Effectiveness of the clinic
The NHS five year forward view advocates care closer to home, which this clinic aims to provide. The average waiting time to be seen in clinic was 1.86 days, reflecting patients being seen in a timely manner. More than half of patients (58.8%) were self-referrals, increasing access to clinic. The most common reason for referral was bleeding in early pregnancy. Of the patients attending the clinic 72.2% were viable intrauterine pregnancies. From the miscarriage group 84.1% were missed or incomplete miscarriages, 15.9% were complete miscarriages. First choice of management of miscarriage was most commonly conservative management 48.6%, followed by 31.5% choosing surgical management and 19.9% choosing medical management. The high percentage of conservative management reflects the role of the specialist nursing team, bedside technology with electronic patient records and point of care testing encourages patients to feel comfortable in the community, avoiding the need for hospital management. NICE 2019 recommends conservative management as first choice for first trimester miscarriages (5). The 2006 MIST trial showed that expectant or medical management of miscarriage produced significantly more unplanned hospital admissions compared to surgical management (6), however the emotional wellbeing and impact of personal choice on management are important factors when designing services. Our service offering medical and expectant management has shown excellent patient feedback and a majority of patients choosing expectant care.
Three studies have shown the introduction of an EPAU resulted in a shorter length of stay in both emergency departments (3) and outpatient clinics (2), a reduction in the proportion of women requiring hospital admission (2,3) and a reduction in the number of women representing to health services(3). Our review has shown low numbers of unplanned admissions and very few ambulance transfers when required to secondary care.
From the patient feedback data collected, patients consistently rated the community clinic higher than the previous hospital clinic, covering areas such as quality of care, environment, staff and emotional support. A 2009 UK study found that over 80% of women rated their satisfaction with privacy, dignity, and care as excellent(7). There is minimal published data on this area in EPAUs, but our results are very positive.
Patients were directly triaged on the telephone from self-referral by a senior nurse, who could appropriately decide if the patient met criteria to come to the EPAU or direct referral to hospital. The low numbers of referrals to A&E indicate this triage is likely effective. From the ectopic pregnancy data the majority of patients received surgical management. From this group of patients there was a low negative laparoscopic rate of one patient, a rate of 3.7%, compared to a rate of 6% in 2016 study (8). Three patients had negative laparoscopies but these were investigative procedures due to clinical findings with a background of miscarriage or pregnancy of unknown location. From the group of ectopic pregnancies managed conservatively or medically, 6 went on to have surgical treatment, a rate of 31.6%.
Safety of clinic
The clinic provides highly trained nurse sonographers and nursing staff who have received skills, drills and human factors training. During the eight months of data collection 25 ambulance transfers were made from the clinic to the John Radcliffe hospital, four of these were for patients who had no transport themselves, and the remaining patients were all due to medical emergency such as being haemodynamically unstable, bleeding, pain, faint, or ruptured ectopic. The use of ambulance transfers was decided based on rigid criteria for patient safety based on the ectopic pregnancy protocol established in the clinic. The typical cost of an ambulance transfer is approximately £250. The first month working in the new community setting there were transfers, however this reduced to 1–4 per month as staff became more confident in assessment. The low number of transfers per month reflects the appropriate triage of the nursing team upon referral, patients with significant pain, heavy bleeding would be triaged to secondary care. Emergency admissions to hospital from EPAU made up only 1.8% of patients seen in the community EPAU. Compared to the MIST trial this percentage is low, the MIST trial reports 49% of conservative management patients, 8% surgical management patients, and 18% of medical management patients having unplanned admissions (6). 71.8% of patients that were unplanned admission to hospital were due to worsening symptoms after attending EPAU, this can be expected as the risks of conservative and medical management of miscarriage include worsening pain or bleeding, which patients are warned about and safety netted to call the gynaecology ward or A&E.