Emergency Gynaecology Assessment Unit Operational Policy

Gynaecology Assessment unit – Pregnancy Pathway WAHT-TP-027

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Emergency Gynaecology Assessment Unit

Operational Policy WRH (EPAU and EGAU)

Department / Service: Emergency Gynaecology Care

Originator:

Mr Jon Hughes, Consultant Gynaecologist Lyn Saunders, Gynaecology Matron Alex Blackwell, Consultant Gynaecologist

Accountable Director: Angus Thomson, Divisional Medical Director Women and Children’s Division

Approved by:

Gynaecology Governance Meeting

Date of approval: 9th October 2020

First Revision Due: 9th October 2023

Target Organisation(s) Worcestershire Acute Hospitals NHS Trust

Target Departments Gynaecology department/ Emergency department

Target staff categories Nursing , Medical , allied health professionals

Policy Overview:

This policy is for the pathway for emergency gynaecology care for women who enter the pathway either via Emergency Department, Primary Care or self-presentation. This operational policy has been developed to provide guidance for the day to day running of the Emergency Gynaecology Assessment Unit (EGAU) at Worcestershire Royal Hospital (WRH). It includes acceptable patient referral pathways and escalation criteria.

Key amendments to this Document:

Date Amendment By:



Introduction This operational policy has been developed to provide guidance to the day to day running of the Emergency Gynaecology Assessment Unit (EGAU) at Worcestershire Royal Hospital (WRH). It includes acceptable patient referral pathways and escalation criteria. Emergency Gynaecology Assessment Unit The Emergency Gynaecology Assessment Unit is a specialised area developed to provide an appropriate location in which to review women with gynaecological conditions as an alternative to the Emergency Department (ED). Patients will be assessed by the Gynaecology Team on call. EGAU incorporates both the Early Pregnancy Assessment Unit (EPAU) and Emergency Gynaecology Assessment Unit. An EPAU will continue to run in WRH, Alexandra Hospital Redditch (AGH) and Kidderminster Treatment Centre (KTC) on an appointment basis. The patients must be clinically stable to attend EGAU. Clinically unstable patients should be reviewed via the ED. Referral processes Patients can be referred via the GP, ED WRH, ED ALEX, Minor Injuries Unit (MIU) KTC, Community Midwives (CMW), self-referrals following recent attendance or admission and other departments. All new referrals will be channeled to the emergency Gynaecology registrar via bleep 654. Patients will be triaged and given appointments to attend the EGAU or reviewed on the referring ward depending on the clinical urgency. AGH or AHR inpatient ward referrals who need a Gynaecology review should be discussed with the Gynaecology consultant on-call in WRH via bleep 474. The consultant will then advise if the patient should be transferred immediately or booked a review in the following 36 hours in EGAU/ Ward bed. The Gynaecology consultant will then ask the EGAU ward clerk or nursing team to contact the referring department or bed manager with an appointment time. It may be possible to arrange a review on the ward in AGH by a Gynaecology consultant but the availability is limited. Please refer to appendix for referral pathways and EPAU booking sheet. A record of Gynaecology telephone advice / assessment will be recorded (refer to appendix). Indications for referral to the Gynaecology Assessment Unit

Pregnancy complications below 16 weeks gestation should be assessed in EGAU / EPAU

If clinically well avoid scanning <6 weeks especially if reassurance scan

Pain associated with gynaecological conditions

Complications following gynaecological procedures

Abnormal or heavy vaginal bleeding

Early pregnancy complications such as miscarriage or ectopic pregnancy

Patient opting for outpatient medical management of miscarriage



Abnormal pregnancy symptoms before 16 weeks

Hyperemesis

Patient requiring trial without catheters (TWOC)

Abdominal fluid retention associated with gynaecological conditions requiring paracentesis or drainage

Difficulty with bladder emptying associated with pregnancy or gynaecological surgery

Urgent complications associated with pessary use

In case of delayed urgent or hot clinic availability due to bank holiday etc. 2 week wait referrals can be seen in EGAU. These referrals should be arranged through the consultant on call. This would only be done if there will be significant delay in their management by waiting for outpatient appointment.

Inpatient referrals from other wards may be reviewed by the EGAU team in the referring ward

Exclusion Criteria for EGAU

Patients with pregnancy over 16/40 patient should be referred to Obstetric Triage

Clinically unstable patients should be assessed in ED i.e. hypotensive, signs of severe clinical sepsis, bleeding excessively including acute anaemia, suspected ruptured ectopic pregnancy.

Patients over 8 Weeks following surgery who are well can be seen by the GP or be sent a follow up appointment to the outpatients department

Patients who are under 16 weeks and are admitted for primarily with non-gynaecological symptoms i.e. acute shortness of breath, neurological symptoms other surgical conditions requiring non gynaecological input should be assessed by the specialist team. Gynaecology on call team would be available for input if necessary and would be happy to review the patient when requested.

Surgical Management of Miscarriage See also Guideline for Management of bleeding in early pregnancy and early pregnancy loss – Pregnancy Pathway WAHT-TP-027 If the patient opts for surgical management of miscarriage and they are stable enough to return home they should be booked on to the next available elective list, preferably in the KTC or AGH. KTC phone booking office on number x55145 x55286 x55276 AGH phone a Gynae secretary on either x44078 or x44577 The following groups of patients are not suitable to be booked for surgical management of miscarriage in KTC or Alexandra hospital due to intraoperative risks

Suspected molar pregnancy

Postpartum LSCS <6 weeks

Uterine anomaly unless for hysteroscopic retrieval of RPOC

CRL >22mm



Twin gestation with larger placental bed

Previous uterine surgery i.e. myomectomy, fibroid resection, septum resection and classical LSCS

Bleeding disorders

HB <100

If the patient is not stable to return home, following medical review they should be admitted to the inpatient ward for further management. Medical Management of Miscarriage See also Guidelines for Management of bleeding in early pregnancy and early pregnancy loss; Outpatient medical management of miscarriage in the first trimester of pregnancy using misoprostol (up to 9 weeks); Medical management of mid-trimester miscarriage or termination of pregnancy using mifepristone/misoprostol – Pregnancy Pathway WAHT-TP-027. If the patient opts for medical management of miscarriage or termination of pregnancy for fetal anomalies below 16 weeks gestation:

initial investigations should be carried out via EPAU

Outpatient medical management also known as short term medical management (STMM) of miscarriage will be carried out in EGAU once it has been established that the pregnancy is no longer ongoing.

If STMM is not appropriate then longterm medical management of miscarriage (LTMM) will be offered. In this instance a bed will be booked for the woman in the Bereavement Suite and the Bereavement Midwifery team will be contacted

to provide additional support as required

Fetal products will be handled with dignity and respect and full discussion with the women will determine individual choice for burial/cremation

A fetal tissue consent form will be completed for every patient.

Please refer to Guidance for Management of miscarriage http://www.treatmentpathways.worcsacute.nhs.uk/womens/gynaeoverview/egau/ Investigations and results for EGAU patients

All Urgent Gynaecology investigation requests from ward referrals for pathology will be requested on ICE and labelled as ward area “WRH Emergency Gynaecology Assessment Unit” regardless of the physical location of the patient.

All inpatient Gynaecology pathology requests will be for the ward area “WRH Gynaecology inpatients”

Radiology requests for Gynaecology patients on wards other than EGAU will be for the ward the patient is admitted to e.g. “WRH Beech” etc.

A purple folder is kept in EGAU recording all investigations requested. This will be reviewed daily by the junior doctor on duty for Gynaecology at the end of the ward



round. Gynae nurses will also check results during the night shift and identify results that need to be acted on and ensure that the Doctors are aware and the necessary contact is made with the patient and GP.

Appointments for EGAU

All referrals will be triaged by the emergency Gynaecology registrar on bleep 654. An appointment will be offered to attend EGAU within 36 hours.

The Nurse In Charge (NIC) can also triage referrals and will make necessary appointments and inform the registrar on call.

The NIC will also triage EPAU patients and offer them an appointment in EPAU on any site.

Patients who are seen in EGAU having been referred from another inpatient ward, will go back to referring ward following assessment with an EGAU report.

Patients who do not need pelvic ultrasound scan may be assessed in the ward where referred from.

A diary system with appointment times will be held in the EGAU

All cases seen in the EGAU will leave with a summary of management and follow-up plan as necessary, recorded on the Bluespier Electronic Discharge System (EDS) and patient record.

Capacity The current capacity of the EGAU when fully open is 5 trolley spaces for assessment. Escalation for EGAU See Matrix Appendix EGAU requirements

Appointment system should be used for patients in EGAU, this diary will be held in the EGAU

Although many patients will be managed per protocolary junior doctors and nursing staff, all patients will have a named consultant (most usually the on call consultant at the time of admission to EGAU)

Any patients who need a senior review should be reviewed by the on call consultant within 14 hours of admission.

Daily consultant led ward round to review all the Gynaecology inpatients at 8:00 AM. A telephone ward round between the on call registrar and the on call consultant at 22:00. It is the responsibility of the on-call consultant to bleep the registrar and get an update. The on call consultant will review complex cases and will always be available for advice and consultation.

All complex patients should be reviewed by the middle grade doctor or consultant before discharge.

The on call consultant for Gynaecology will be responsible for all admissions via emergency Gynaecology unit for the day.

All the beta HCG results should be reviewed by the on call middle grade and any difficult cases should be discussed with the on call consultant.



Privacy and dignity

Single examination rooms are available for all women attending EPAU/EGAU

Chaperones are available to accompany Doctors – no examinations or consultations should take place without a chaperone (See Chaperone Policy and add reference / policy number)

When room door is closed staff must knock on door and wait to be invited to enter.

The room door should be closed when a consultation or examination is taking place – this will limit conversations being overheard and provide a private space for the women

Curtains within the room will be pulled across to prevent anyone entering uninvited from seeing the patient

Dignity sheets will be provided for all women

Staffing Levels

Staffing EGAU should be sufficient to ensure prompt and safe patient care at all times

Minimum levels are: 07:00-19:30 one nurse and one HCA 19:00-07:30 one nurse and one HCA

If staffing is not as above then EGAU may be put on divert.

The divert status must be reviewed on a shift by shift basis

This may change due to the capacity and demand increasing and may move to 2 nurses and 1 HCA in the future.

During the Covid 19 pandemic this has increased to 2 nurses and 1 HCA

EGAU patients on ED requiring medical review

Patients to be reviewed by the EGAU on call registrar (Bleep 654) or consultant (Bleep 474) in ED within 1 hour of referral to minimise long wait.

For patients who are critically unwell and need admission, an appropriate place for admission should be decided by the Consultant on call.

Unstable patient attending EGAU

Urgent medical review with EGAU on call SHO and /or registrar (Bleep 685 / 654) and inform the on call consultant for Gynaecology

Contact critical care outreach team (Bleep xxx) if appropriate and arrange ITU consultant review if necessary

Monitoring EGAU EGAU activity needs to be accurately captured on the booking form see appendix. The minimum dataset includes:

Date & time of referral

Mode of referral

Appointment date & time

Date & time of EGAU attendance

Time of assessment by nurse

Time of assessment by doctor

Date & time of decision to admit/ discharge



Reason for delay of cancellation of review in EGAU

Trigger List for Datix Incident Reporting in Gynaecology Insert once approved



Contribution List

This key document has been circulated to the following individuals for consultation;

Designation

Jon Hughes Consultant Gynaecology

Rachel Duckett, Clinical Director

Lyn Saunders Matron Gynaecology

Becky Williams Divisional Director of Operations

Countywide Consultants Obstetricians and Gynaecologists

Gynaecology Governance Team

Committee

Gynaecology Quality Governance Meeting



Appendix 1 Patient for Assessment, Emergency Gynaecology Assessment Unit

Patient referral to EGAU

Telephonic triage by the on call

Registrar Bleep 654

Consultant via switchboard if AGH patient

Patient needs Gynaecology review

Is patient medically stable? Yes No

Gynae registrar to liaise with nurse in charge of EGAU

Nurse in charge of EGAU to arrange appointment

Commence booking form

Contact patient/referring ward with appointment time

Patient assessed in the EGAU at appointment time

Registrar/Consultant to attend ED to assess patient Provision of Gynaecology Equipment trolley and transport of ultrasound machine to an A&E cubicle if necessary

Patient to be admitted to WRH ED for assessment



Appendix 2 For relevant guidelines see Medical guidelines page The flowcharts will be accessible via the link Gynaecology soon. Management of ectopic WAHT-Gyn-002 Medical management of miscarriage / TOP

WAHT-TP-027 WAHT-Gyn-009

TOP midtrimester WAHT-GYN-001 OHSS WAHT-GYN-006 PID WAHT-Gyn-008

Appendix 3 Contents of the Gynae Equipment Trolley:

Working Torch

Gloves

Ticept or other antiseptic liquid to cleanse

Aquagel

Small / Medium and Large Cuscos speculum

Plastic Sponge forceps

Metal Polyp forceps

Gauze

Swabs

Silver Nitrite sticks for cautery

Vaginal ribbon gauze for packing

Proflavin

Vaginal oestrogen cream - unopened tube eg ovestin

In out catheter

Kidney dish

Catheterisation kit

http://nww.worcsacute.nhs.uk/departments-a-to-z/clinical-policies/gynaecology-care-key-documents/?p=1



Appendix 4 EPAU REFERRAL FORM Tel: 01905 763 333, Extn.39329

DATE PATIENT NAME OR

HOSPITAL LABEL

HOSPITAL NUMBER

D.O.B CONTACT NUMBER

REASON FOR REFERRAL REFERRED FROM NOTES

✓



Only to be used for referrals out of normal EPAU hours. A CONTACT NUMBER MUST BE GIVEN FOR ALL REFERRALS.



Appendix 5 EGAU Results to be Chased

Date Initials / number Summary Investigation Action if result not normal



Appendix 5 – Gynaecology Matrix

Insert once approved



Appendix 6 – Gynaecology Trigger List

Insert once approved

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Emergency Gynaecology Assessment Unit Operational Policy