregnant patients, the easier it becomes.” His group of 11 hospitalists and four midlevels at Martha Jefferson Hospital regularly assumes the role of admitting physician for many patients who are less than 20 weeks into their pregnancy and have a primary medical diagnosis.

It’s a policy that he and the head of the obstetrics section negotiated two years ago after several awkward encounters where the ED was caught in the middle. The one exception to the new policy is when the pregnant patient’s main concern is abdominal pain.

“Our feeling was that if it’s less than 20 weeks, abdominal pain is either going to be something surgical or something related to the pregnancy,” Dr. Tesoriere says. “There would be no reason to get a hospitalist involved as a middleman between an OB and a surgeon to manage the case.”

Who covers in the ICU?
In Glens Fall, N.Y., that type of ED confrontation over a very sick pregnant woman a year ago led to eventual detente and compromise.

“I got a call from the ED saying that nobody is seeing a patient with extensive bilateral pneumonia who is 30 weeks pregnant and too unstable to transfer,” recalls Farhana Kamal, MD, clinical director of the hospitalist program at Glen Falls Hospital. The obstetrician on call and the hospitalist onsite were locked in a stalemate. Neither would agree to admit the patient, and both felt they were out of their league.

“I told my hospitalist to go see her and that we would figure out where the patient would go,” Dr. Kamal says. “The last thing I’d want is a patient sitting in the ER and nobody claiming to manage her.”

Afterward, Dr. Kamal and her OB equivalent sat down and worked out the following policy: The ED always calls the obstetrician first, but any patient who is pregnant less than 20 weeks and has a medical diagnosis can be admitted by the hospitalists “as long as the OBs do not wish to admit her to their service.

If the pregnancy is beyond 20 weeks, the patient will always be admitted to the obstetrics service, unless the patient needs to be in intensive care for a primary medical critical diagnosis. In the ICU, Dr. Kamal explains, the hospitalist becomes the attending of record the entire time the patient is in critical care, while an OB consultant evaluates the patient early in the ED and comanages in the ICU. In addition, an OB nurse is assigned to the ICU for continuous fetal monitoring.

Negotiating response time
The other key part of that negotiation, Dr. Kamal says, was a candid discussion about responsiveness when obstetricians are contacted.

“We talked through scenarios, and we decided that if hospitalists are going to admit, we have to be certain that the OB service would be very responsive for consults and medication management,” she explains. “It’s an overwhelming concern in community hospitals” that specialists are slow to leave their offices and come to the hospital to see other physicians’ patients.

“OBs can sometimes take an unacceptably long time to respond to a consult request,” Dr. Kamal says. “We can’t do that with pregnant patients. We said, ‘We need a promise from you that when I call and say I need you to come and see my patient now, that means now.’ ”

When Dr. McFarling in St. Cloud thinks of the pregnant patient he admitted this fall, he keeps coming back to how absurd it would have been to make an obstetrician come in instead: “It would have been absolutely silly for me to say, ‘No, I won’t admit her.’ It would have been a waste of the obstetrician’s time to do the admission.”

While that admission made sense, hospitalists have no national guidelines that they can consult to help steer admission decisions. And while some hospitalists think the solution might ultimately rest with the new and growing trend of “laborists” “OB hospitalists “Dr. McFarling isn’t so sure.

“That OB doc would still be uncomfortable admitting a patient with a medical issue,” he points out.

But Dr. Cummins in Arkansas thinks laborists could be a good way to go. “If more hospitals hire laborists just to deliver babies and not do the prenatal care and post-natal follow-up, then you might have an opportunity to integrate them into your hospitalist group and have a much tighter working arrangement,” he says. “You could set up protocols for who would take care of what, and it would be easier to get consults and help if there is an issue.”

Deborah Gesensway is a freelance health care writer based in Toronto who covers U.S. health care.