359 The Role of Specific Discharge Instructions in Follow-Up for Pregnancies of Uncertain Location

Abstract

To determine if the creation of new discharge (DC) instructions for patients diagnosed with pregnancy of uncertain location (POUL) resulted in a change in follow-up compliance. A retrospective chart review was conducted on all emergency department (ED) patients with the diagnosis of POUL during the year prior to and immediately following the implementation of the new DC instructions. All ED patients with a positive pregnancy test and a pelvic ultrasound performed demonstrating POUL were included. Prior to this change, patients received generic discharge instructions such as “vaginal bleeding,” or “bleeding in pregnancy.” After implementation, patients received the new instructions, entitled: “Threatened Ectopic Pregnancy (TEP).” The study was conducted in the Emergency Department of MedStar Washington Hospital Center in Washington, DC: a 926-bed level 1 trauma acute care urban academic hospital with 87,475 annual ED visits. A chart reviewer, blinded to patient identifying information, reviewed all charts for physician documentation, ultrasound results, and DC instructions. Notation was made as to whether or not the patient was told to follow up in 48 hours, and to whom the patient should follow up with (the ED or their obstetrician). For the post-implementation group, the chart was reviewed to see whether or not the new TEP DC instruction was given. The primary outcome was the rate of follow-up, comparing the pre-TEP instruction group to the post-TEP instruction group. The secondary outcomes were the diagnosis at the second ED visit, and obstetric consultation during either visit. Overall, the percent of patients told to return within 48 hours increased from the pre to post-implementation group (89% versus 93.5%). In addition, it does not appear that obstetric consultation correlates with increased patient follow-up (26% follow-up within 48 hours with obstetrics consultation versus 30% without obstetrics consultation). Finally, the most common diagnosis at second ED visit in the pre and post-implementation groups was “Threatened Miscarriage” (91%). Ectopic pregnancy is a life-threatening diagnosis. Frequently, patients present to the ED and are evaluated too early in pregnancy to determine whether or not an ectopic pregnancy is present. The implementation of the specific TEP DC instruction has ensured urgent follow-up for these cases. Prior to implementing the new DC instruction, various diagnoses were given to patients, masking the potential serious complication of ectopic pregnancy The TEP DC instruction underscores the indeterminate status of the pregnancy, the potential complications of an ectopic pregnancy, and the importance of the prescribed urgent follow-up. The increase in the number of patients with POUL returning within 48 hours demonstrates the success of this new DC instruction. Limitations include the unknown rate of patients with POUL who elect to follow up with their primary obstetrician rather than the ED. Additionally, patient population characteristics and availability of emergent ultrasound and obstetric consultation may differ at different facilities.