Case Studies

Case study #1:  Joint Emergency Medicine-OB/GYN Training

IMG 0144An estimated 500,000 Emergency Department (ED) visits each year are for complaints of “pregnant and bleeding,” comprising half of the approximately 1 million early pregnancy loss (EPL) diagnoses each year. All three management options: expectant, medical, and surgical, are safe, effective, and acceptable and can be offered not only in the operating room but in all appropriately equipped settings, including offices and emergency rooms. However, aspiration is often perceived as difficult to provide in the emergency room due to perceptions about scope of practice and lack of training opportunities. TEAMM has prioritized emergency medicine inclusion in EPL training in order to help fill a gap in training of appropriate EPL care in the ED setting; the training addresses technical skills, systems issues, and coordination with other women’s healthcare providers.

At a large county hospital located in Oakland, California, TEAMM provided a training intervention to over 35 emergency medicine and OB/GYN providers and support staff to aid their goal of integrating miscarriage management care into their emergency room (ER) and outpatient clinics.At a large county hospital located in Oakland, California, TEAMM provided a training intervention to over 35 emergency medicine and OB/GYN providers and support staff to aid their goal of integrating miscarriage management care into their emergency room (ER) and outpatient clinics.

The interdepartmental didactic session and follow-up training with key support staff gave everyone the opportunity to learn about best practices including the most current protocols and the importance of giving women options. The site continued their work to make the system-wide change to integrate miscarriage management care into their emergency room and outpatient clinics. TEAMM was pleased to hear that one provider cared for over ten women in one month in the ER, including some that had been seen by their Obstetrician (OB) for expectant or medication management

“Your presentations definitely resonated with our providers…I have heard from nearly a dozen providers who were present at both trainings that they think you all did an incredible job, that they are on board with this procedure, and they see a future for manual uterine aspiration in emergency care.”“Your presentations definitely resonated with our providers…I have heard from nearly a dozen providers who were present at both trainings that they think you all did an incredible job, that they are on board with this procedure, and they see a future for manual uterine aspiration in emergency care.”

-Site Champion

As a result of TEAMM’s success using this interdepartmental training model, TEAMM now focuses training efforts on inclusion of the multiple medical specialties to which women experiencing early pregnancy loss present, enabling everyone who comes into contact with these patients the opportunity to collaborate effectively and provide high quality patient care.As a result of TEAMM’s success using this interdepartmental training model, TEAMM now focuses training efforts on inclusion of the multiple medical specialties to which women experiencing early pregnancy loss present, enabling everyone who comes into contact with these patients the opportunity to collaborate effectively and provide high quality patient care.

 

Case Study #2: Community Health Care Setting

“… we {providers} feel protective of the women we work with, and it didn’t feel good to refer them to people we didn’t have much contact with. Now, it’s nice to be able to have that continuity of care for them.”

-Site Champion

In 2013, TEAMM began working with the largest provider of primary medical and dental care for low income and uninsured individuals in the Seattle area to help them reach their goal of providing a full range of outpatient miscarriage management services for their patients. Several of their staff had participated in our annual Regional Training, and TEAMM provided on-site training for staff as well as follow-up training for nurses, protocol refinement, post-procedure debriefs, assistance in adapting patient education materials, and phone consultations.

TEAMM develops ongoing relationships with sites after training has ended and often receives reports regarding specific care for patients. This site’s second patient experiencing early pregnancy loss after they completed TEAMM training had “had an eight week embryonic demise by ultrasound [three weeks previously] and failed to have bleeding on Misoprostol.”  The provider reported that “with several passes with the Manual Vacuum Aspiration (MVA) I was able to clear the uterus and manage the bleeding. The patient was comfortable and safe throughout.” The entire team, having learned and discussed the value of offering care in the clinic rather than referring her to a hospital, was able to work together effectively to provide the most patient centered EPL care possible.TEAMM develops ongoing relationships with sites after training has ended and often receives reports regarding specific care for patients. This site’s second patient experiencing early pregnancy loss after they completed TEAMM training had “had an eight week embryonic demise by ultrasound [three weeks previously] and failed to have bleeding on Misoprostol.”  The provider reported that “with several passes with the Manual Vacuum Aspiration (MVA) I was able to clear the uterus and manage the bleeding. The patient was comfortable and safe throughout.” The entire team, having learned and discussed the value of offering care in the clinic rather than referring her to a hospital, was able to work together effectively to provide the most patient centered EPL care possible.

In addition to improving patient access to care, this site is also proud of one of their certified nurse midwives who went on to champion this work at conferences including delivering a presentation on early pregnancy loss at the 2016 UWCNE Advanced Practice in Primary and Acute Care. Since their TEAMM site intervention, they have fully integrated miscarriage management care into multiple health centers.