Learning from practice

Guy’s and St Thomas’ Emergency Gynaecology Unit (EGU) opened in 2003 and gives the female population of Lambeth, Southwark and Lewisham 24-hour open access to emergency care for gynaecology and early pregnancy problems.

The EGU has reduced waiting times and improved accessibility to a dedicated team of nurses and doctors who are skilled and specialise in emergency gynaecology. Although predominantly nurse-led, senior medical input is provided by a medical consultant who runs an urgent clinic for patients seen in the EGU who have more complex needs.

Women who are not registered with a GP are advised to seek one, but this does not prevent them from receiving care at the Unit. If required, an onward referral to outpatients can be made. There had previously been a long established nurse-led EPAU (Early Pregnancy Assessment Unit) open from 9am-5pm Monday to Friday but there were long waiting times in A&E when the Unit was closed and women with early pregnancy problems did not receive the same standard of care.

Says Debbie Holloway Nurse Consultant, Gynaecology, “There was variation in the care that women with early pregnancy problems received outside the EPAU’s opening hours and we found that many women were admitted to the ward only to be reviewed and then discharged the next day.” This also meant that women who were not pregnant had to go through A&E as there was no other way for them to access the services they needed. They usually ended up being seen and intimately examined by several doctors and had to wait for an ultrasound and the return of results of other investigations.

Continues Debbie; “This all led to a slow, inefficient, occasionally sub-standard level of care with unnecessary admissions. It also meant that patients would only see a consultant if they were admitted to the ward, so women being sent home from A&E would sometimes have incomplete management plans, which could lead to repeat attendances. We therefore believe that the care of all gynaecology emergency referrals should be referred to the EGU 24-hours a day, seven days a week.”

A business case was written that took into account the reduction in junior doctors’ hours and the need to reduce waiting times in A&E. It built on the successful nurse-led EPAU and resulted in the EGU, which is open 24-hours a day, seven days a week.

In terms of staffing, this mainly required an increase in staff at what was the F grade level, with a G manager and an H CNS and HCA support. The vision for this was driven by a desire in the women’s health department to place women at the centre of their care, decrease waiting times for women who had an emergency gynaecological problem and increase access and availability for women who had problems in early pregnancy.

It was also hoped that it would decrease the risks or near incidents associated with the late night operating of patients on the priority table, and standardise care by introducing a dedicated team of nurses and doctors who are skilled and specialise in emergency gynaecology. There have been numerous challenges in getting the Unit up and running successfully. One of the biggest according to Debbie is the ongoing retention of nurses who are trained for the extended role, especially in London.

The team has worked with King’s College to try to tackle this and is about to start a course for EGU nurses. A dedicated consultant gynaecologist working alongside the nurses is needed to ensure that all information and clinical management is standardised and that protocols are followed.

Having a medical consultant dedicated to emergency cases will also mean that a consultant can operate or supervise operations on all women who require operative intervention. Not having weekend or out-of-hours access to ultrasound is also an ongoing issue, as is ensuring that the unit is not used as an outpatients clinic and that patients are directed to the appropriate service.

The unit has held several open days to promote understanding about what it offers and make the link with primary care. In terms of patient feedback, there hasn’t been any formal evaluation as yet but patient comment cards have been generally positive. Says Debbie; “We can also measure patient satisfaction through repeat visits; for example we see women who have had a miscarriage, get pregnant again and return to us for their scans and care, despite there being other units in London.’” As the unit is mainly nurse-led, patients benefit from seeing the same nurses most of the time – there is even a dedicated ultrasonographer.

Patients also benefit from open access to advice and care and can then be directed onto the best service if needed. The unit also now has a dedicated medical lead consultant which has provided enormous benefits and a medical lead who provides extra clinics for semi-acute patients.

The Care Closer to Home Demonstration Project has been set up to consider how care can be shifted and delivered in innovative ways to make it more convenient for patients. The project is evaluating care pathways and models of care in six specialities - dermatology, orthopaedics, gynaecology, urology, ENT and general surgery. DH web page gives more details at http://digbig.com/4nken