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Gynaecology Assessment unit – Pregnancy Pathway WAHT-TP-027
Page 1 of 15 This information should be used in conjunction with the Gynaecology Assessment unit – Pregnancy WAHT-TP-027. Use the version on the internet to ensure the most up to date information is being used.
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:
Gynaecology Assessment unit – Pregnancy Pathway WAHT-TP-027
Page 2 of 15 This information should be used in conjunction with the Gynaecology Assessment unit – Pregnancy WAHT-TP-027. Use the version on the internet to ensure the most up to date information is being used.
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
Gynaecology Assessment unit – Pregnancy Pathway WAHT-TP-027
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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
Gynaecology Assessment unit – Pregnancy Pathway WAHT-TP-027
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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
Gynaecology Assessment unit – Pregnancy Pathway WAHT-TP-027
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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.
Gynaecology Assessment unit – Pregnancy Pathway WAHT-TP-027
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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
Gynaecology Assessment unit – Pregnancy Pathway WAHT-TP-027
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Reason for delay of cancellation of review in EGAU
Trigger List for Datix Incident Reporting in Gynaecology Insert once approved
Gynaecology Assessment unit – Pregnancy Pathway WAHT-TP-027
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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
Gynaecology Assessment unit – Pregnancy Pathway WAHT-TP-027
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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
Gynaecology Assessment unit – Pregnancy Pathway WAHT-TP-027
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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
Gynaecology Assessment unit – Pregnancy Pathway WAHT-TP-027
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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
✓
Gynaecology Assessment unit – Pregnancy Pathway WAHT-TP-027
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Only to be used for referrals out of normal EPAU hours. A CONTACT NUMBER MUST BE GIVEN FOR ALL REFERRALS.
Gynaecology Assessment unit – Pregnancy Pathway WAHT-TP-027
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Appendix 5 EGAU Results to be Chased
Date Initials / number Summary Investigation Action if result not normal
Gynaecology Assessment unit – Pregnancy Pathway WAHT-TP-027
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Appendix 5 – Gynaecology Matrix
Insert once approved
Gynaecology Assessment unit – Pregnancy Pathway WAHT-TP-027
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Appendix 6 – Gynaecology Trigger List
Insert once approved
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