Pregnancies lost and found: a quality improvement project to increase follow-up for early pregnancy complications

Abstract

Pregnancy of unknown location (PUL) and medically managed ectopic pregnancy (EP) require longitudinal surveillance to avoid adverse outcomes; however, patients with PUL/EP in the United States (U.S.) are often unable to adhere to recommended treatment plans. This quality improvement (QI) project sought to improve PUL/EP follow-up using a three-pronged intervention: standardised recall procedures, direct patient-provider communication and electronic medical record (EMR) documentation templates and tracking. We compared patients with PUL/EP managed before and after the QI project. Our primary outcome was completion of PUL/EP clinical care. Demographics, initial diagnoses and adverse outcomes were similar between 87 pre-QI and 81 post-QI patients. Significantly more patients completed PUL/EP clinical care post-QI (80.2 vs. 65.5% p = .03). Post-QI, more providers contacted patients at standard intervals (100 vs. 57.1%, p < .0001), and EMR documentation was improved (100 vs. 69.0%, p < .001). Simple changes to PUL/EP management improved completion of clinical care and compliance with standardised recall and documentation.

IMPACT STATEMENT

• What is already known on this subject? Pregnancy of unknown location (PUL) and medically managed ectopic pregnancy (EP) require longitudinal surveillance to avoid adverse outcomes; however, patients with PUL/EP in the United States (U.S.) are often unable to adhere to recommended treatment plans.

• What do the results of this study add? By standardising recall procedures, ensuring direct communication between patients and providers using a dedicated cell phone, and integrating case tracking and documentation into the electronic medical record (EMR), this quality improvement (QI) project improved completion of clinical follow-up for patients with PUL/EP (overall, 80.2 vs. 65.5% pre-QI, p=.03) and for the subgroup with medically managed EP not requiring surgery (76.5 vs. 36.4% pre-QI, p= .05). We also improved providers’ compliance with standardised recall procedures and EMR documentation post-QI (p < .0001). There was no difference in the number of attempts to contact patients, or in the number of surveillance blood draws actually performed. Post-QI, survey responses indicated that patients were easily able to contact their provider and understood the importance of follow-up processes.

• What are the implications of these findings for clinical practice and/or research? Early pregnancy care providers can utilise simple strategies to improve follow-up of patients with PUL and medically managed EP, without increasing burdens to their health systems. Patients’ favourable experiences with this management support its implementation.

Keywords:

• Pregnancy of unknown location
• ectopic pregnancy
• methotrexate
• follow-up
• quality improvement

Acknowledgements

The authors would like to acknowledge Laurel Garber, DO and Andrea Leung, MD for assistance with data collection.

We are grateful to David Jaspan, DO, Lynne Unikel, PhD, Anneliese Gualtieri, RN and Elizabeth Datner, MD, for their institutional leadership in support of this Quality Improvement project and its implementation.

We thank Jessica M. Atrio, MD, MSc, and Arnold Cohen, MD for their advice and editorial support during manuscript preparation.

Disclosure statement

For Dr. Hosein, none was reported.

Dr. Latteman was the resident leader of the QI project. As described, the Albert Einstein Society provided this internal grant for resident research focussed on quality improvement and patient safety.

Mr. Paoletti performed the statistical analysis and received remuneration for his time in accordance with our institution’s standard wage for data analysis; this was funded as planned in the quality improvement grant budget.

Dr. Gurney was a Nexplanon^® trainer for Merck during the quality improvement project. This unpaid position allowed her to train our department’s residents in contraceptive implant insertion once per year. She was the faculty mentor for the resident-led QI project.

Data availability statement

The data that support the findings of this study are available from the corresponding author, [EPG], upon reasonable request.

Additional information

Funding

A Quality Improvement and Patient Safety Seed Grant from the Albert Einstein Society [no grant number] funded this work. This grant supports resident-led quality improvement projects at our institution. Grant funds were used by our Department in the implementation of the quality improvement activities, including: purchasing and maintaining the cell phone, patient remuneration for survey participation, printing of patient follow-up instructions, and statistical support. No payment occurred simply for performing the project. The Albert Einstein Society was not involved in study design, data collection, data analysis or the decision to submit the work for publication.