Gynaecology • GynécologieDelays to Surgery in Emergency Department Cases of Ectopic Pregnancy: A Quality Improvement Study
Introduction
Ectopic pregnancy (EP), accounting for 1% to 2% of all pregnancies, is responsible for an estimated 75% of first trimester deaths and between 9% and 13% of all pregnancy-related deaths.1 An EP occurs when an embryo implants outside the uterine cavity, most commonly in the fallopian tube.2 An EP is often suspected from an abnormal rising of serial serum β-human chorionic gonadotropin (β-hCG) measurements and is diagnosed through ultrasound.3 Tubal EPs can be managed expectantly, medically, or surgically with salpingectomy or salpingotomy.3 Despite continued improvements to guidelines and growing research on the diagnosis and management of EP, the mortality rates have remained relatively unchanged because of missed diagnoses and delays to appropriate management.4
Delays in the care of EPs are associated with an increased rate of rupture and, therefore, rupture-related morbidity, including severe hemorrhage, need for transfusion, increased length of hospital stay, and implications for fertility.5,6 In addition, prolonged wait times, the need for blood transfusion, and the amount of hemoperitoneum are known as significant markers for patient satisfaction undergoing care for EP.7,8 Although there is some evidence to support specific clinical features of EP presentation as prognostic markers for rupture, such as β-hCG levels and previous EP, to date, there are no clinical features that have been proven to reliably predict the rupture of an EP.5,9, 10, 11 As such, early diagnosis and management remain 2 of the strongest methods to prevent an EP-related morbidity.5,6,12
Clinical care pathways have been used for other surgical emergencies, including ovarian torsion and appendicitis.13, 14, 15 The goal of this study was to conduct a process map to better understand the surgical management of EP and identify gaps amenable to quality improvement at a large tertiary care centre.
Section snippets
Methods
Research ethics board approval was obtained through Sunnybrook Health Sciences Centre (REB 424-2019).
Results
Eighty-eight patients underwent surgical management for an EP during the study period. Seventy-three patients met the inclusion criteria for analysis. A process map is shown in the Figure. Forty-six patients (65%) were initially seen by the ED staff before being referred to gynaecology and 18 (25%) were seen directly by gynaecology. The cases seen directly by gynaecology were sent to the ED by a gynaecologist; these cases had a known EP diagnosis, a plan in place for care, and the patients had
Discussion
Despite multiple evidence-based guidelines on the early and accurate diagnosis of EP, the mortality rate in EP has remained relatively static.3,4,16 In the context of largely inconclusive literature to predict patients at risk of severe morbidity in EP, timely diagnosis and management remains essential to reducing EP-related morbidity.5,6
The present study identified that roughly half of stable EP cases were brought to the OR within the recommended time window as outlined by their surgical
Conclusion
This is the first study to map the ED presentation of EPs requiring surgery and identify processes amenable to quality improvement. The management of EPs would benefit from the development of evidence-based surgical triage, the implementation of a clinical care pathway, and, specifically, the increased use of screening bedside ultrasound. Future work should identify if non-gynaecologic surgeries have similar rates to the OR within a recommended time window.
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Disclosures: L.P. has received an honorarium from AbbVie. All other authors declare they have nothing to disclose.
Each author has indicated they meet the journal’s requirements for authorship.
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Amanda Poxon and Lauren Clarfield are co-first authors.