VOL: 102, ISSUE: 50, PAGE NO: 31-32
Alison Bain, Bsc, RGN
Independent nurse prescriber, is gynaecology nurse practitioner, Staffordshire General HospitalABSTRACT: Bain, A. (2006) Development of nurse-led gynaecology services. www.nursingtimes.net.
ABSTRACT: Bain, A. (2006) Development of nurse-led gynaecology services. www.nursingtimes.net.
On average 180 women a month are currently assessed at the unit and there is potential for that number to increase. Anaudit has revealed that only 7.2% of women seen in the unit required admission, the remainder being suitable to be treated asoutpatients. Before the unit was established, it was normal practice that any referrals were automatically admitted onto theward until the junior doctor on call could assess them and decide on an appropriate plan of care.
Keywords: Gynaecology; Nurse-led; Development
The gynaecology emergency assessment unit (GEAU) at Staffordshire GeneralHospital was established in November 2002. It wasdeveloped primarily in response to a service need, acknowledging that an increasing number of women were being referred to thegynaecology ward for assessment. These referrals came from GPs, A&E and the hospital's diagnostic unit, and were leading toconcerns that the ward would become unable to offer care to all the women being referred for assessment and those admitted forelective and emergency treatment. We recognised that an outpatient assessment service may be able to avert unnecessaryadmissions and ensure women were cared for in the most appropriate way.
The development also met with Agenda for Change stipulation that the quality of patient care should be improved byextending the practice of senior and specialist nurses. It also met requirements of The NHS Plan(Department of Health, 2000) that nurses be given greater opportunities to extend their roles. The GEAU isnurse-led and continually aims to fulfil these objectives.
What kind of service?
Initially there was some debate about whether the hospital should set up a GEAU rather than an early pregnancy assessmentunit (EPAU). While many other hospitals have EPAUs the GEAU appeared to be a new concept to the West Midlands. The servicesdiffer in that a GEAU accepts women with acute gynaecological problems whether or not these are related to pregnancy, while anEPAU only accepts women with pregnancy-related problems.
Before the service was implemented in 2002, an audit of previous admissions was carried out to ascertain what percentageof women attending the hospital's gynaecology unit did so with problems related to early pregnancy. This revealed that 61% ofreferrals were women with pregnancy-related problems but 39% were non-pregnancy-related (Fig 1). If the new service had been anEPAU, therefore, it would have failed to meet the needs of 39% of the women requiring assessment.
The audit also revealed that only 7.2% of women needed to be admitted to hospital. The remainder were suitable to betreated as outpatients. Before the GEAU was implemented, it was normal practice that any referrals to the gynaecologydepartment were automatically admitted onto the ward until the junior doctor on call was available to assess them and decide onan appropriate plan of care. This was wasteful of resources and inconvenient for those women who could have been treated on anoutpatient basis.
The new service
The results of the audit led to a decision to set up the GEAU, to enable us to meet the needs of the maximum number ofwomen. The unit has a number of key features:
- It offers rapid access to assessment via dedicated nurses;
- It offers fast-tracking for pelvic ultrasound;
- Allocated theatre time is available for emergencies such as women needing evacuation of retained products of conception and Bartholin's gland excision;
- Minor procedures, such as endometrial biopsies and removal of intrauterine contraceptive devices, can be undertaken;
- Women have prompt access to the gynaecology ward if they need to be admitted;
- GPs can phone direct for referrals or for advice;
- The fact that women do not have to enter via A&E takes pressure off that department.
On average the GEAU currently sees 180 women a month. As more GPs in the area become aware of the service and what it canoffer, there is potential for that number to increase. At present women cannot refer themselves to the unit as we do not havethe resources. The average age of women attending the unit is 30 years and 6 months, with a range of 18-43 years.
The unit is staffed 8.30am-5pm Monday to Friday by the gynaecology nurse specialist and a senior staff nurse, both of whomare independent and supplementary prescribers. They are supported by the on-call medical team. Outside these times access togynaecological assessment is via A&E - this ensures that an acutely ill woman does not arrive on a ward where there are nosenior staff to assess her.
Initially the nurse assesses the patient using a structured assessment sheet that was designed to ensure thatthe information gathered is specific and concise, and that appropriate investigations are organised, such as blood tests, scansor X-rays. When all the necessary information has been gathered the patient is assessed. The system has shown clear benefitsboth for patients and the trust (Box 1).
Box 1. Benefits of the GEAU
If the patient has a condition the nurses can deal with, a plan of care is devised following locally agreed protocols andfollow-up is arranged if necessary. These conditions include:
? Suspected ectopic pregnancy;
? Ovarian pathology, for example, cysts, fibroids;
? Pelvic inflammatory disease;
? Bartholin's abscess.
If the patient needs emergency surgery the unit's nursing staff can arrange this and anaesthetic assessment - breakingdown the boundary that stipulated that only medical staff could arrange such things. Fig 2 illustrates the proportion of womenseen by nursing staff only.
If the nurses need advice or a patient to be assessed by a senior doctor this is arranged with the on-call team. Beforethe GEAU was implemented, it was the responsibility of the on-call senior house officer to assess all emergency referrals, inaddition to covering other clinical areas. As a result, it was not unusual for patients to wait several hours for assessmentand organisation of investigations and then have another lengthy wait before final assessment. Waiting times was another areatargeted by the government for improvement (DH, 2000) and as Table 1 illustrates, the unit has had a real impact on thesethanks to its staff being dedicated to these patients; in addition, women who have presented to A&E can be redirected toGEAU.
Table 1. Waiting times in the GEAU
Seen immediately by a nurse
Seen within 30 minutes by a nurse (118 within 15 minutes)
Seen in 30 minutes to 1 hour by a nurse
Seen in 1-2 hours by a nurse
Seen by a SHO outside GEAU normal hours) within 30 minutes
Seen by a SHO outside GEAU normal hours) in 4.38 hours
Nurse-to-registrar assess within 15 minutes
Nurse-to-consultant assess within 1.5 hours
More recently a new aspect of emergency care has been evolving. We have had a number of situations where awoman has presented with acute symptoms and after initial assessment has been suspected of having a gynaecological malignancy.Liaison between the gynaecology clinical nurse specialist and the gynaecology-oncology clinical nurse specialist is enabling usto ensure these women have rapid access to investigations and assessment, therefore ensuring they also receive a prompt reviewby a consultant.
The services provided within the GEAU are continually evolving to improve the care offered to the women referred to theunit. Developments currently underway include:
? Nurse prescribing is to be developed further;
? Clinical management plans for all acute gynaecological instances are being put in place;
? Further development of diagnostic service is underway for women who are suspected of having a gynaecological cancer;
? Bridging of gaps between services provided by gynaecology clinical nurse specialist and gynae-oncology clinical nursespecialist.
It is a challenging but rewarding time in the NHS. There are many aspects of the service highlighted by papers such as The NHS Plan(DH, 2000) and Essence of Care(DH, 2001) that have to be improved.
By responding to local service need and utilising experienced staff we have improved women's healthcare in Stafford andare addressing other areas to be developed.
All women who attend GEAU can be offered a pelvic scan and blood investigations on the day of attendance, thisis not the case at other local hospitals. Our service has recently become more streamlined as the GEAU has moved onto adiagnostic unit where further outpatient women's health clinics are situated along with an obstetric and gynaecology scanningdepartment. Direct communication between staff on hysteroscopy and colposcopy clinics enables broader treatments if necessary -further enhancing care.
Fig 1. Proportion of patients with early pregnancy problems, January to April 2002
Fig 2. Patients seen by nursing staff only
Department of Health (2001) The Essence of Care: Patient-focused Benchmarks for Healthcare Practitioners. London: DH.
Department of Health (2000) The NHS Plan: A Plan for Investment, A Plan for Reform. London: DH.