Quality Improvement Initiative to Optimize Management of Pregnancy of Unknown Location

Abstract

Introduction: Gynecology often gets consulted for patients with pregnancy of unknown location (PUL). Management is often delayed until a definitive diagnosis is made, despite the life-threatening nature of a missed or delayed diagnosis of ectopic pregnancy. A patient may undergo multiple blood draws and ultrasounds and wait days prior to diagnosis and treatment. In collaboration with the emergency department, a protocol was created to standardize the management of patients with PUL. The goal was to decrease the time to final diagnosis of pregnancy location, the time to resolution of management, and the total healthcare costs. Methods: This was an IRB approved (#15137) QI initiative that involved retrospective analysis of patients prior to and after implementation of the protocol. The protocol centered around offering management options after trending 3 β-HCG values. Provider education was implemented via presentation at Grand Rounds and periodic emails. Chi-square, Wilcoxon rank sum, and Kaplan Meier estimation tests were used for analysis. Results: Compared to preimplementation there was a decrease in the number of days to diagnosis from 9 days to 6 days (p=0.008). The distribution of ultrasounds (as presented from 25th to 75th percentile) performed prior to resolution changed from [1,3] preimplementation to [1,2] postimplementation (p=0.044). There was no significant difference in days to resolution (p=0.984) or number of blood draws performed prior to diagnosis and resolution (p= 0.150 and p=0.711). Conclusion: The implementation of a protocol standardizing management of PUL resulted in decreased time to final diagnosis and the number of ultrasounds patients required prior to diagnosis. This protocol highlights the benefits of cost-conscious patient-centered care in a common area of gynecologic practice.