Compliance with a guideline on outpatient medical management of miscarriage in a gynaecology ED
This article describes the clinical audit of the Outpatient Medical Management of Miscarriage Guideline (Guideline 2) within the Gynaecology Emergency Department (GED) at a single site dedicated Gynaecology and Maternity Hospital in the UK, the Liverpool Women's NHS Foundation Trust. Clinical audits are quality improvement processes used to identify areas of improvement against a set criterion and, as a result, implement any required change(s) (National Institute for Health and Care Excellence, 2002). An audit ensures that the guidelines have been followed to certify safe, effective treatment for women who have suffered a first trimester missed miscarriage and the audit described in this article analysed the success of treatment in avoiding admission to hospital and further intervention, such as surgery. The main findings of the audit were that the GED fell short on compliance rates against some standards, mainly standard 1 (performing a baseline point of care test to measure haemoglobin) and standard 5 (providing the patient with a follow-up phone call, with higher compliance levels to standards 3 and 4, which are in relation to prescribing and administering the treatment. The audit found that 15% of patients required further intervention such as admission to hospital for observation (9%) and surgical intervention to complete the miscarriage (6%). Further training in the clinical setting is required to ensure improved compliance with all standards. A checklist will also be created to ensure all standards are being met.
Over the course of the past 12 months, spurred on by the COVID-19 pandemic, the Gynaecology Emergency Department (GED) at Liverpool Women's NHS Foundation Trust made some adaptations to the care provided to pregnant women, in line with guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) (2020). One of the adaptations made was to offer women who have had a missed miscarriage the option of having medical management as an outpatient. The Miscarriage Association (2022) defines a missed miscarriage as one where the fetus has not developed or has died, often with the woman displaying no signs or symptoms.
Guideline 2 on the management of miscarriage at Liverpool Women's NHS Foundation Trust was recently updated following new evidence from the MifeMiso trial by Chu et al (2020a). Previously, the Trust's Guideline 1 was implemented in 2018 to reflect the National Institute for Health and Care Excellence (NICE) (2021) guideline on the diagnosis and initial management of ectopic pregnancy and miscarriage. Prior to offering outpatient management, all women were admitted as an inpatient to the Gynaecology Unit. Not only was the updated guideline in line with current evidence, it offered women and their families greater autonomy and involvement in decision-making in their care, which is advocated by the RCOG (2016). As a result, it also avoided unnecessary hospital admissions and reduced footfall throughout the Trust; this was particularly important at a time when we were trying to reduce transmission of COVID-19. Due to changes in practice, it was therefore vital to ensure that standards of practice we being adhered to in order to provide safe and effective treatment to patients. The audit looked at the outcomes of this treatment and its potential cost-effectiveness in relation to avoiding hospital admissions.
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