The Impact of Acute Gynaecology/ Early Pregnancy Assessment Units

1. The Impact of Acute Gynaecology/ Early Pregnancy Assessment Units Special acknowledgement to A/Prof George Condous, Dr T Bignardi & Dr D Al-Hamdan Nepean Centre for Perinatal Care, SWAHS

2. Background & Challenge • Providing women in early stage & non-viable pregnancy with timely, appropriate care in a supportive environment • Difficulty in accessing “out of hours care” and relationship with ED & OPD • How can assessment services be delivered and what benefits can be derived? • Defined referral pathways and business rules have been established with ED’s and O&G teams at all SWAHS facilities – first established at Auburn Hospital circa 2001

3. SWAHS AGU/EPAC Attendances

4. The Model of AGU at Nepean Hospital • Set up in Nov 2006, The Acute Gynaecology Unit (AGU) at Nepean Hospital is a dedicated service that provides quick and easy access to diagnosis and treatment of acute gynaecological and early pregnancy complications. • This is an USS-based model of care which evaluates all women with acute gynaecological problems (pregnant and non-pregnant) using ultrasound at the primary interface. • Prior to setting this model of care, data was collected on all presentations, ectopic pregnancies and admission rates managed at Nepean between Aug 2004 and Nov 2006. This was then compared with all women who presented to the AGU between Dec 2006 and Feb 2008.

5. Measuring the Efficacy of AGU • Data collected on all acute gynaecological women who presented to the AGU between March and May 2007, i.e. after the unit had been established for 4 months. • Outcome measures included: Time to see doctor, Time to ultrasound, admission rates, number of women admitted for an ultrasound scan, length of stay (LOS) as an outpatient, LOS as an inpatient, occupied bed stays, surgery rates, expectant and medical management rates. P-values were obtained using t-test, chi-square or Fisher’s exact test for equality of two proportions. • Results: 133 consecutive women were reviewed before the introduction of the AGU (o ld model) and 157 consecutive women after the introduction of the AGU (new model). • The new USS-based model of care resulted in a significant decrease in admission rates, time to see doctor, to for an USS, LOS as an outpatient. • There was also an overall reduction in occupied bed stays as well as a decrease in surgery intervention rates and an increase in the number of women managed expectantly

6. Efficacy of Access to Care

7. Financial Efficiencies • Calculated admission rates and occupied bed stays in all women who attended Nepean (24/07/2006 - 08/09/2006) prior to the setting up of the AGU • Compared the admission rates and occupied bed stays of the AGU (26/03/2007 - 16/05/2007) to the traditional approach and extrapolated the data to the equivalent of one year’s duration and compared the costs of bed occupancy. • Cohort: 133 women in the pre-AGU group and 157 in the post-AGU group were included. No significant difference in age, proportion of pregnant women, complaints and final diagnoses between the two groups. • Results: Admission rates in the pre- and post-AGU 36.1% vs. 7%. • Total bed occupancy in the pre- and the post–AGU models of care were 85 and 30 days. • Total bed costs for the pre-AGU model of care were $47,600 AUD (over 46 day period) compared to $16,800 AUD (over 51 day period) for the post-AGU model of care. • Daily costing of $1035 (pre-AGU) for inpatient care vs. to $329 (post-AGU). • Estimated annual saving for the new model of care is $257,617

8. Management of Ectopic Pregnancies • Results: Reviewed in total 127 complete records of women treated for ectopic pregnancy in the two study periods. • After the unit was established, we observed a significant reduction in laparoscopic salpingectomy rate and a significant increase in expectant management. • There was a trend in reduction of laparotomic salpingectomy rate and a trend in increased use of MTX, however not statistically significant

9. Conclusions: • The new USS-based model of care for women with acute gynaecological complications significantly improves patient care. This new model of care streamlines the management of women with acute gynaecological problems; maximising outpatient management and minimising unnecessary inpatient theatre allocation. • The Acute Gynaecology Unit has changed the way we manage ectopic pregnancies with a shift towards more conservative approaches. This is potentially due to high-quality ultrasound and subsequently earlier diagnosis of ectopic pregnancy. • High surgical rate for ectopic pregnancy before the introduction of the AGU is highlighted to support the need for greater emphasis on medical and expectant management. • The new model of care resulted in a reduction of admission rates, bed occupancy and in turn in cost savings. This WAS NOT at the expense of misclassification of serious gynaecological conditions.