This article outlines an initiative to improve services for women with complications in early pregnancy
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AUTHOR Kristie Hill, RGN, is early pregnancy clinical nurse specialist, Yeovil District Hospital NHS Foundation Trust, Somerset.
ABSTRACT Hill, K. (2009) Improving services provided in an early pregnancy assessment clinic. Nursing Times; 105: 6, 18-19.
This article outlines an initiative to improve services provided by an early pregnancy assessment clinic to women experiencing complications in early pregnancy or who had experienced previous ectopic pregnancies. The need to improve had been identified in the areas of patient safety and continuity of care and this was achieved through measures such as improving documentation, staff training and health promotion.
The development started in October 2007 when I took up the post of early pregnancy assessment clinic (EPAC) clinical nurse specialist. It was a new role in the trust as lead nurse responsible for managing the EPAC service.
This service assesses women who are 6-18 weeks pregnant and who are experiencing complications, such as pain and bleeding, have had tubal surgery or experienced an ectopic pregnancy.
The clinic consists of myself, two ultrasonographers and, as required, an on-call registrar. It is available weekday mornings, via referral from GPs, midwives and doctors in the hospital. The rationale for having an EPAC is as follows:
Shorter waiting times;
Increased patient satisfaction;
Reduced out-of-hours demand;
Reduced inappropriate bed occupancy;
Improving the service
I noticed that a number of women who were referred to the clinic did not meet the criteria. Often this was because they were less than six weeks or more than 18 weeks pregnant. Referral at less than six weeks pregnant made diagnosis difficult while women over 18 weeks pregnant should be assessed in the maternity unit. Furthermore, some women referred via their GP had not had a positive pregnancy test confirmed before referral. Coady (2008) noted that the large number of inappropriate referrals pose huge problems for ultrasound departments.
To overcome these problems, a new referral form was devised with clear stipulations for referral so that staff who allocate appointments are now less likely to accept women who do not meet the criteria. We also sent GP practices a brief letter explaining the appropriate EPAC referral criteria for women experiencing complications in early pregnancy.
Appropriate medical terminology
The use of incorrect medical terminology is not only insensitive and likely to heighten distress when addressing patients and/or relatives but also adds confusion to what is an already distressing situation.
The clinic has a zero-tolerance approach towards staff who use inappropriate terminology in patient notes or on consent forms. Staff concerned are informed and educated about the correct terminology, as well as the rationale behind it.
Raising the clinic’s profile in the trust
Although the service was already running, it was not fully used by other departments in the hospital. It was also not meeting patient needs effectively and there was no named or dedicated member of staff providing care in the clinic. My aim was to raise the profile both of my own role and that of the clinic.
Information such as opening times, contact details, referral criteria, philosophy, standards of care and clinical guidelines have been placed on the trust intranet. This enables staff to access information on the service easily. Similar information has been included in the handbook for doctors new to the trust.
I have also worked with the communications department to ensure that the role of the clinic is profiled in all the appropriate internal publications.
Since women attending the clinic are understandably often anxious or distressed, they are unlikely to absorb or retain verbal information. It is therefore essential to provide clear and concise written information to supplement discussions.
I devised patient leaflets with information covering issues such as morning sickness and molar pregnancy and the trust’s clinical governance department approved them.
We have also devised care pathways for certain clinical procedures, such as evacuation of retained products of conception, to ensure correct practice and to improve documentation of care.
An existing ‘outcome letter’ sent to GPs has been revised to improve communication between referrers and the clinic. This ensures primary care professionals are alerted in cases of pregnancy loss.
A consultant gynaecologist at the trust has updated clinical guidelines and clinical protocols, ensuring they comply with best-practice guidance such as the Royal College of Obstetricians and Gynaecologists’ (2006) guideline.
We also produced a philosophy of care and quality and standards policy, which helped to highlight and confirm the outcomes I hoped to achieve.
The hospital has a large number of student nurses/midwives and medical students, as well as doctors on rotation, and they need education and support. It is also essential that staff responsible for providing care in my absence feel both competent and confident to provide this.
Our new competency-based training package explains responsibilities and facilitates comprehensive assessment. This ensures that staff who provide care in my absence are assessed as competent and, importantly, feel confident and supported.
We provide information on a range of topics including folic acid, healthy diet, exercise and pregnancies after miscarriage.
The Department of Health’s (1998) anti-smoking strategy set targets to reduce the percentage of women who smoke during pregnancy from 23% to 15% by 2010, falling to 18% by 2015. This approximates to 55,000 fewer women in England smoking during pregnancy.
We launched a Stop Smoking in Pregnancy campaign in March 2008, which highlighted the complications caused by smoking in early pregnancy, to coincide with national No Smoking Day. A staff member from the Somerset stop smoking service provided help, while posters, literature and displays gave information. As a result of the campaign, patients are referred directly from the clinic to the local stop smoking service.
In addition, chlamydia screening for women under 25 is now available and follow-up advice is provided by the Somerset chlamydia screening programme.
We carried out a patient satisfaction survey and clinical audit to improve the service’s quality and promote high standards of care (see appendix 1 and appendix 2).
The survey was carried out at the clinic. It was over a two-month period with a 100% response rate (82 women). Answers were anonymous and patients posted completed questionnaires in a sealed box in the clinic.
I hoped that this structured process would identify any elements of poor practice so that strategies could be put in place to remedy them. Previous patient complaints or concerns were also discussed and managed in a constructive manner.
The results were extremely positive. The vast majority (84%) of women said the overall level of care was excellent, 13% said it was good and 2% did not answer.
Comments included patients expressing their gratitude for ‘a wonderful place with great care’, while another said a ‘terribly distressing situation was handled sensitively and professionally’. Others said they felt all staff were excellent and caring, although one patient complained of a particularly lengthy wait to see the registrar.
A clinical audit (appendix 2) was carried out over three months in order to monitor patient throughput and timekeeping and to improve these where necessary. This showed that the majority of patients were seen on time.
I have felt empowered, motivated and supported throughout this process.
The acronym iCARE, developed by one of the matrons, is based on the principles of Communication, Attitude, Respect and Environment. These principles are used to engage and motivate staff. High levels of staff satisfaction lead to positive patient experience and better clinical outcomes - iCARE not only mirrors the aims of the EPAC improvement initiative but also has helped to facilitate and optimise its success.
Miscarriage and complications in early pregnancy are distressing events, which require rapid, sensitive and experienced one-to-one assessment, care and support.
Clear and defined goals need to inform care provision to ensure patients’ experiences of services are positive. Care must also be delivered in the context of valid, up-to-date guidelines to ensure optimal outcomes.
The recent patient satisfaction survey and clinical audit indicate that the early pregnancy assessment clinic is delivering high-quality care.
Implications for practice
Coady, A. (2008) The role of ultrasound in early pregnancy: we have created a monster. Journal of the British Medical Ultrasound Society; 16: 3, 138-145.
Department of Health (1998) Smoking Kills - A White Paper on Tobacco . London: The Stationery Office.
Royal College of Obstetricians and Gynaecologists (2006) The Management of Early Pregnancy Loss. Green-Top Guideline No 25 . London: RCOG.
The Miscarriage Association (2006) Acknowledging Pregnancy Loss . TMA: West Yorkshire.