OzEMedicine - Wiki for Australian Emergency Medicine Doctors

see also:

• Western Health ED main page
• gynaecology
• vaginal bleeding in early pregnancy
• obstetric and gynaecology services at Western Health
• WH O&G rosters
• O&G in the ED (2017) 4Mb Powerpoint presentation - intranet only
• new JKWCH EPAS model of care

• The EPAS service is to provide expert advice and continuity of clinical care for women presenting with complications of early pregnancy.
• EPAS is an ambulatory (outpatient) service for clinically stable patients.
• The service is a combination of:
  • Dedicated EPAS clinic (now in JKWCH on Women’s Clinic ‘B’, on Level 1 - RN contact phone 53148)
  • EPAS registered nurses with specific expertise in the management of early pregnancy
  • 8 booked appointments for EPAS are available from 08:30 – 12:00 Monday to Friday (via iPM referrals from ED)
  • Between 12:30 - 17:00 Monday to Friday, a walk in service is available for women presenting to the Sunshine Hospital (SH) Emergency Department (ED) or the JKWC MAC
  • EPAS does not provide any service after hours, on weekends or on public holidays, these patients will be redirected to the ED.
  • EPAS RN shift is rostered from 08:30 – 17:00 Monday to Friday.
  • Nominated EPAS registrar 0800 – 1600 M-F (afternoons this is the EDOG registrar?) with on-call O&G consultant.
  • Dedicated sonographer/sonologist service with immediate reporting.
  • Clinical guidelines and algorithms to support care:
    • EPAS clinical practice guideline – NICE early pregnancy management
    • Algorithm for bleeding and pain in early pregnancy
    • Information for EPAS patient referred from ED
    • Pathways of Care for Early Pregnancy complications - flow sheet
  • Patient information for ED, inpatients and EPAS clinic attendances.

EPAS (from 6/3/17) will be a single site continuity of care model – clinical review, ultrasound, medical and surgical management and ongoing review by telephone. Discharge planning will include verbal and written communication to referring GP.

• Pregnancy confirmed with urine or blood HCG that is complicated by pain or PV bleeding (or both)
• Gestation less than or equal to 16 weeks’ (includes ultrasound diagnosed missed miscarriage)
• Patient is clinically stable (not requiring parenteral analgesia and minimal PV loss).
• Clinically stable confirmed or suspected Ectopic Pregnancy (EP) may be suitable for EPAS referral, but MUST be discussed with EPAS team or on-call O&G registrar.

If uncertain as to eligibility for EPAS, discuss with either EPAS RN, EPAS registrar (M-F) or on-call O&G.

• >16 weeks - refer to MAC instead.
• clinically unstable
  • intra-uterine pregnancy with ongoing moderate to heavy PV bleeding
  • suspected inevitable miscarriage with cervical shock
  • suspected or confirmed ectopic pregnancy with pain/hypotension/tachycardia etc.
  • demographic barriers to OP care (language/transport etc)
• EPAS is NOT the referral point for gynaecology conditions such as ovarian/adnexal pathology or hyperemesis gravidarum.
• Suspected fetal anomalies with outside scans and/or at-risk genetic screening results should be discussed with the MFM unit (foetal / fetal medicine)

• EPAS appointments are made through iPM or via direct phone call to the EPAS RN Monday-Friday 0800-1600
• The ED clerical staff will be trained in the iPM referral process
• The EPAS RN will review the referrals received in the morning Monday-Friday and contact the patient
• EPAS referrals approved after discussion or review by the O&G team are made in the same way through ED clerical staff.

• tests to order in ED:
  • FBE
  • Blood group and antibody screen if not known to be Rh +ve
  • Quantitative B-HCG if indicated
  • Pelvic ultrasound referral for EPAS team – on standard imaging request – “TA/TV pelvic ultrasound – early pregnancy”. Patient to bring this to the EPAS appointment.
• Should Anti-D be administered in ED?
  • If the EPAS referral is going to be < 24 hrs, Anti-D can be deferred to the EPAS team.
  • If the interval from referral to appointment is > 24 hrs (Friday/Sat), Anti-D 250IU IMI should be administered to patients with Rh-ve blood group.
  • Sunday-Thursday presentations will be contacted by EPAS RN the next morning and Anti-D
• provide patient information:
  • The EPAS patient should be given the “Early Pregnancy Assessment Service (EPAS)” Pamphlet.
    • This pamphlet contains information on when to expect contact, directions to the EPAS clinic (2A), EPAS RN contact number in case no contact is made or patient is unable to find the clinic, what to expect at the EPAS appointment, circumstances in which re-presentation to ED is appropriate. They can also be directed to the WH internet- Patient Information will be uploaded onto this site
  • Vic DHS - bleeding in early pregnancy (pdf)
  • Vic DHS - miscarriage (pdf)
• documentation:
  • Normal ED documentation in EDIS
  • EPAS clinic documentation is on a dedicated database (G+ - Solutions Plus) which interfaces with Bossnet to transfer a summary of each EPAS visit to the DMR.