Delays to Surgery in Emergency Department Cases of Ectopic Pregnancy: A Quality Improvement Study

Abstract

Objective

Create a process map for emergency department (ED) presentations of surgical ectopic pregnancy, and identify areas of management amenable to quality improvement.

Methods

A retrospective chart review of all patients undergoing surgical management of ectopic pregnancy at a large, urban, academic tertiary care centre from 2015 to 2017 was performed.

Results

Seventy-three patients were included. There were 6 (8.2%) unstable A cases (recommended time to operating room [OR] 0–2 hours), 23 (31.5%) stable A cases, and 44 (60%) B cases (recommended time to OR 2–8 hours). The percent of patients who were in the OR within the recommended time window were 6 (100%) for unstable A cases, 13 (56%) stable A cases, and 29 (65.9%) stable B cases, respectively (P = 0.139). Notable time delays include the time from gynaecology referral to the time seen by gynaecology (29.7% of total wait time for stable A cases from ED to OR) and the time the OR was booked to the time the patient was brought to the OR (53.2% of total wait time for stable B cases). Of the patients seen by physician at the emergency department first, the time from triage to the OR was significantly shorter for patients that received bedside ultrasound only (0.67 ± 0.5 hours vs. 2.1 ± 1.8 hours [P = 0.007]).

Conclusion

This is the first study to map the ED presentation of surgical ectopic pregnancy. The management of ectopic pregnancy would benefit from the development of surgical triage decision aids, a surgical care pathway, and increased use of screening bedside ultrasound.

Résumé

Objectif

Dresser le parcours de prise en charge chirurgicale de la grossesse ectopique au service d’urgence, et déterminer les secteurs de prise en charge où la qualité pourrait être améliorée.

Méthodologie

Un examen rétrospectif a été effectué pour les dossiers de toutes les patientes ayant subi une prise en charge chirurgicale d’une grossesse ectopique dans un grand centre de soins tertiaires urbain pendant la période de 2015 à 2017.

Résultats

Soixante-quinze patientes ont été incluses. De ce nombre, on compte 6 cas A instables (8,2 %) (délai urgence-chirurgie recommandé de 0–2 h), 23 cas A stables (31,5 %) et 44 cas B (60 %) (délai urgence-chirurgie recommandé de 2–8 h). Le nombre de patientes s’étant retrouvées en salle d’opération dans les délais recommandés était de 6 (100 %) pour les cas A instables, de 13 (56 %) pour les cas A stables et de 29 (65,9 %) pour les cas B stables, respectivement (p = 0,139). On observe un temps d’attente notable entre la demande de consultation en gynécologie et le moment où la patiente est vue par un gynécologue (29,7 % du délai urgence-chirurgie pour les cas A stables) et entre le moment d’attribution du temps opératoire et l’arrivée de la patiente en salle d’opération (53,2 % du délai total pour les cas B stables). Des patientes vues par un médecin à l’urgence d’abord, le délai triage-chirurgie était significativement plus court pour celles ayant eu une échographie au chevet seulement (0,67 ± 0,5 h p/r à 2,1 ± 1,8 h [p = 0,007]).

Conclusion

Il s’agit de la première étude qui dresse le parcours de prise en charge de la grossesse ectopique au service d’urgence. Il serait bénéfique, pour la prise en charge de la grossesse ectopique, d’élaborer des outils d’aide au triage chirurgical, d’établir un parcours de prise en charge chirurgicale et d’augmenter l’utilisation de l’échographie au chevet.

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.