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Delivering Quality care - What can acute gynaecology learn from acute obstetrics?

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Delivering Quality care.  What can acute gynaecology learn from acute obstetrics?

Bika O1,  Edozien L2
1 Rotherham NHS Foundation Trust Hospital, Rotherham, United Kingdom
2 Saint Marys Hospital Manchester, Manchester, United Kingdom

Background:  Emergency obstetric care in the UK has been systematically developed over the years to relatively high quality standards. Acute gynaecology on the other hand is a rapidly emerging sub-speciality. With its expansion, rising expectations on the part of patients and advances in technology, there is a largely unmet need for organisational change in order to meet quality and safety goals. For high standards of care in acute gynaecology, it needs to become well established as a sub-specialty area in gynaecology to universally deliver the highest standards of care. 

Objectives:  We highlight lessons from acute obstetrics that are potentially transferable to acute gynaecology and present a framework for taking acute gynaecology closer to the organisational and clinical standards that have become more established in acute obstetrics. (labour ward care) 

Discussion:  The UK National Institute for Health and Clinical Excellence (NICE) recently published guidelines for the management of early pregnancy problems and called for better organisation of care for women with these problems. Arguably, the gaps in service delivery identified by NICE apply not just to early pregnancy problems but to all emergency gynaecological care. Two decades after the introduction of Early Pregnancy Assessment Units, acute gynaecology services remain relatively underdeveloped in most hospitals. During the same interval, acute obstetrics has made the transition from neglect and obscurity to recognition and success. Areas such as clinical leadership, risk management, patient flow pathways, out-of-hours care, clinical guidelines and protocols, education and training, and facilities - where lessons from obstetrics are potentially transferable to acute gynaecology.

Dedicated consultant cover:       In many acute gynaecology units the service is nurse-led, with a consultant gynaecologist providing nominal leadership, but is less than satisfactory for optimal clinical decision making and the training and supervision of staff and patient care.  A system of consultant cover providing continuous care is associated with better outcomes for adult patients admitted as an acute medical emergency, prevents unnecessary hospital attendance, and bed occupancy and allows better patient flow through the emergency gynaecology unit and referring units. Hospitals in which admitting consultants had no other fixed clinical commitments while on acute take have a lower adjusted case fatality rate and a lower readmission rate. 

Supporting staff:        With financial pressures and a reduction in working hours, it is unrealistic to expect significant increases in numbers of staff; however in obstetrics, deployment of existing staff and looking at new ways of working has been effective. Nurses and support staff can be trained up to be efficient and capable staff in various designated tasks e.g. skills in counselling, protocol-based management of selected conditions, and trans vaginal ultrasound scan while health support staff can assist in providing holistic care to the patients. 

Facilities and equipment:       Women should get the best care from the best person, in the best place and at the best time. The acute gynaecology unit; as in obstetrics should be housed in a readily accessible location and in surroundings where women can be clinical assessed while maintaining their dignity and privacy.  The availability of dedicated assessment rooms, ring-fenced inpatient beds, prompt blood results, well stocked consumables, quick access to drugs and equipment, trans vaginal and trans abdominal ultrasound scan should be a minimum requirement; allowing speedy diagnosis, improving patient flow, reducing delays, unnecessary hospital admission and follow-up appointments.

EGU as an A & E department:     Acute gynaecology units serving a large population should assume the status of an A & E department and be subject to the targets set for A & E departments in respect of waiting times and patient experience. Ideally, the acute gynaecology service should be run 24 hours a day, 7 days a week to prevent unnecessary hospital admissions out of hours. The physical unit may be closed after hours, but the service for triage and initial management of acute gynaecological cases continues on the inpatient ward.

Clinical governance:   Quality and safety monitoring should be formally incorporated into the acute gynaecology operating procedures. The unit should also have its own risk management, audit and research committee, quality dashboard and prospective risk assessment. The implementation of new approaches to management of acute conditions introduces new risks, and these have to be identified and contained. Electronic information systems should be deployed in tracking patients, capturing process data and analysing clinical outcomes. Evidence-based clinical practice guidelines should be in place and the lead consultant has the responsibility of updating and developing guidelines. Effective communication is an index of quality. As in acute obstetrics, there should also be a formal handover of care and multidisciplinary involvement. Simulation training, skills and drills, which have proved useful in obstetrics, should be applied in emergency gynaecology.

Conclusion:  Emergency gynaecology units should consider adapting the model of care that has evolved in acute obstetrics, where relative neglect has given way to flagship service. Obstetrics has made the transition from an area of neglect to one led by consultants with a special interest in intrapartum care, working to national standards set at a high level and monitored prospectively. Emergency gynaecology is in a position to tread a similar path and learn from its sister specialty. The ideas outlined in this paper are not prescriptive but merely suggest a framework for taking emergency gynaecology closer to the service standards that have become established in acute obstetrics.

References:

1.National Institute for Health and Clinical Excellence (NICE). Ectopic pregnancy and miscarriage: Diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage. CG154; December 2012.
2.Bigrigg MA, Read MR. Management of women referred to early pregnancy assessment unit: care and cost effectiveness. BMJ 1991; 302: 577–579.
3.Khalid A, Condous G, Bourne T Should all emergency gynaecology patients have an ultrasound scan? Ultrasound in Obstetrics & Gynaecology 2003;22( S1):52
4.Royal College of Physicians. An evaluation of consultant input into acute medical admissions management in England Report of: Hospital service patterns versus clinical outcomes in England 2012. London, RCP January 2012
5.Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Towards Safer Childbirth. Minimum Standards for the. Organisation of Labour Wards. Report of a Joint Working Party. RCOG & RCM 1999.
6.Jones K, Pearce C. Organizing an acute gynaecology service: equipment, setup and a brief review of the likely conditions that are managed in the unit. Best Pract Res Clin Obstet Gynaecol. 2009; 23:427-38.

 

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