Attending Information

General FAQ's:

When to I need to be in house at each hospital?

Meriter:

Per policy OB providers are expected to be in the hospital for patients in active labor or 6 cm, whichever comes first; or when requested to be in-house by a trainee, nurse, or OB provider

Providers must also be inhouse by policy for the duration of all TOLAC labors

Providers are expected to be in house for the management of Magnesium for preeclampsia 

St Mary's:

There is no written policy at this time.  In general, attendings have been in house at 6 cm for multips and 8 cm for primes.  Again it is appropriate for an attending to be in-house whenever requested by trainee. 

Who do the residents see in the ED?

Meriter:

FMONs team sees patients >18 weeks with an OB related issue in the ED (or has these patients directed to triage for evaluation once medically stabilized); patients <18 weeks should be evaluated by UW OB and if an antepartum admission is needed they may contact the FMONs team (hyperemesis, pyelonephritis, etc).  GHC does not do antepartum admissions and is contracted with UW OB who are the appropriate ante providers.

If a patient needs a medical admission they should be admitted to the hospitalist service.  The FMONs service is not a consult team so does not consult on hospitalized patients, if the hospitalist service needs an OB consult this should be done by the OB or MFM teams. 

St Mary's:

At St Mary's residents do not evaluate patients in the ED, these consults go to the high risk resident on OB.  Patients <20 weeks are evaluated in the ED for all complaints except vaginal bleeding or abdominal pain if >14 weeks.  Patients >20 weeks come to Triage first. See policy for details 

The ED physician will contact the patients family medicine physician if further evaluation is needed.  You may get phone calls about these patients when on call or when on St Mary's attending.  

What patients do residents manage on antepartum at Meriter?

All DFMCH patients (residency and community) that do not require OB consultation and Wildwood patients at the discretion of the attending

All GHC antepartum admissions should be managed by OB per their contractual relationship

What if a patient doesn't want to work with residents?

Then the residents should not be expected to be involved in any way with their care including writing notes, orders, or coordinating with nursing staff. We strongly recommend that all community providers discuss the role of residents in obstetrical and newborn care during prenatal visits so that patients know what to expect in the hospital.  

Ex "I wanted to talk a little bit about what care looks like in the hospital.  I work with resident partners to provide care in the hospital.  Residents are doctors who have completed medical school and are doing additional training in the field of family medicine.  They are an essential part of the care team and a routine part of the care that I provide at the hospital.  Do you you have an questions about that?"

What patients are we credentialed to see at Meriter?

Triage patients of all gestational ages, labor management down to 34 weeks gestation, and newborns down to 36 weeks gestation (for details see the most recent credentialing forms here)

What is the situation with Mag  privileges?

As of March 2022.  Once your IV insulin/magnesium/anti-hypertensive privileges have been approved, you can co-manage patients with OB (OB consult is required). Due to the varied experience with insulin and magnesium among us, there are several ways this could look. As experience, trust, and confidence grows, you may find yourself shifting from one approach to the next. Key themes across each approach: clear communication with OB regarding experience/comfort and expectation of roles and responsibilities.

1. FM manages labor course with OB managing insulin/mag/ant-hypertensives. A good starting point to gain experience while ensuring patient continuity for you and our residents.

2. FM manages labor and insulin/mag/anti-hypertensives. In this scenario, the FM attending has prior experience with the IV medication being administered and, in discussion with the OB attending, is comfortable placing orders, conducting q4hr mag checks, and maintaining open communication with the OB consult.

3. I’m certain there will be addtl approaches we discover. This list is not exhaustive.

This past week, we had an example of each approach. The residents involved expressed their appreciation for the experience and have offered to speak at a future faculty meeting. The patients, too, valued having a familiar and trusted face throughout their hospitalization.

An FM and OB working group has drafted a Co-management Protocol. This protocol (with a May 2, 2022 roll out) is a suggested (not required) outline of resident and attending roles/responsibilities for IV Anti-hypertensives/Mag. The protocol is meant to serve as a tool to assist both FM and OB residents and faculty as we navigate new waters. We will develop a QR code/link to gather feedback about the process; we expect to evaluate the protocol in Nov/Dec 2022 and identify areas for improvement.

MEWs reminder

The Residency attending carries the MEWs pager on days when a senior resident isn't present (generally on Wednesdays but possibly on holidays as well). MEWS algorithm and MEWS powerpoint  

When should you expect a call from a resident?

• Whenever a treatment decision is being made

  • For example regarding workup for a patient in triage, whether a patient should be admitted/sent home, when a consult is needed, when a new medication is required, when a change in labor management is being made, etc

  • If the treatment decision has been previously discussed with an attending and a plan has been made, the resident should follow this plan for contacting the attending (for example, if you already decided another miso should be placed if no cervical change AND that the attending only needed to be notified if there was cervical change, you could place the miso without notifying the attending provided that the patient situation is otherwise appropriate.  Communication about when someone would like to be contacted for ongoing management is key)

• When there is a change in patient status

  • For example vital sign changes, rupture of membranes, significant cervical change (attendings should be alerted to facilitate being in house by 6 cm for multips and 8 cm for primips), etc

• If there are any questions from the resident or if nursing has concerns that cannot be addressed by the resident independently

• Or as otherwise discussed between the resident and the attending at the time of admission/arrival to triage