Milton Keynes Clinical Effectiveness

Nurse LedHysteroscopy Service

A Patient Satisfaction Clinic

March 2009

Jayne Nicolaou

ANP Hysteroscopist

CONTENTS

Executive Summary

Introduction

Methodology

Results

Discussion

Recommendations

Appendices

Appendix 1 Questionnaire

Appendix 2 Patients’ comments

Trust Action Plan

References

page1

Executive Summary

A retrospective study of Postmenopausal women who attended the Hysteroscopy clinic these were performed by the Nurse Hysteroscopist. It takes into account their experiences, their fears during outpatient hysteroscopy.

The service is fast and vital for women with post-menopausal bleeding where there could be a diagnosis of endometrial malignancy. The hysteroscopy team is committed to women’s health and its philosophy is to give women informed choices to enable them to take charge of their own health. The Patient satisfaction questionnaire has shown that 37 out of 38 women were very satisfied and suggestions made by the patients have been acted upon.

Privacy and dignity was maintained this has shown to be 97% we have no designated changing area and make do with what is available, these results are reassuring.

High patient satisfaction has assured its quality and success.

Recommendations:

Maintain and develop protocols to guide the appropriate delivery of service

Accountability for maintaining good practice
Amend referral criteria more efficient service re lack of sonographer support to clinic.
Insufficient support for formal data collection
Repeat audit taking into consideration a larger sample size
Different data collection method/Postal questionnaires/Bar code questionnaires via Healthcare Governance Support Unit more efficient
To continue to evaluate patient satisfaction and inform patients of retrospective audits
All patient information, patient letter and initial phone will be made via Cancer Services two week wait office for women with postmenopausal bleeding which will make the service more efficient.

Introduction

I qualified as a Nurse Hysteroscopist December 2005 my theory training was based atBradfordUniversity under the guidance of Sian Jones Consultant Gynaecologist and President of the British Society for Gynaecological Endoscopy (BSGE). I started performing hysteroscopies independently in April 2006. My Lead Consultant in Milton Keynes is Mr Stock any issues or concerns I have regarding patient management I am able to discuss with him. I also work closely with the Gynaecology Oncology ANP our work often over laps. We are all part of a very important team the Gynaecology Multidisciplinary team. Meetings are held every Monday linking Milton Keynes with Northampton Hospital Foundation Trust. Live TV video link is made to discuss further management of confirmed endometrial cancer and conditions such as endometrial hyperplasia.

Referral to my clinic is made via Cancer Services ‘Two Week Wait’proforma. GP’s have direct access to this service. The endometrial assessment service has to be efficient in order to meet such targets and optimise patient prognosis. Traditional investigation of women with post menopausal bleeding (PMB) was under General Anaesthetic using blind dilatation of the cervix and curettage of the endometrium (D&C) is now considered outdated and has been replaced by initial Out Patient Department endometrial evaluation (OPD). This includes trans- abdominal and transvaginal scanning prior to hysteroscopy. I do not have a sonographer allocated to my clinic so I’m unable to offer a ‘One Stop Service’ my patients are mostly scanned prior to appointment.

The majority of women with PMB have benign pathology. However, rapid referral for endometrial assessment is mandatory because 5-10 per cent of women with PMB will have endometrial cancer and 10-25 per cent will have endometrial hyperplasia, both conditions that may impact on patient prognosis (Clark & Gupta, 2005).

To maintain good practice and high standards of care, a retrospective study of Postmenopausal women who attended the Hysteroscopy clinic these were performed by the Nurse Hysteroscopist. It takes into account their experiences, their fears during outpatient hysteroscopy.

The service is fast and vital for women with post-menopausal bleeding where there could be a diagnosis of endometrial malignancy. The hysteroscopy team is committed to women’s’ health, and its philosophy is to give women informed choices to enable them to take charge of their own health. The Patient satisfaction questionnaire has shown that 37 out of 38 women were very satisfied and suggestions made by the patients have been acted upon.

Aim

The patient satisfaction survey was undertaken to assess and improve the nurse-led service provided to women undertaking hysteroscopy.

Objectives

Improve verbal and written information prior to hysteroscopy
Improve understanding of the procedure
Patient satisfaction
Maintain privacy and dignity at all times

Audit design

Retrospective
Written questionnaire post procedure

Guidance from Health Governance Facilitator

Methodology

50 questionnaires were printed only 38 patients completed the form. The forms were given to patient after the hysteroscopy and taken to a private room to complete the questionnaire the completed forms were then placed in a sealedbox.
Confidentiality and Data protection maintained
Retrospective study of womanwho presented with postmenopausal bleeding via the Two week wait cancer services route.
The study took place over several weeks in September 2008

Results

Graph 1

All women are contacted prior to hysteroscopy via cancer services two week wait team, yet only 17 state they had a phone call. 26 patients received the hysteroscopy leaflet and a further 18 received a combination of patient information and letter.

Graph 2

The patients felt the information received what ever form verbal and written was very good.

Graph 3

Shows 35 patients out of 38 felt they had the every opportunity to ask questions regarding the hysteroscopy procedure.

Graph 4

Majority of women attending for OPD hysteroscopy understood the reason they were attending and what the procedure entailed. Pre-hysteroscopy procedure was understood by 82% of women and similar understanding for post-hysteroscopy procedure of 84%.

Graph 5

Pain/ discomfort during OPD hysteroscopy is variable. 53% of women felt they did not require any pain relief prior to hysteroscopy.

Sixty-six percent (66%) of women preferred not to have aGeneral anaesthetic for hysteroscopy. Sixteen per cent (16%) would have preferred a general anaesthetic but tolerated the procedure.

Graph 6

Vaginal bleeding post hysteroscopy remained not alarming and for the majority was ‘as expected’.

Graph 7

High patient satisfaction has assured its quality and success. Thirty-seven out of thirty-eight women were very satisfied and suggestions made by the patients have been acted upon.

Ninety-seven percent (97%) of the patients thought that privacy and dignity was maintained throughout the Hysteroscopy process.

Positive comments were received from majority of patients (Appendix 2).

“Jayne and her team reassuring and supportive. A positive experience. Thank you Jayne”.

Other feedback regarding appointment letter/patient information leaflet have been addressed by implementing a streamlined approach using Cancer Services.

“Appointment came via appointments office by telephone. No further information until I telephoned to ask. Then after x3 transfers eventually found out what I was coming for. Letters arrived at the weekend for Tuesday appt. Since then and the day of appointment cannot fault excellent service, explanations etc despite failed attempt. Would just say that the quick appt wait may have jeopardised the advanced warning & muddled things a bit but that can be rectified- Thank you all!”

Discussion

The first Nurse Led OPD hysteroscopy patient satisfaction
The sample size was small; a positive result has been achieved in patient satisfaction.
Privacy and dignity has been maintained to a very high standard
The patients are well informed about the procedure, and had received written information in some form prior to attending the nurse Lead hysteroscopy clinic
66% of women preferred not to have a general anaesthetic for OPD hysteroscopy
My patients felt at ease to ask me questions regarding the hysteroscopy procedure

Weakness of audit

Sample size wastoo small
Was not a postal questionnaire
Using a bar coded questionnaire would have been more efficient

Recommendations

To continue to evaluate patient satisfaction
Inform patients of retrospective audits
Maintain written protocols and guidelines
Repeat audit with larger sample size
Postal questionnaires
All patient information, patient letter and initial phone will be made via cancer services two week wait office for women with postmenopausal bleeding which will make the service more efficient.

Appendices

Appendix 1 Questionnaire

Appendix 2 Patients’ comments

Nurse Led Hysteroscopy Clinic

Patient Satisfaction

1.What form of information did you receive about your appointment?

□Letter only

□Patient Information leaflet

□No Information

□Telephone

2.How would you rate the written information you received prior to your hysteroscopy?

Very Good□Good□Fair□ Poor□ Very Poor□

3.How would you rate the verbal information that you received before the scan and hysteroscopy?

Very Good□Good□Fair□ Poor□ Very Poor□

4.Regarding the information you received before the hysteroscopy, did you have:

□More information than you wanted?

□About the right amount of information you wanted?

□Less information than you wanted?

5.Did you understand why you were having the hysteroscopy?

Completely□ Partially□ Not at all□No response □

6.Did you sign a consent form?

7.Did you receive any verbal information after your hysteroscopy?

Yes□ No□ Unable to remember□

8.How would you rate the verbal information that you received after your hysteroscopy?

□Very good □Good□Fair □Poor □Very poor

9.After the hysteroscopy, did you understand the explanation regarding the procedure?

□Completely □Partially □Not at all □No response

10.After the hysteroscopy did you understand what other treatment you may require if necessary?

□Completely □Partially □Not at all □No response

11.Did you have the opportunity to ask the hysteroscopist any questions after the procedure?

□Yes□No□Unable to remember

12.How would you rate the discomfort experienced during hysteroscopy?

□Severe □Moderate □Mild□No discomfort

13.If you had to have the hysteroscopy repeated would you prefer:

□Without anaesthetic □General anaesthetic (put to sleep)

14.Would you have preferred to have had a General Anaesthetic?

□Yes□No □Unsure

15.In relation to pain/discomfort would you have preferred pain killers prior to the hysteroscopy?

□Yes□No □Unsure

16.Would you describe any vaginal blood loss or discharge experienced after the procedure as:

□None

□Less than you expected

□As you expected

□More than you expected

□Much more than you expected

□Needed to seek medical advice

17.How would you describe your satisfaction with your outpatient Hysteroscopy treatment?

□Excellent □Good □Adequate□Fair□Poor

18.Did you feel your dignity & privacy was maintained at all time?

□Yes□No □Unsure

19.Was it helpful to have the contact details of the hysteroscopist?

□Yes□No □Unsure

20.We are interested in your commentsand suggestions to do with all aspects of your post menopausal care. Please use the space below to write these: ……………………………………………………………………
………………………………………………………………………………….

………………………………………………………………………………….

Patients’ comments

Not having had this procedure before, I was quite apprehensive, but the explained everything to me and put me at ease.
I am sure that is why I was relaxed during the procedure
My menopausal care has been very good by both Hospital and GP
Appointment came via appointments office by telephone. No further information until I telephoned to ask.
Then after x3 transfers eventually found out what I was coming for.
Letters arrived at the weekend for Tuesday appt. Since then and the day of appointment cannot fault excellent service,
explanations etc despite failed attempt. Would just say that the quick appt wait may have jeopardised the advanced
warning & muddled things a bit but that can be rectified- Thank you all!
I only knew I was to have a hysteroscopy on the morning I attended- Iwas expecting to see a
Gynae consultant as a follow-up to a biopsy
You really need the patient information leaflet prior to the appointment.
A lot of information to take in during a quick consultation.
The team I had were very good. The leaflet had all the info but only covered post menopausal care,
perhaps another leaflet for people who are not yet menopausal.
Staff very helpful and caring
All the ladies were very good excellent no complaints just very good
Long wait to be seen
All nurses were very helpful
Everything was good - what more can I say!
Excellent, calm, service appreciated
We are very happy with the staff and treatment. Staff are friendly and helpful.
Felt completely at ease with abdominal scan and vaginal scan. Very pleasant and helpful staff.
All explanations understood completely
I received 2 letters for appts, 1 from O&G outpatients and 1 from U/S.
In fact the U/S was done at first appt and this was confusing and it could have been
better if my treatment at each appt had been made clear
Only had smear
Jayne and her team reassuring and supportive. A positive experience. Thank you Jayne.
All aspects of my postmenopausal care have been excellent.
I will certainly be happy to make others aware of the good service I have received from
Mr Stock initially and then from Jayne Nicolaou and her excellent team.
Recovery time and a cup of tea very useful. Local anaesthetic next time.
Perhaps when the sec phones to check if a particular date would be suitable she could tell the patient
that she should have someone with her and should not drive and not leave this to become
apparent when the confirmation letter arrives.
I was very pleased with all aspects of my care.
Too early to tell after hysteroscopy
Perhaps a leaflet explaining polyps, fibroids and anything nasty.

Trust Action Plan

RECOMMENDATION / ACTON TO BE TAKEN / LEAD RESPONSIBILITY / TIMESCALE / MONITORED BY / EXPECTED OUTCOME / EVIDENCE
Maintain and develop protocols to guide the appropriate delivery of service / Collaborative working to set out clear guidance as to referral criteria/ treatment / Nurse Hysteroscopist/ Lead Consultant / On going / Nurse Hysteroscopist / Clear guidance from referral to treatment / Trust approved protocols
Review data long term / Re audit / Nurse Hysteroscopist / On going / Nurse Hysteroscopist / Data base on day / Regular audits
Accountability / Update & maintain protocols / Nurse Hysteroscopist / On going / Nurse Hysteroscopist / Safe & best practice / Trust approved protocols
Amend referral criteria moreefficient service re lack of sonographer support to clinic. / Endometrial thickness recorded on proforma via GP prior referral / Nurse Hysteroscopist
Matron / On going / Nurse Hysteroscopist
& Cancer Services / To reduce organisational time prior to appointment / Self audit
Insufficient support for formal data collection / Discuss with Cancer Services regarding Somerset Cancer Register / Nurse Hysteroscopist / On going / Nurse Hysteroscopist
Matron / Improve data collection / Access to the Register

References

Clark,J., Gupta, JK (2005)Handbook of outpatient hysteroscopy. A complete guide to diagnosis and therapy. Oxford university press. London.

Useful websites

AUTHORISATION FOR RELEASE OF EXECUTIVE SUMMARY

PROJECT TITLE

DATE

AUTHORS

I, (insert Project Leader’s name and professional title), give permission for the executive summary of the above project to be released in total or in part from the Clinical Effectiveness Support Unit for Trust purposes.

Primarily this document will be used to inform:

The Trust Clinical Governance Committee

The Annual Report

External assessors, eg CHI, district auditors

Any request for information other than that which is contained within this summary will be passed on to the project leader or directorate audit lead for a decision on disclosure.

I confirm that I have consulted with the project team who are happy for this executive summary to be released.

PROJECT LEADAUDIT LEAD

Signature……………………………..……………………………….

Name……………………………..……………………………….

Prof. Title……………………………..……………………………….

Department……………………………..……………………………….

Tel. No.……………………………..……………………………….

Date…………………………......