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May 2017 Newsletter
IN THE NEWS
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SIM Corner
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SOGH May 2017 Newsletter

The Society of OB/GYN Hospitalists is dedicated to improving outcomes for hospitalized women and supporting those who share this mission.

Comments or Questions about the Newsletter?  Contact us!

 

PRESIDENT'S MESSAGE

It is with great enthusiasm that I announce Vision 2020, SOGH’s first multi-year strategic plan.  The Board along with the Society’s Executive Director, Toni Capra, has established goals, priorities and benchmarks for our organization over the next three years.  The major focus will be on delineating core competencies which define expectations of practitioners who identify as OB/GYN Hospitalists. 

In this newsletter’s coding section is a timely article on changes that may impact practitioners via  Medicare payment methodology.  With such a significant percentage of prenatal care being provided in Federally Qualified Healthcare clinics and with a majority of deliveries being paid for by Medicaid, it is logical to anticipate future change in our practice and compensation.  Your feedback is important in helping to proactively shape the role of OB/GYN hospital care.

With summer approaching, concern about Zika virus infection in pregnancy is rising.  While we can help pregnant women through education about avoiding mosquito bites, reducing risk by avoiding unintended conception remains challenging.  One strategy for the most vulnerable population is post placental IUD placement.  Until a dedicated postpartum IUD inserter (one has been developed) becomes available, SOGH will continue a skill station at our ACM.  While formal training is recommended prior to incorporating this into clinical practice, this protocol (link) for insertion may be informative. For more about copper or hormonal IUD use, as well as other postpartum contraceptive options, please see the CDC Medical Eligibility Criteria Summary Chart. click here..

Hoping to see you at the ACOG Annual Meeting in San Diego.

Meredith

Meredith Morgan, M.D.
President, SOGH
e-mail

 


 

IN THE NEWS

Planning to Attend this year's ACM?

As part of SOGH's new strategy to make the event location part of the overall meeting experience, this year's ACM is slated for the international acclaimed city of New Orleans, rich in history, culture and cuisine, and home to the French Quarter, Mardi Gras and jazz. We encourage all attendees to add a day or two at the front or back end of their travel plans to enjoy some of the truly amazing aspects of the Bayou City! The Roosevelt Hotel has promised to honor conference room rates one night prior and one night after the conference!

10 Fun Facts you need to know about the Bayou City!
  1. The official elevation of New Orleans is two feet below sea level.
  2. There are more than 40 museums in New Orleans, including the famous National WWII Museum, New Orleans Museum of Art and The Sydney and Walda Besthoff Sculpture Garden.
  3. The term "Dixieland" arises from the state of currency that was used in New Orleans, the "dix" when states were using their own currencies.
  4. Nearby New Orleans is the Causeway. It is the longest contiguous bridge in the world, stretching 24 miles.
  5. Louisiana is the only state that does not have counties. Instead, Louisiana is broken into subdivisions called parishes.
  6. The Louisiana Purchase, which doubled the size of the United States, was made for the primary purpose of securing the city of New Orleans and its port.
  7. New Orleans is where the first opera was performed in the U.S., back in 1796.
  8. Alligator and turtle are readily available delicacies.
  9. There are no open container laws in New Orleans. Bars can stay open all night and frequently offer "to go" cups. 
  10. Prior to Katrina, the St. Charles Avenue Streetcar was the oldest continually operating streetcar line in the world.
Learn more about what's in store at ACM 2017!

  


 

 “CODE THIS!”

New Code for Specialist Self Designation

by Renée Allen, MD, MHSc., FACOG and Meredith Morgan, MD

April 14, 2017 

 

SOGH strives to keep our members abreast of news that impacts our practice as hospitalists; news that you are unlikely to gain through other media. With that in mind, in lieu of a case of the month, “Code This”, has decided to instead share with you new developments within the coding world that may affect our field.

As of April 3, 2017, hospitalists can use their own dedicated specialty code. The dedicated code known as C6, allows hospitalists to differentiate themselves from those of outpatient practitioners including internists and family physicians.

According to Hospital Medicine, the C6 code may improve the accuracy of tracking hospitalists’ benchmarks such as performance and cost. Current measures fail to consider the unique complexities of the hospitalists’ patients as compared to an outpatient practice. Hospitalists serve patients from all demographics, often with severe illnesses, little available history and limited pre-admission care. Benchmarks used for an outpatient practice simply will not apply for the hospitalist. For this reason, hospitalists may be inappropriately penalized under meaningful use requirements. For instance, when a hospitalist designates a patient encounter as observation, this may be erroneously evaluated as part of an outpatient encounter. This leads to flawed evaluation of quality and cost metrics, which in turn misrepresents the performance and costs associated with being a hospitalist. Having this new code may help shape the Medicare Access CHIP Reauthorization Act (MACRA) and future healthcare policies.

Use of the new code by hospitalists is voluntary and its use should not affect billing. The potential information provided by those choosing to employ this new code will provide more accurate metrics for their performance. Benchmarks established by the self-designated specialty population of providers using the code should accordingly reflect the processes and outcomes of the data from those providers.

Currently, physicians self-designate their Medicare physician specialty at the time of enrollment in the Medicare program. Per CMS Manual System Pub 100-04 Medicare Claims Processing, Number 9716.04.1, “Contractors shall make all necessary changes to recognize and use the new physician specialty code C6 as a valid primary specialty code or a secondary specialty code for Hospitalist.”

While there are a few OB/Gyn hospitalists who limit their practice to OB/Gyn surgery, the number who restrict their practice to internal medicine inpatient care is unknown. SOGH welcomes feedback about any OB/Gyn hospitalists who do limit their practice to inpatient cognitive services (gynecologic or otherwise), internal medicine-type cases, and/or to Medicare beneficiaries such as pregnant patients on dialysis.

At the time of this writing, the self-designation status seems to primarily focus on internal medicine (CMS specialty code 11 and hospitalist C6). There are 59 physician specialty codes including 16 which designate obstetrics and gynecology.  Currently the Center for Medicare and Medicaid Services (CMS) states “MLN article: A provider education article related to this instruction is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ .“

The option for OB/Gyn hospitalist to self-designate primary and secondary specialties is available. However, it may be prudent to await analysis of the aforementioned MLN article to determine the use of C6 as primary and 16 as secondary as opposed to 16 as primary and C6 as secondary. Until then, it seems logical that OB/Gyn hospitalists medical claims will be in the 16 specialty designation. Currently, the impact of changing from one’s established designation is unclear.

The C6 designation is strictly for usage with CMS (Medicare/Medicaid/tri-care) services databases.  When enrolling into the Medicare/Medicaid program, it is up to the provider or practice to self-designate what specialty to which they most closely align themselves. Providers may change their specialty designation through the Medicare enrollment application (Form CMS-8551) or through CMS’ online portal (Provider Enrollment, Chain, and Ownership System, or PECOS). As this does affect how data is tracked, the self-designation may impact flagging of “over/under usage” in additional data and claims that are pulled through the CMS system by providers.  Private third-party payers are not obliged to follow those guidelines.

Your thoughts on self-designation as a hospitalist are welcome. Please complete and submit this form. Feedback and analysis will be published in a future newsletter.

Dr. Meredith Morgan, serves as President of  SOGH

Dr. Renée Allen is the SOGH Liaison to the ACOG Committee on Health Economics and Coding, Chair of the SOGH Coding Committee and Co-Chair of the SOGH Development Committee.  She currently works as an OB/GYN Hospitalist with Mednax/Obstetrix at Eastside Medical Center in Snellville, Georgia.

 


Sim Corner

Magnesium Sulfate Toxicity

Presented by Carrie Johnson, MD

February 22, 2017

 

Case Summary:

31 y/o G1 P0 @37 weeks gestation who presented with complaints of severe headache and visual changes. Shortly after arrival in triage, the patient has a witnessed seizure. Per usual hospital protocol, 4gm IV magnesium sulfate loading dose followed by 2gm/hour IV maintenance dose are administered. Within the first hour after admission, the patient has another seizure and receives an additional 2gm IV bolus of magnesium sulfate.

 

 Length:  10-15 minutes

Target group:  Obstetricians, Midwives, Nurses

Possible Team Members for Scenario:

  • Obstetrician
  • Midwife or Obstetrician #2
  • Anesthesia
  • Primary RN
  • Secondary RN
  • Patient
  • Family Member
General Learning Objectives:
  • Communicate effectively with patient/family.
  • Communicate effectively with team using crisis resource management skills.
Scenario Specific Goals:
  • Identify & Declare Emergency
    • Respiratory Distress
    • Magnesium Toxicity
  • Obtain staff and tools to optimize outcome.
  • Implement TeamSTEPPS principles, focusing on leadership, SBAR, situation monitoring and shared mental model. TeamSTEPPSportal.org
  • Inform Patient and family of treatment plan and likely outcome
Patient Case Summary:

Mrs. Maggie Magenta is a 31 y/o G1 admitted with the diagnosis of eclampsia. After 24 hours of labor she delivered vaginally without complications.

Additional Information:
  • Past Medical/Surgical History:  Negative
  • Past Ob History:  s/p SVD one hour ago
  • Prenatal Care:  uncomplicated
  • Allergies:  NKDA
  • Medications:
    • Magnesium Sulfate IV @ 2gm/hour
    • Oxytocin IV 20mu/500 cc @ 80 cc/hour
    • Labetalol for BP control
  • Vital Signs
    • afebrile, RR <10/minute, BP 100/50, pulse 60

Set Up

  • Patient holding newborn in labor bed with IV in place, magnesium sulfate infusion and postpartum oxytocin running. Family member is at bedside.

 Equipment:

  • High or low fidelity mannequin
  • Non-Rebreather O2 Mask
  • Crash cart
  • “Simulated” Medications, (Magnesium Sulfate, Calcium Gluconate)
  • Stethoscope, reflex hammer
  • Vital sign monitors,

(SimMonitor app, $12.99)

Sequence of Events:

1.  Family calls out that patient is having trouble breathing. (Patient and family member are in the room)

2.  RN # 1

  • Responds to family’s call for help
  • Assesses patient
  • Calls for help while remaining with patient
3.  OB #1
  • Receives SBAR
  • Recognizes and announces emergency
  • Requests additional staff
  • Activates “OB Rapid Response” team
4.  RN # 2 Arrives with OB #2
  • Receive SBAR
  • Prepare for CPR
  • Bring crash cart in room
  • Ensure magnesium sulfate is turned off
  • Prepare/administer antidote, may need to repeat
5.  Anesthesia
  • Receive SBAR
  • Assesses patient
  • Initiate/Assist with CPR if necessary

Debrief:    

  • Review sequence of events.
  • Review learning objectives.
  • Review communication and teamwork skills.
  • How did you feel? What went well?
  • What would you change or do differently?
  • What is your take home message?
 Teaching Points:
  • Once magnesium toxicity is noted or suspected magnesium sulfate infusion should be discontinued and emergency procedures initiated, i.e “OB RAPID Response”.
  • A patient may become toxic even in the therapeutic range. Physical exam is the best indicator of the effects of magnesium sulfate on a patient.
  • All staff should know the location of crash carts and emergency procedures.

  • Calcium Gluconate should be included in EMR order sets for all patients on magnesium sulfate.

 

Magnesium Toxicity Review:

Magnesium sulfate is considered a high alert medication, requiring pharmacy premixing and independent verification of the dose and rate prior to initiation. Most institutions have a nursing policy on administration to cover the specifics. But in general:
  • Ensure compatibility with other IV fluids and medications.
  • Administer as a premixed IV piggy back.
During administration the patient’s vital signs, DTRs and urine output should be monitored on a routine schedule. (This will vary by institution).
 
Signs of magnesium sulfate toxicity:
 
*      Absent DTRs                    * RR < 12        * SOB
*      Respiratory Arrest            * Chest Pain    * Coma
*      Significant drop in BP       *Urine Output < 30cc/hour
*      Signs of Fetal Distress

 

Magnesium Levels 

 

mEq/L

mmol/L

Therapeutic Range

5-7

2.5-3.5

Loss of Deep Tendon Reflexes

10

> 5

Respiratory Failure

12-15

> 7.5

Cardiac Failure

25

> 12

 

Calcium gluconate is the antidote for magnesium sulfate toxicity. The standard is to administer 1 ampule IV over 10 minutes. A repeat dose may be given if needed.

1 ampule of Calcium Gluconate =

  •        10mL of 10% solution
  •         1 gram of Calcium

 Patient needs to be on continuous ECG during administration.

 

Carrie Lynn Johnson, MD is an OBGYN Hospitalist who currently practices in Cleveland, OH area.

 


 


CLINICAL PEARL

"A CASE WITH A TWIST"

by Tanner Colegrove, MD, FACOG

March 24, 2017

 

A 26 year old G2P1 at 24 0/7 weeks gestation presented to the emergency department with acute onset severe RLQ pain. 

Prenatal care began at 8 wks and was complicated by:

  1. Markedly elevated AFP and severe IUGR at 20 wks necessitating transfer of care to MFM
  2. Bicornuate uterus (prior pregnancy carried in left horn; current pregnancy in right horn)
  3. History of C-section at term for breech presentation
  4. Episode of mild right lower quadrant pain two weeks prior; evaluated in triage, diagnosed as round ligament pain, resolved spontaneously

Patient reported the onset of severe, “10 out of 10” RLQ abdominal pain which woke her from sleep a few hours prior to arrival. She denied vaginal bleeding, leaking of fluid, or fever. During transport from ED to L&D via wheelchair, she vomited and had an episode of syncope.  On arrival to L&D, she was awake and alert, diaphoretic, and in severe pain.  Her blood pressure, pulse and O2 saturation were normal.  Her abdomen was exquisitely tender diffusely with guarding.  A bedside US showed fetus in the uterus with heart rate 140 bpm.  Speculum exam was unremarkable, no blood or pooling noted and os closed. An IV was placed and fluids and Dilaudid were administered.  A stat CBC revealed a WBC of 16 cells/microL and Hgb at 13 g/dL. Appendicitis was high on the list of differential diagnoses given the history of RLQ pain two weeks prior and no obvious OB etiology. MFM and Gen Surgery were consulted.  MFM recommended evaluation via a CT scan but after discussion with the radiologist and surgeon an abdominal ultrasound and a non-contrast MRI were performed instead. Sonography revealed an ill-defined mass posterior to the uterus; the appendix was not visualized. MRI revealed a small amount of free fluid, an enlarged right uterine horn containing 24 wk fetus, normal appearing small left horn, and ill-defined mass posterior to the uterus--possibly bowel vs. adnexa.  Her appendix was normal.

The patient was transported back to L&D where her vital signs, the fetal heart tones, and a repeat H/H remained stable.  Her abdominal exam did not improve. Despite treatment with narcotics she was immobilized by her pain and remained diaphoretic with a rigid abdomen.  With no clear etiology but a persistently surgical abdominal exam, an emergent exploratory laparotomy was recommended.  In preparation for possible delivery of the fetus, neonatologist and pediatric team were consulted.  The patient and her family were counseled regarding outcomes in the setting of extreme prematurity and severe IUGR.  The decision to resuscitate was deferred to the neonatal team who would base that decision on the baby’s birth size and weight.  Two units PRBCs were cross matched and available.  The primary surgical team --the OB hospitalist and an OB/GYN generalist—was assembled.  The neonatal team prepared a main OR room for delivery, and a general surgeon was available on standby. 

Intraoperatively, the patient was found to have 1.5 L hemoperitoneum, torsion and rupture of an ischemic and necrotic enlarged right uterine horn (containing the pregnancy) and adjacent adnexa. The right adnexa was adherent to the posterior wall of the uterus explaining the findings on US and MRI.  A 3 cm rent in the inferior-lateral aspect of the right uterine horn near the torsion site was noted. The left uterine horn and appendix were both normal.  A hysterotomy was made in the fundus of the right horn and a live male fetus was delivered weighing 338 gm with heart rate 70 and APGAR scores of 1 and 1 respectively. The decision to not attempt resuscitation was straightforward.  The neonate expired at 40 minutes of life. The hemoperitoneum was evacuated and the ischemic right horn was amputated and the base was oversewn.  The left horn and adnexa were intact.  An appendectomy was performed by the general surgeon. Estimated blood loss was 1.5 L and she was transfused 2 units PRBCs. The patient tolerated the procedure well.

Clinical Pearl:  “Treat the patient, not the numbers.”

The patient’s vital signs, labs, and imaging studies were unremarkable throughout the initial evaluation but were not consistent with her presentation of severe, unrelenting pain and distress.  With an abundance of sophisticated lab and imaging tests at our disposal, it is often easy to place more merit in ancillary tests than in our physical exam findings and even more tempting to be reassured by normal results.  In this case however, the astute team avoided these pitfalls, treated the patient and not the numbers, and maintained a high index of suspicion. In so doing, they coordinated a complex, multidisciplinary care plan in a step-wise, timely manner, efficiently recruited all of the appropriate personnel, and avoided a delay in diagnosis that could have had a catastrophic result for the patient.

 

Tanner Colegrove, MD is medical director of an OB hospitalist program in Illinois.  She is currently on the Board of Directors for SOGH and serves as the organization’s president elect.

 


 

SOGH Presents Trends of Our Trade at ACOG Annual Meeting. 

 We hope to see you in San Diego May 6th - 9th at the ACOG Annual Clinical and Scientific Meeting!

As part of the meeting, three SOGH Board members will provide an opening day presentation titled Trends of Our Trade which will feature three key components:

  • Cate Stika, MD:  Society of Ob/Gyn Hospitalists Survey Results
  • Brigid McCue MD:  The OB ED:  Safe, Efficient and Profitable!
  • Tanner Colegrove, MD:  Core Competencies for the Ob/Gyn

Join us on May 6th from 1:00 - 4:00 pm, Room 33C in the San Diego Convention Center for what is certain to be an informative and engaging presentation!