Marcus C. Hermansen, MD
Southern New Hampshire Medical Center
8 Prospect Street
Nashua, NH 03061
E-mail: [email protected]
Physician Staff (FTE)
Valeria Atkins, MD, Neonatologist and Pediatric Hospitalist
Suzanne Fetter, MD, Pediatric Hospitalist
Anshula Greene, MD, Pediatric Hospitalist
Marcus C. Hermansen, MD, Neonatologist and Pediatric Hospitalist
Sumana Myneni, MD, Pediatric Hospitalist
Cynthia Wright-Devine, CRNP, Neonatal Nurse Practitioner
Lisa Ormond, Practice Manager
The Original Challenge and Solution
The Southern New Hampshire Medical Center maintained a relatively small neonatal intensive care unit (NICU) and pediatric ward. Neither was large enough to justify the desired 24/7 in-house coverage. A combined neonatal-pediatric hospitalist program has been developed and staffed by a combination of neonatologists and pediatric hospitalists. 24/7 in-house coverage is now provided.
History and Background
The Southern New Hampshire Medical Center traditionally staffed its Level 3A NICU with 1 or 2 neonatologists. Approximately 1,500 deliveries take place annually at the medical center; however, these tend to be relatively low-risk deliveries and do not provide enough clinical activity to support a larger group of neonatologists. This prevented the neonatologists from providing the desired 24/7 in-house coverage. To increase clinical activity, the program expanded to include pediatric hospitalist services in 1999. Within 2 years, the combined neonatal-pediatric hospitalist program had grown to allow for 24/7 in-house coverage.
Clinical and Educational Services
The neonatal-pediatric hospitalist team provides services for both the hospital’s neonatology and the pediatric practices. Prior to the team’s development, all community pediatricians were expected to attend high-risk deliveries with availability upon 30 minutes request. Since the development of the in-house neonatal-pediatric hospitalist team, only these team members attend high-risk deliveries. The team attends approximately half of all births at the hospital and has a goal of availability upon 2 minutes notice. Members of the neonatal-pediatric hospitalist team are certified in both neonatal and pediatric resuscitation.
The neonatal-pediatric hospitalist team serves as the attending physician for all admissions to the NICU. Prior to the team’s establishment, it was not possible to care for critically ill infants in the NICU requiring 24/7 in-house attendance; however, with the current team, the NICU can care for smaller and more acutely ill neonates. Additionally, the hospital’s obstetrics department has been able to improve recruitment of high-risk obstetrical patients based upon the improved neonatal staffing.
The team’s non-neonatal pediatric care includes providing consultations in the emergency department and services on the 8-bed pediatric ward. Nearly all of the community pediatricians and family practitioners have asked the hospitalist team to perform the necessary pediatric inpatient history and physical examinations. The unique circumstances of each case determine whether the hospitalist or the PCP serves as the attending physician in the hospital. Additionally, the neonatal-pediatric hospitalist team currently serves as the attending physician in the normal new-born nursery for approximately 25% of all newborns.
Staffing and Schedule
Each day is divided into 2 12-hour shifts: 7:30 a.m. to 7:30 p.m., and 7:30 p.m. to 7:30 a.m. Each fulltime clinician is expected to work 3 or 4 shifts each week. A physician is always available as “back-up” coverage when the neonatal nurse practitioner is providing the in-house coverage. The typical patient load consists of 8–12 NICU patients, 2–4 pediatric ward patients, and 2–5 normal newborns. Each member of the team is employed by The Medical Center and receives a guaranteed salary and benefits.
Certain principles have been followed during the development of the program. These include:
- All services are offered to community PCPs on a voluntary basis. No hospitalist service is mandatory.
- Close communication with the PCP is of primary importance. Telephone, email, and transcribed summaries are provided throughout the hospital stay and at discharge.
- High-quality patient care must be provided. The team members recognize that some patients are too sick for care at The medical center and are better served at one of the nearby tertiary academic centers.
The primary challenge stems from the relatively small neonatal and pediatric services. Combining the neonatal and pediatric programs to provide 24/7 coverage required the difficult task of recruiting of neonatologists willing to provide pediatric care and pediatric hospitalists willing to provide care in the NICU. Additionally, because of the small services, there is limited pediatric subspecialty support available at the Medical Center. The hospitalist occasionally serves as consultant to community PCPs on issues related to pediatric cardiology, neurology, endocrinology, and other disciplines for which there are no other consulting specialists available.
Although the team has grown to include 5 full-time healthcare providers, the small size of the team still provides challenges. There is little flexibility in scheduling, making it difficult for 2 providers to take an extended vacation at the same time. Finally, the small size of the group prevents the ability to provide back-up coverage to the in-house hospitalist. Community pediatricians fulfill this function.
Every year the team is producing improved financial results but still does not generate revenues to support the team’s salaries; a hospital subsidy provides the difference.
The neonatal-hospital team continues to explore opportunities for growth. Opportunities under consideration include provision of pediatric conscious sedation, developing Level II pediatric intensive care unit services, performance of circumcisions on normal newborns, marketing the NICU to nearby primary care community hospitals to obtain more neonatal, pediatric, and obstetric referrals and provision of expanded services in the emergency department.