Table 5.2Findings for service organisation and delivery of EPAUs

StudyCharacteristics of model of careOutcomes
StaffingReferral systemsAvailability of out-of-hours careService outcomesWomen's views and experiences of care
Cross-sectional data from surveys of early pregnancy assessment units (EPAUs)
Poddar et al., 2011Practitioner performing ultrasound (n/total [%])

Sonographers: 67/140 (47.9%)

EPAU nurse specialist: 12/140 (8.6%)

Trained midwife: 7/140 (5%)

Medical staff: 2/140 (1.4%)

Combination: 52/140 (37.1%)
Direct referral system for women (n/total [%])

With previous EP: 125/140 (89%)

With recurrent miscarriage: 113/140 (81%)
Availability of service in clinics (n/total[%])

Weekday:

3-5 hours each weekday: 47/135 (34.8%)

6-11 hours each weekday: 74/135 (54.8%)

3 days a week: 1/135 (0.7%)

2 hours a day: 1/135 (0.7%)

Mean opening time/hours:

7.3 ± 3.6

Median (range) opening time/hours:

8 (2–24)

Weekend:

Full or partial weekend service: 42/140 (30%)
  • Open Saturday and Sunday: 21/140 (15%)
  • Open Saturday: 11/140 (7.9%)
  • Open Sunday: 8/140 (5.7%)
Inconsistent weekend service: 2/140 (1.4%)

Availability of 24 hour contact telephone (n/total [%])
  • For women receiving conservative/medical miscarriage management: 103/140 (74%)
  • For women receiving methotrexate for ectopic pregnancy: 99/125 (79%)
None reportedNone reported
Twigg et al., 2002Practitioner performing ultrasound (%)

Ultrasonographer: (52.0)

Radiologist: (2.0)

Gynaecologist: (11.8)

Gynaecology nurse: (4.9)

Other: (2.9)

Midwife: (2.9)

Combination: (23.5)


54.9% of units said that their scanning practitioners had formal training in breaking bad news.

51.5% of clinics said that all patients were seen by a gynaecologist.

95.8% said that they received adequate gynaecological back-up.
Proportion of clinics accepting women by each referral method (%)

Referral from other clinicians and general practitioners (GPs): 100

Direct from patients: 51

Other (e.g. midwives, Accident and Emergency [A&E], gynaecology): 21
Availability of service in clinics (%)

Weekday only: 77.4

Seven-day: 13.7

Once per week: 1

24-hour: 7
None reportedNone reported
Descriptive data from individual EPAUs
Akhter et al., 2007Senior sonographer, junior doctor and dedicated counselling midwife. (Consultant input is available for complicated cases)502/603 (83%) of women were self-referred.

The remainder were referred by their GP or the A&E department of other hospitals
No.

The clinic is open Monday to Friday 7.30 am to 10 am.
Number of patients seen

650 women attended during the study period of approximately 6 months

Waiting time/hours (range):

1 – 3

Need for a repeat scan (n [%]): 121 (20%)
None reported
Bignardi et al., 2010A gynaecological consultant is in charge of the unit on a day-to-day basis. History-taking, clinical examination and transvaginal ultrasound are all undertaken by the consultant.Referrals must be made by another practitioner (walk-ins are not permitted). The majority are referred by their GP or the emergency department.No.

The clinic is open 9 am – 1 pm Monday to Friday.
Waiting time/minutes (mean)
  • To see trainee gynaecologist: 172
  • For ultrasound exam: 199
Length of stay/minutes (mean)
  • as an outpatient: 45
  • as an inpatient: 274
Admission rate (n [%])
  • Total: 11 (7)
  • For ultrasound: 4 (2.5)
None reported
Bigrigg & Read, 1991Women are seen by the duty senior house officer (SHO), but a registrar and consultant are available on-site if needed.GPsUnclear.

Open 7 days a week, with a limited on-call system. Out-of-hours operating is avoided.
Number of women seen

In the first year, 771 women were referred to the unit.

Length of stay/days
  • Maximum: 1.5
  • For women with viable IUP or not pregnant: 0.08 (2 hours)
  • For women needing evacuation of uterus: 1
Need for a repeat scan (%): 11
None reported
Brownlea et al., 2005Women are reviewed by an obstetrics and gynaecology registrar who performs transvaginal ultrasound.Referrals are received from both the emergency department (ED) and GPs.

Referrals from a non-ED source (%)

Year 1: 26

Year 7: 48
Unclear.

The paper reports that referred patients are reviewed on a weekday morning.
Number of patients seen in Jan-Feb of years following establishment of EPPS (n)

Year 1: 15

Year 7: 61

Proportion of patients discharged from ED followed up in EPPS (n/total [%])

Year 1: 11/54 (20%)

Year 7: 36/52 (69%)

Proportion of EPP patients representing to ED with further pain and/or bleeding (n/total [%])

Year 1: 12/95 (13%)

Year 4: 12/82 (15%)

Year 7: 6/81 (7%)

Proportion of EPP patients requiring hospital admission (n/total [%])

Year 1: 41/95 (43%)

Year 4: 28/82 (34%)

Year 7: 29/81 (36%)

(P = 0.6 for trend)
None reported
Davies & Geogheg an, 1994Nurse-led unit, with a team of ward clerks, doctors, scan stenographers and phlebotomists.

Following the scan, a registrar compares the scan with the patient's history and makes a diagnosis.
GPsNo details givenNone reportedNone reported
Edey et al., 2007An audit of the unit found that only 29% of the women needed to be seen by the junior doctor in the clinic, with the rest being managed by the sonographer and nurse practitioner.Source of referrals (%)

GPs: 40

A&E: 2

(No further details given)
Unclear.

The clinic is open daily, but no further details are given. It is unclear whether this includes weekends or not.
None reportedNone reported
Fox et al., 1999Out of 198 women, 120 (61%) were managed by a nurse only. 78 (39%) required medical assessment.Midwives or GPsNo.

The clinic is open 5 days a week.
In 198 cases (100%), a nurse practitioner made the correct initial diagnosis in her assessment of the woman's condition.None reported
Harper, 2003Midwife provides care, with later referral to medical personnel if needed.Self-referrals are accepted, as well as referrals from miscarriage assessment clinic, antenatal clinic, GPs, A&E, team-based midwives.Unclear.

Women are provided with a 24-hour telephone advice number
None reportedNone reported
Hill, 2009Clinical nurse specialist (runs service), two ultrasonographers and an on-call registrar when requiredSource of referrals (n/total [%])

GP: 96/230 (42%)

EPAC: 44/230 (19%)

Consultant: 27/230 (12%)

A&E: 24/230 (10%)

Midwife: 14/230 (6%)

SHO: 9/230 (4%)

Antenatal: 8/230 (3%)

Registrar: 3/230 (1%)

Re-scan: 3/230 (1%)

Jas: 2/230 (0.9%)
No.

The clinic is open weekday mornings.
Patients seen on time (n/total [%])

Yes: 217/237 (92%)

No: 1/237 (0.4%)

Not stated: 12/237 (5%)

N/A: 2/237 (0.8%)

Did not attend: 5/237 (2%)

Acceptable wait for appointment referral (n[(%])

Yes: 161 (68%)

No: 1 (0%)

Probable rescans or further treatment: 75 (32%)

Number of patients seen:

82 over a two-month period
Women reported being seen on time (n [%])

Yes: 79 (96%)

No: 3 (4%)

Women felt wait for appointment was acceptable (n [%])

Yes: 76 (94%)

No: 5 (6%)

Women felt care in scanning department was given in a sensitive manner (n [%])

Yes: 80 (99%)

No: 1 (1%)

Sonographer explained results in a way that women could understand (n [%])

Yes: 81 (99%)

No: 1 (1%)

Women felt they were given a thorough explanation (n [%])

Yes: 81 (99%)

No: 1 (1%)

Women felt questions were answered in a way they could understand (n [%])

Yes: 80 (98%)

No: 2 (2%)

Women's satisfaction with interaction with different staff (n/total [%])
  1. Receptionist
    Excellent: 27/63 (43%)
    Good: 30/63 (48%)
    Fair: 5/63 (8%)
    Poor: 1/63 (2%)
  2. EPAC Nurse Specialist
    Excellent: 76/82 (93%)
    Good: 6/82 (7%)
    Fair: 0/82
    Poor: 0/82
  3. Sonographers
    Excellent: 66/81 (81%)
    Good: 14/81 (17%)
    Fair: 1/81 (1%)
    Poor: 0/81
  4. Doctors
    Excellent: 13/22 (59%)
    Good: 9/22 (41%)
    Fair: 0/22
    Poor: 0/22
Women's satisfaction with privacy, dignity and care (n/total [%])
  1. Privacy
    Excellent: 65/80 (81%)
    Good: 14/80 (18%)
    Fair: 1/80 (1%)
    Poor: 0/80 (0%)
  2. Dignity
    Excellent: 69/80 (86%)
    Good: 11/80 (14%)
    Fair: 0/80 (0%)
    Poor: 0/80 (0%)
  3. Care
    Excellent: 69/80 (86%)
    Good: 11/80 (14%)
    Fair: 0/80 (0%)
    Poor: 0/80 (0%)
Sellapan et al., 2009Out of 198 women, 125 (66.5%) were managed by midwives only. 45 (23.9%) were managed by medical staff.Source of referrals (n/total [%])

GP: 90/188 (47.8%)

Emergency department: 17/188 (9%)

Self-referral: 31/188 (16.5%)
No details givenWaiting time/minutes (n)
  • Up to 30 minutes: 95
  • Up to 60 minutes: 55
  • More than 60 minutes: 18
Average waiting time/minutes: 11

Need for a repeat scan: 25/188 (13.3%)
None reported
Shillito & Walker, 1997No details givenMost referrals come through GPs or A&ENo.

The clinic is open Monday to Friday from 8 am to 12.30 pm; however staff deal with telephone enquiries until 8 pm.
Workload per week (average): 30

Time of discharge (%)

Same day: 89

Immediately: 80

After same-day evacuation: 9
In a survey of 100 women, over half wanted to see a specialist nurse and less than 10% expected to see a doctor.
Tunde-Byass & Cheung, 2009Team of dedicated gynaecologists and experienced obstetrical nurses. Gynaecologists perform the ultrasound scans.Source of referrals (n/total [%])

Emergency room (ER): 557/1448 (38.5%)

Family physician: 445/1448 (30.7%)

Obstetrician-gynaecologist: 349/1448 (24.1%)

Midwife: 30/1448 (2.1%)

Other: 67/1448 (4.6%)
No.

The clinic is open three mornings per week from 9 am to 12 noon.
Number of women requiring repeat ER assessment (n/total [%]): 738/3062 (24.1%)None reported

A&E accident and emergency department, ED emergency department, EP ectopic pregnancy, EPAC early pregnancy assessment clinic, EPAU early pregnancy assessment unit, EPPS early pregnancy problem service, ER emergency room, IUP intrauterine pregnancy, P probability, SHO senior house officer

From: 5, Early pregnancy assessment units

Cover of Ectopic Pregnancy and Miscarriage
Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management in Early Pregnancy of Ectopic Pregnancy and Miscarriage.
NICE Clinical Guidelines, No. 154.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG; 2012 Dec.
Copyright © 2012, National Collaborating Centre for Women's and Children's Health.

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