Services for emergency department patients experiencing early pregnancy complications: A survey of Ontario hospitals

Time to Make Early Pregnancy Care a Priority in Canada

Early pregnancy is a critical period often accompanied by complications like early pregnancy loss. Early Pregnancy Assessment Clinics (EPACs) provide specialized and compassionate care to those experiencing these complications. First introduced in the UK, EPACs have been found to improve quality of care, reduce wait times, and cut costs. In Canada, EPACs are primarily limited to large urban centers at hospital sites. Access in other parts of the country, especially in rural areas, remains limited. Low-volume units managed by specialist nurses and family doctors, with support from specialists, are the best way to bring EPACs to more Canadians in need.

Cross-sectional study to assess the impact of the COVID-19 pandemic on healthcare services and clinical admissions using statistical analysis and discovering hotspots in three regions of the Greater Toronto Area

OBJECTIVES

The COVID-19 pandemic disrupted healthcare services, leading to the cancellation of non-urgent tests, screenings and procedures, a shift towards remote consultations, stalled childhood immunisations and clinic closures which had detrimental effects across the healthcare system. This study investigates the impact of the COVID-19 pandemic on clinical admissions and healthcare quality in the Peel, York and Toronto regions within the Greater Toronto Area (GTA).

DESIGN

In a cross-sectional study, the negative impact of the pandemic on various healthcare sectors, including preventive and primary care (PPC), the emergency department (ED), alternative level of care (ALC) and imaging, procedures and surgeries is investigated. Study questions include assessing impairments caused by the COVID-19 pandemic and discovering hotspots and critical subregions that require special attention to recover. The measuring technique involves comparing the number of cases during the COVID-19 pandemic with before that, and determining the difference in percentage. Statistical analyses (Mann-Whitney U test, analysis of variance, Dunn's test) is used to evaluate sector-specific changes and inter-relationships.

SETTING

This work uses primary data which were collected by the Black Creek Community Health Centre. The study population was from three regions of GTA, namely, the city of Toronto, York and Peel. For all health sectors, the sample size was large enough to have a statistical power of 0.95 to capture 1% variation in the number of cases during the COVID-19 pandemic compared with before that.

RESULTS

All sectors experienced a significant decline in patient volume during the pandemic. ALC admissions surged in some areas, while IPS patients faced delays. Surgery waitlists increased by an average of 9.75%, and completed IPS procedures decreased in several subregions.

CONCLUSIONS

The COVID-19 pandemic had a universally negative impact on healthcare sectors across various subregions. Identification of the hardest-hit subregions in each sector can assist health officials in crafting recovery policies.

Psychologic Sequelae in Early Pregnancy Complications

Early pregnancy complications, including miscarriage, ectopic pregnancies, and hyperemesis gravidarum, are common discomforts accounting for about 15% to 20% of all pregnancies. A proportion of women with early pregnancy complications will experience short- and long-term psychologic sequelae in the aftermath of pregnancy complications, including anxiety, depression, and post-traumatic stress disorder (PTSD) which are the most commonly reported psychologic reactions. This review will focus on the course and impact of these psychologic sequelae in early pregnancy complications, and the noninvasive interventions to improve mental health are also briefly discussed.

Experiences and outcomes of women with bleeding in early pregnancy presenting to the Emergency Department: An integrative review

BACKGROUND

Bleeding in early pregnancy occurs in approximately a quarter of all pregnancies and is a common reason for presentation to the Emergency Department (ED). This review combined current knowledge about experiences, interventions, outcomes and frequency of women presenting to the ED with per vaginal (PV) bleeding in the first 20 weeks of pregnancy.

METHODS

This integrative literature review was conducted using electronic database and hand searching methods for primary research published from 2000; followed by screening and appraisal. Articles were compared and grouped to identify characteristics and patterns that guided the synthesis of categories.

RESULTS

Forty-two primary research articles met inclusion criteria. Four main categories related to experiences and outcomes of women with bleeding in early pregnancy presenting to the ED were identified: presentation frequency and characteristics; women and their partners' experiences in the ED; interventions and treatments; patient and health service outcomes.

CONCLUSIONS

Negative and often frustrating experiences are reported by women experiencing PV bleeding, their partners and ED healthcare providers. While strategies such as early pregnancy assessment services contribute to improved outcomes, the availability of these services vary. Further research is needed to identify specific needs of this group of women and their partners, and the staff providing their care in the ED, to inform strategies for improved quality of care.

Women's experiences of health care utilization in cases of early pregnancy loss: A scoping review

BACKGROUND

Approximately 25% of pregnancies end in miscarriage, most occurring within the first trimester (<13 weeks). For many women early pregnancy loss has implications for short- and long- term mental health, and women's well-being following early pregnancy loss is impacted by their experiences within the healthcare setting. To improve quality of care, it is crucial to understand women's' experiences within the healthcare system in cases of early pregnancy loss.

QUESTIONS

What does the research literature tell us about the experiences of early pregnancy loss within healthcare settings? Are these experiences positive or negative? 'How can care improve for those experiencing early pregnancy loss?'

METHODS

A scoping review of the research literature was undertaken. Three research databases were searched for relevant articles published in English since 2009, with key words related to 'Experience', 'Healthcare' and 'Early Pregnancy Loss'. A thematic analysis was undertaken to identify and summarize key findings emerging from the research literature.

FINDINGS

Twenty-seven (27) articles met our inclusion criteria. Three main themes were identified: (1) issues related to communication, (2) challenges within care environments, and (3) inadequacies in aftercare.

DISCUSSION

The literature suggests that women's experiences related to healthcare for early pregnancy loss are largely negative, particularly within emergency departments. Recommendations to improve women's experiences should extend beyond attempts to improve existing care structures, to include emerging environments and providers.

CONCLUSION

Women's experiences identified within the literature provide further insights on what women are seeking from their care, and how care models can be improved.

Exploring the services and management available to women experiencing complications in early pregnancy: a survey of Ontario, Canada hospitals

This investigation surveyed the gynaecologic services and management available to women experiencing early pregnancy complications in the province of Ontario, Canada. The Chiefs of Gynaecology/Obstetrics of 61 Ontario hospitals were invited to complete a 55-item, online questionnaire using modified Dillman methodology. Forty-three hospital site respondents completed the survey (a response rate of 70.5%). It was reported that 18 (41.9%) hospitals had access to an early pregnancy assessment unit (EPAU), and 12 (66.7%) EPAUs had ≤2 days between the referral and the first appointment. Of the 25 (58.1%) hospital respondents without an EPAU, 14 (56.0%) reported previous consideration of creating an EPAU. At these hospitals, patients with early pregnancy complications have access to care through the ED (n = 22, 88.0%), obstetricians/gynaecologists (n = 22, 88.0%), person on-call (n = 16, 64.0%), family physicians (n = 11, 44.0%) or midwives (n = 9, 36.0%). This investigation found great heterogeneity in the care accessible to women experiencing early pregnancy complications in hospitals in Ontario, Canada.Impact statementWhat is already known on this subject? Early pregnancy assessment units (EPAUs) are the standard for evaluating and caring for complications of early pregnancy. It has been well documented that EPAUs result in positive health service outcomes such as more cost-effective care, more timely management, and improved quality of care and patient satisfaction.What do the results of this study add? This investigation found that the province of Ontario, Canada has begun to adopt the EPAU model; however, a great heterogeneity exists in the care accessible to women experiencing early pregnancy complications throughout the province. Nonetheless, where EPAUs are available, they provide a structured referral system for women experiencing complications of early pregnancy that require gynaecologic assessment, such as ectopic pregnancy, providing close follow-up and predictable pathways of care for this patient population.What are the implications of these findings for clinical practice and/or further research? This study highlights the need for hospitals in the province of Ontario to improve their current service delivery models for women experiencing early pregnancy complications. Further research should be undertaken to determine whether the positive health service outcomes of EPAUs are also relevant in the Canadian healthcare system.

Emergency department use by pregnant women in Ontario: a retrospective population-based cohort study

BACKGROUND

Peripregnancy emergency department use may be common, but data specific to health care systems like that in Canada are lacking. As prior research was limited to livebirths, omitting pregnancies ending in miscarriage or induced abortion, the current study quantified and characterized emergency department use among women in Ontario with a recognized pregnancy.

METHODS

This retrospective population-based cohort study included all recognized pregnancies among Ontario residents aged 10-55 years with an estimated date of conception between Apr. 1, 2002, and Mar. 31, 2017. We defined peripregnancy emergency department use as any emergency department visit during pregnancy or within 42 days after pregnancy. We used modified Poisson regression with a robust error variance to generate relative risks (RRs) and 95% confidence intervals (CIs) for the outcome of any peripregnancy emergency department use in association with maternal age, parity, residential income quintile, location of residence, immigrant status, antenatal care provider and number of comorbidities within 120 days before the clinical start of the pregnancy (expressed as total number of Aggregated Diagnosis Groups [ADGs] obtained with the Johns Hopkins Adjusted Clinical Group System). All RRs, except for number of comorbidities, were further adjusted for number of ADGs.

RESULTS

Peripregnancy emergency department use occurred in 1 075 991 (39.4%) of 2 728 236 recognized pregnancies, including 35.8% of livebirths, 47.3% of stillbirths, 73.7% of miscarriages and 84.8% of threatened abortions. A peripregnancy emergency department visit was more likely among women who were less than 25 years of age (adjusted RR 1.16, 95% CI 1.16-1.17), were nulliparous (adjusted RR 1.13, 95% CI 1.13-1.13), resided in the lowest income quintile area (adjusted RR 1.16, 95% CI 1.15-1.16) or in a rural area (adjusted RR 1.50, 95% CI 1.50-1.51), were Canadian-born (adjusted RR 1.22, 95% CI 1.22-1.23), were not seen by an obstetrician (adjusted RR 1.66, 95% CI 1.54-1.80) or had a greater number of ADGs. Emergency department use peaked in the first trimester and in the first week postpartum. Compared to women residing in urban areas, those residing in rural areas had an odds ratio (OR) of 3.44 (95% CI 3.39-3.49) for 3 or more emergency department visits. Women with 3-4 (OR 1.99, 95% CI 1.97-2.01), 5-6 (OR 3.55, 95% CI 3.49-3.61), or 7 or more (OR 7.59, 95% CI 7.39-7.78) prepregnancy comorbidities were more likely to have 3 or more peripregnancy emergency department visits than were those with 2 or fewer comorbidities.

INTERPRETATION

Peripregnancy emergency department use occurred in nearly 40% of pregnancies, notably in the first trimester and early in the postpartum period. Efforts are needed to streamline rapid access to ambulatory obstetric care during these peak periods, when women are susceptible to miscarriage or a complication after a livebirth.

The emergency department experience of patients with early pregnancy complications: A qualitative study

OBJECTIVE

The purpose of this qualitative study was to explore the experiences and perceptions of care of women treated for early pregnancy complications in a Canadian emergency department (ED) and early pregnancy clinic (EPC).

METHODS

We conducted a descriptive qualitative study to understand the perceptions, meanings, and perspectives of women of 18 years and older who presented to the ED or EPC of an urban, tertiary care hospital with early pregnancy complications or loss. Using a semi-structured interview guide, a 45- to 60-minute telephone interview was conducted by a trained qualitative interviewer at 4 to 6 weeks after the ED visit. All interviews were digitally recorded and transcribed verbatim for analysis. Data analysis occurred in conjunction with data collection in order to continuously monitor emerging themes and general areas for further exploration. Interviews were conducted until thematic saturation had occurred.

RESULTS

Interviews were completed with 30 women between June and August 2018. Three key themes arose: disconnect of the ED's role in the provision of care, normalization of a chaotic healthcare experience, and finding connection through the institution's EPC.

CONCLUSIONS

Perspectives of women with early pregnancy complications highlight the ways in which ED care often does not meet the expectations or needs of patients and their families. The emotional complexity of this medical situation is often overlooked by ED staff and can produce encounters that are distressing. However, negative experiences were often mitigated by follow-up care in the institution's EPC.