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Development of the WHNP Postpartum Hospitalist Role: Perspectives From Philadelphia

Author(s): By Jamille Nagtalon-Ramos, EdD, MSN, WHNP-BC, IBCLC, FAANP; Kara Reymann, MSN, WHNP-BC; and Annelies Wood, MSN, RNC, WHNP-BC

The women’s health nurse practitioner (WHNP) role continues to advance and proliferate to meet the national demand for maternal health services. Postpartum WHNP hospitalists are now integral members of inpatient teams in hospitals across the United States, and in Philadelphia, the role of this subspecialty has continued to develop in championing the optimization of postpartum health and improving maternal health outcomes. This article’s examination of the postpartum WHNP hospitalist role may serve as an exemplar for the development of similar roles in the US.

The nurse practitioner (NP) role has evolved tremendously since the role’s creation in 1965 by Drs. Loretta Ford and Henry Silver.1 Ford and Silver’s primary aims were to expand the nursing role to meet national demand for primary care providers and increase patient care access, objectives which remain salient in today’s healthcare environment.2 One example of continual NP role expansion is the advancement and proliferation of the women’s health nurse practitioner (WHNP) role to meet national demands for maternal health services. According to the National Certification Corporation, the certifying body for the WHNP population focus, there are currently 12,356 certified WHNPs in the United States.3 WHNPs provide primary care for women from puberty on with an emphasis on common and complex gynecologic, sexual, reproductive, and menopausal care; both uncomplicated and high-risk antepartum and postpartum care; and sexual and reproductive healthcare for men. This care is provided in inpatient, outpatient, community, and other settings.4,5

Although the majority of WHNPs work in an outpatient primary care setting, in the 2018 NPWH WHNP workforce survey, 16% of 2,137 respondents reporting they provide direct patient care, indicated managing the care of hospitalized patients as at least part of their practice.4 The majority of this group provided antepartum, postpartum, and gynecologic care. If a healthcare provider focuses specifically on managing care in a hospital setting, they may be referred to as a hospitalist.6 A major contributing factor to the birth and rise of advanced practice providers (APPs) in hospitalist roles was the implementation of rules by the Accreditation Council for Graduate Medical Education (ACGME) in 2003, including one about residents not working more than 80 hours per week or 24 consecutive hours on duty.7,8 To accommodate the growing healthcare needs of patients within these resident work–hour restrictions, support resident teaching, and contribute to continuity of care through a team-based approach, health systems across the US increased their recruitment and use of NPs, physician assistants, and other APPs in a hospitalist role.9

In Philadelphia, the 6th most populated US city with a population of almost 1.6 million, the workload problem is compounded by the dwindling number of hospitals providing obstetric care to only six maternity units.10,11 Between 1997 and 2012, 13 of 19 obstetric units in Philadelphia closed down, which resulted in funneling patients to the remaining hospitals that continue to provide obstetric care.11 This shifting of patients to remaining hospitals has resulted in increased patient volume and need for more women’s health providers at Penn Medicine, the oldest university-owned teaching hospital in the country. The Hospital of the University of Pennsylvania (HUP), an entity of Penn Medicine, was one of the first hospitals to adopt the APP hospitalist role into their obstetrics and gynecology department, followed by Pennsylvania Hospital, another entity of Penn Medicine, 6 years later. This article examines the role of the postpartum WHNP hospitalist by highlighting the contributions of inpatient WHNPs in Philadelphia.

Maternal mortality

A nation’s healthcare quality can be gauged by the population’s maternal mortality.12 The World Health Organization defines maternal mortality as: “The annual number of female deaths from any cause related to or aggravated by pregnancy or its management…during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy.”12 Late maternal mortality is defined as maternal deaths between 42 days and less than 1 year postpartum.12 Despite having the largest healthcare spending among the world’s high-income nations, the US distressingly leads in maternal mortality rates.13 Approximately 700 US women die each year due to pregnancy-related conditions.14 Although much focus is on the period of pregnancy and parturition, the most dangerous period of time in a woman’s life comes after birth. Alarmingly, more than half of these maternal deaths happen during the postpartum period.14 WHNP postpartum hospitalists play a crucial role in improving maternal health by optimizing postpartum care.

WHNP postpartum hospitalist role at Penn Medicine: Example of role development

More than 4,000 infants are born at the HUP each year.15 To meet staffing demands to provide safe, high-quality care for an ever-increasing patient load on obstetrics and gynecology (ob/gyn) residents, the first two WHNP hospitalist roles were created in 2003 within the ob/gyn department at HUP. These WHNP hospitalists were integrated into the obstetrics (ie, high-risk antepartum and postpartum) and benign gynecology teams, respectively. The WHNP hospitalists were the first of two dozen APP hospitalists at the HUP, where there was a growing demand for inpatient practitioners across all specialties.

In 2008, Pennsylvania Hospital (HUP’s sister hospital across the city) shifted from a single-provider obstetric care model to a laborist-based care model. The purpose of this new model was to streamline clinical responsibilities while decreasing error and improve provider satisfaction to accommodate growing patient volume.16 Following successful implementation of the laborist model, the workload of caring for patients on the postpartum floor was given to first-year residents. The responsibilities of daily postpartum rounding, providing ongoing inpatient medical care, and discharge planning provided first-year residents fewer opportunities to manage patient care in the labor and delivery unit. Moreover, the residents were not able to maximize their clinical training by attending births and performing surgeries, such as Cesarean section and bilateral salpingo oophorectomy. In 2009, the ob/gyn department at Pennsylvania Hospital responded to this need by hiring a WHNP to provide care to postpartum patients. This postpartum WHNP hospitalist collaborates with the resident team and attending physicians to provide comprehensive postpartum care on a continuum, from arrival to the postpartum unit until discharge from the hospital.

Benefits for patients

Optimizing postpartum care

Postpartum WHNP hospitalists play an important role in optimizing patient care and providing patient education prior to discharge from the hospital. They prioritize not only the patient’s physical needs but also address their psychosocial wellbeing by screening and providing necessary support for postpartum mood disorders, substance misuse, and intimate partner violence. They have a critical responsibility in setting the stage for the long-term health and wellbeing of their postpartum patients. The postpartum hospitalist collaborates with patients and their outpatient providers to bridge the gap between the hospital stay and their first postpartum outpatient visit. The American College of Obstetricians and Gynecologists recommends postpartum women have contact with their obstetrics provider within the first 3 weeks postpartum, with a comprehensive exam no later than 12 weeks postpartum.17 Obstetric complications that arise both during and outside of pregnancy require timely outpatient follow-up. The postpartum WHNP hospitalist has the unique perspective of identifying those at higher risk of postpartum complications and facilitating initiatives to decrease complications once patients leave the hospital. The following subsections outline initiatives at Penn Medicine, at which WHNP postpartum hospitalists play a key role in providing tailored support to meet individual patient’s needs.

Detecting urgent postpartum conditions and complications

Postpartum WHNP hospitalists play an essential role in early detection of postpartum complications in the immediate days after childbirth. Most commonly, these complications include hemorrhage, hypertensive disorder, and infections.18 As healthcare systems work to decrease maternal morbidity and mortality in acute care settings, standardizing care and improving quality and safety has led to the development of clinical emergency systems such as an obstetrics RTT [Rapid Response Team] and Team STEPPS [Team Strategies & Tools to Enhance Performance and Patient Safety]. These emergency systems enhance communication skills and teamwork to build a culture of safety between the RN team and APPs. This leads to a timely response by the WHNP, who is generally the first to be called to an emergency because of their availability and proximity to the postpartum unit, to assess, triage, and treat maternal clinical conditions. Through risk factor identification, monitoring of vital signs, interpretation of laboratory and diagnostic tests, and physical examination, the WHNP identifies early changes in maternal conditions that may require higher levels of care when clinically appropriate. The WHNP develops a plan of care based on assessment findings, works collaboratively with the healthcare team to manage urgent postpartum conditions and complications, and continuously evaluates outcomes of the ongoing plan of care, while facilitating transition to outpatient postpartum and continuing well-person care.19

Hypertensive disorder of pregnancy identification

Hypertensive disorder of pregnancy is a globally leading cause of maternal and perinatal death.20 It is common for peak blood pressure to occur 3 to 6 days following delivery.21 At this stage, the patient may already be home with blood pressures not being monitored closely and routinely, unless the patient returns for a follow-up visit in the outpatient facility. Returning to an in-person follow-up visit in the immediate postpartum period, however, may be challenging for many women. These postpartum patients may be worried about bringing their newborns to a medical facility (particularly following onset of the Covid-19 pandemic), finding babysitters for older children, or navigating a lack of transportation. Through the Heart Safe Motherhood (HSM) program—a text-based blood pressure monitoring program developed by physicians at Penn Medicine—patients can self-monitor and track their blood pressures at home and share their results using smartphone technology.22 The WHNP postpartum hospitalist plays a vital role in identifying women who may be at risk of developing unsafe blood pressures levels at home; providing education about the disease, management, monitoring, and follow-up; and completing steps of enrollment into the HSM program. Programs like HSM help to eliminate barriers to care while decreasing maternal morbidity and mortality related to hypertensive disorder of pregnancy.

Breastfeeding support

Healthcare providers play an important role in educating women during pregnancy about the benefits of breastfeeding for the mother and their newborns. In response to declining breastfeeding rates, which were attributed to a lack of support by healthcare providers, the Baby-Friendly Hospital Initiative (BFHI) was established to promote and support breastfeeding in both outpatient and inpatient settings.23 To obtain a BFHI designation the facility must accomplish the Ten Steps for Successful Breastfeeding, the foundation of BFHI, which includes training “all healthcare staff in the skills necessary to implement the required policies and procedures.”24 With training and certification (eg, certified lactation counselor and international board-certified lactation consultant), the postpartum WHNP hospitalist is able to lead in the initiative by taking a hands-on approach to breastfeeding support at the bedside. Teaching proper positioning to assist with latching, identifying concerns with pain, discussing benefits of breastfeeding and skin to skin contact, along with educating mothers about the physiology of breastmilk, can promote strong breastfeeding relationships between mother and infant immediately after birth. The postpartum WHNP hospitalist can identify mothers who need higher levels of lactation support, which includes consulting lactation specialists and bridging them over to community resources, such as lactation counselors who can provide support at home.

Contraceptive counseling

WHNPs play an essential role in providing postpartum contraceptive counseling and facilitating access in both inpatient and outpatient settings. Ideally, women should be counseled on family planning options during prenatal care instead of the immediate postpartum period, wherein the patient is busy tending to their own recovery and their infant’s immediate needs. By learning about contraceptive options during pregnancy, patients will have more time to ask questions, ponder their decisions, and discuss with their partners if they wish. In the immediate postpartum period, the WHNP hospitalist has the opportunity to discuss family planning and reassess and address the patient’s contraceptive needs. The timing of initiation of postpartum contraception depends on the method the patient and provider select through a shared decision-making process. If a patient desires methods such as bilateral tubal ligation or the intrauterine device, they may have the option to plan for and obtain these methods at the time of delivery.

The progestin implant is another option for patients prior to discharge from the hospital. Placement of the implant depends on institutional policies, accessibility of the method through the hospital pharmacy, and the availability of a provider trained in the procedure to insert the method. WHNP hospitalists at Penn Medicine are able to offer this procedure for patients who desire a progestin-only long-acting reversible contraceptive (LARC). LARCs play an important role in contraceptive management during the postpartum period by preventing short interpregnancy intervals. These intervals may lead to both maternal and newborn complications, including increased risk of preterm birth, low birth weight, and preeclampsia.25 At Penn Medicine, the WHNP hospitalist can also send a prescription for the chosen contraceptive method to the hospital’s outpatient pharmacy for convenient delivery directly to the patient’s room, or for the patient to pick up prior to discharge from the hospital. If the patient prefers, the prescription can be electronically sent directly to their own outpatient pharmacy.

Decreased length of stay

In times when the patient census is high—particularly during the Covid-19 pandemic, when patients want to decrease exposure to the hospital environment and minimize their stays—WHNP hospitalists are able to adjust their workflow to minimize delays and facilitate timely discharge. In collaboration with the rest of the healthcare team, the postpartum WHNP hospitalist develops a postpartum care plan tailored to the patient’s individual needs and provides anticipatory guidance and discharge education so the patient is adequately prepared to go home. Data from a large number of hospitals using APPs have shown an overall decreased length of stay (LOS). However, data specific to the role of the WHNP hospitalist in decreasing length of stay for the postpartum population has yet to be explored.26

Despite the overall risk of severe illness being low, pregnant and postpartum individuals who test positive for Covid-19 are at a higher risk for severe illness (eg, hospitalizations, intensive care unit admissions, placement on ventilators) when compared to nonpregnant individuals.27 WHNP hospitalists can manage the care of uncomplicated, asymptomatic Covid-19 positive patients on the postpartum unit, which helps ease the burden on the ob/gyn team who need to attend to sicker patients. The postpartum WHNP hospitalist assesses the patient for evidence of worsening signs or symptoms and collaborates with the healthcare team in the event a patient’s clinical picture changes. Because patients with Covid-19 are at greater risk for venous thromboembolism, the postpartum WHNP hospitalist utilizes hospital-specific protocols to determine the need for and provide prophylactic anticoagulants during the hospital stay with continuation for a short duration of some higher-risk individuals after discharge. To bridge care between the inpatient setting and home, postpartum WHNP hospitalists provide discharge education for patients specifically related to their Covid-19 illness. The WHNP hospitalists enroll their affected patients in Penn Medicine’s text-based programs to monitor symptoms at home and provide support.

Future of the WHNP hospitalist role

Benefits to the WHNP

Beyond benefits to the patient, there are also professional benefits that may attract the WHNP to a hospitalist role. The WHNP in this role is able to deliver care independently and collaboratively with healthcare teams.28 The role gives a WHNP the opportunity to manage postpartum patient care in a tertiary care setting. An acute care NP certification is not required for this role because the WHNP is providing care that is part of their established role competencies. Informed by the patient’s obstetric, gynecologic, medical, and surgical history, the postpartum WHNP hospitalist performs client-centered, comprehensive physical examinations on the postpartum patient. The WHNP evaluates, diagnoses, and develops a management and treatment plan that includes, but is not limited to, ordering and interpreting laboratory and diagnostic tests, prescribing medications, providing lactation support, counseling on contraceptive options and family planning, and coordinating outpatient services.

WHNP hospitalists often have access to management and leadership opportunities, continuing education within the hospital, evidence-based innovations, research and publishing opportunities, access to academic resources (eg, university libraries), and close professional relationships with nurse practitioner colleagues and other healthcare team members from different specialties and disciplines.

Challenges and opportunities to expanding WHNP hospitalist role

Although highly qualified WHNPs are successfully providing in-patient postpartum care, there are challenges to maintaining and expanding this role. One possible reason for the underutilization of WHNPs in this area of practice is lack of familiarity in general with regulatory and legal factors about the full scope of NP practice by those who are responsible for hiring, credentialing, and privileging APP hospitalists. Further, they may be more familiar with acute care and primary care adult/gerontology NPs and family NPs because of their larger representation in the hospitalist role.29 Another challenge may be lack of knowledge among faculty of WHNP programs about the postpartum hospitalist role to support including it as part of the curriculum. Based on findings of the Health Care Advisory Board, there are many opportunities for ob/gyn departments to increase revenue, but department officials will need to expand their APP teams to do so.30 Challenges result from declining inpatient volumes, increased complexity of care, and lower reimbursements.30 For ob/gyn departments to remain competitive, the focus should remain on women’s health specialty physician services, such as outpatient gynecology cases, reproductive endocrinology, and women’s behavioral health.30 More job opportunities may become available for APPs to serve in a hospitalist role as physicians focus on expanding specialty programs within the ob/gyn service line.

Outcomes of the postpartum WHNP hospitalist role

The role of the NP hospitalist continues to expand across many subspecialties. Hospital and ambulatory settings continue to grow their APP programs. Emergent research has demonstrated the value inpatient NP employment has contributed to in a large sample of hospitals. As one researcher explains: “Hospitals employing a larger number of NPs had significantly better outcomes including lower mortality, fewer readmissions, shorter LOS, higher patient satisfaction, and lower Medicare Spending Per Beneficiary in addition of favorable outcomes on other quality indicators.”26

To the authors’ knowledge, there is no published research specific to the postpartum WHNP hospitalist role and the impact on patient health outcomes. Research is needed to determine how the role of the postpartum WHNP hospitalist impacts patients’ LOS; patient, nursing, and resident satisfaction levels; readmission rates; and finances.

Conclusion

Postpartum WHNP hospitalists are integral members of the inpatient teams in US hospitals. In Philadelphia, this subspecialty of the WHNP role was initially created to alleviate a burgeoning workload due to ACGME’s restrictions on medical resident work hours. Over the past 18 years, WHNP hospitalists in Philadelphia have continued to develop their role in championing the optimization of postpartum health and improving maternal health outcomes. As the expansion of the WHNP role in inpatient postpartum care continues, there will be greater opportunity to explore metrics including patient length of stay; patient, nurse, and resident/medical team satisfaction; readmission rates; and decreased healthcare costs. This article’s examination of the postpartum WHNP hospitalist role may serve as an exemplar for the development of similar roles across the US.

Jamille Nagtalon-Ramos is an Assistant Professor at Rutgers University in Camden, New Jersey, and a postpartum WHNP hospitalist at the Hospital of the University of Pennsylvania. Kara Reymann and Annelies Wood are both postpartum WHNP hospitalists at Pennsylvania Hospital. The Hospital of the University of Pennsylvania and Pennsylvania Hospital are entities under Penn Medicine in Philadelphia, Pennsylvania. The authors have no actual or potential conflicts of interest in relation to the contents of this article.

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Key words: women’s health nurse practitioner, WHNP hospitalists, postpartum care

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