GP INFORMATION EVENING – MAY 11 TH 2017 Dr Nicola Yuen Clinical Director Obstetrics and Gynaecology / Deputy Chief Medical Officer
Introduction Dr Nicola Yuen – Clinical Director of O&G Dr Shobie Shobanan – Staff Specialist O&G Dr Kishor Singh – Staff Specialist O&G Dr Sarah Van Der Wal – Staff Specialist O&G
O&G Department at Bendigo Health New hospital opened in January 2017 Department restructured in late 2016 and implementation of new structure in February 2017
O&G Department Restructure The process of reviewing the structure considered: • Identifying service gaps and reviewing the appropriateness and configuration of services • Best practice in models of care • Maintaining and improving patient access to care • Flexibility of clinical systems to respond quickly to changing environments • Improving consistency and quality of care, safety and clinical governance • Workforce planning, ensuring the right clinical teams in the right place at the right time • Strengthening partnerships with our regional hospitals and referring GPs including driving shared care and education
Staffing – Senior Medical Staff O&G • Director of O&G (0.5FTE) • 3 full time staff specialists – at least 2 are working M-F 0730-1730; 1 is rostered to birth suite with no other responsibilities • 5 VMOs providing sessional support for clinic and theatre as well as after hours cover
Staffing - Junior Medical Staff - O&G • Senior Registrar • 2 accredited RANZCOG trainee Registrars • 3 unaccredited Registrars (12 month positions) • 2 Advanced Diploma GP Registrars (12 month positions) • 1 Senior RMO (6 month position) • 3 HMOs ( 3 month position)
What does this mean for the GPs? More staff available to answer calls! Birth Suite Reg 54546018 (24 hrs / 7 days) Assessment Reg 54547205 Monday – Friday 0730-1730 – Birth Suite Consultant; Birth Suite Registrar; Assessment / EPAS Registrar After hours – 24 hour in hospital Registrar cover (including weekends); Consultant
Models of Care • A range of models of care will need to be available to reflect clinical needs, safety factors and woman’s choice, and reflect the complexity of care required. • The aim is to provide responsive and integrated models of care. • The models will aim to ensure continuity of care for the woman whilst reducing a fragmented approach to care.
Obstetric Clinics Each week • 4 Booking in Clinics • 3 Obstetric Clinics (high risk) • 1 multidisciplinary Diabetes in Pregnancy Clinic • 4 Midwives Clinics (low risk) • Assessment Centre 0900-1700 Mon-Fri
Shared Care • Process currently being reviewed to bring in line with other maternity hospitals • Process of accreditation • E-credential system • Access to ongoing education from Bendigo Hospital
Documentation for Shared Care • Medical Registration • Medical Indemnity Insurance • Practice Accreditation certificate • Evidence of postgraduate qualifications • Referees • Signed agreement of care
Ongoing accreditation as SMCA Triennial (as per CPD triennium with RACGP / ACCRM) Under development Will require evidence of ongoing CPD relevant to Obstetrics
Gynae Clinics Each week • 3 General Gynae clinics • 2-3 Colposcopy sessions • 1 Gyn Assessment clinic (post-op reviews; urgent reviews etc) • 1 Family Planning clinic • 1 Choices clinic • EPAS Mon-Fri 0900-1700
Referrals into the O&G Unit
Obstetric referrals Booking in appointment with MW at 15-18 weeks unless otherwise indicated Triaged after booking by Consultant O&G to either low or high risk care and plan for care made Schedule of visits followed for high or low risk care All patients seen at 34-36 weeks by O&G Consultant or accredited Registrar
Gynae referrals Women’s Clinics Referral Triaging Guidelines for Gynae, Colposcopy, Pap, Surgical, TOP and FPC Requires workup investigations to be accompany referral • Urgent – refer to ED • Cat 1 – receive and attend apt within 30 days • Cat 2 – receive and attend apt 30-90 days • Cat 3 – receive and attend apt within 365 days
Gynae triage guidelines Cat 1 – Immediate Conditions requiring immediate assessment and management in ED – These referrals will not be accepted by Women’s Clinics – results and referrals midwife will phone woman, phone GP and ED and forward referral and investigations to ED. Excessive blood loss (send to ED) Severe, debilitating abdominal or pelvic pain (send to ED) Acute Bartholin’s abscess (send to ED)
Gynae Triage guidelines CHOICES CLINICS (STOP) AND EPAS REFERRALS Category 1 – to receive and attend appointment within 30 days (dependent on EDD) • Surgical termination of Pregnancy: only performed <12/40 at BH • EPAS: dependent on EDD
Gynae triage guidelines Urgent – to receive & attend apt within 30 days Asymptomatic ovarian cyst in women >40 yrs (specified cyst >8cm) Hyperplasia with endometrium > 12mm in all women Malignancy detected on a pap smear – Category 1 Colposcopy Ovarian cyst with pain (>8cm) Peri menopausal bleeding with endometrial lining >12mm Ultrasound report Post-coital bleeding – Category 1 Colposcopy if abnormal pap smear, or abnormal appearance of cervix PAP results Post-menopausal bleeding pelvic with ultrasound/FBE Prolapse – with urinary retention (consider treating in ED) Severe pelvic pain (consider treating in ED) Unilocular cyst > 50 years of age (>5cm) Pain and Bleeding in Pregnancy – Category 1 EPAS
Unavailable services at Bendigo Hospital • Medical Termination of Pregnancy - < 8/40 not done at BHCG Results and referrals midwife will refer to Bendigo Community Health Centre (BCHC) after discussion with woman (phone 54481600, fax 54481699) • Reversal of tubal ligation – not done at BH. GP notified that referral not accepted • IVF – advise of local availability and advise GP to refer woman to Monash IVF website
How does this affect GPs? Guideline provides recommended and mandatory (*) investigations to accompany referral Pap smear results history * Abnormal pap smear HPV vaccination history If at-risk of STI, high vaginal swab MC&S and STI screen (endocervical swab for chlamydia and gonorrhea PCR, others as indicated) Serum b-HCG * Pelvic pain Pelvic ultrasound * High vaginal swab MC&S * STI screen (endocervical swab chlamydia and gonorrhea PCR, others as indicated) * Urine MC&S *
Our performance 100% 45 89% 90% 40 85% 81% 79% 78% 80% 35 70% 68% 70% 65% 30 62% 61% 58% 60% 55% 25 50% 20 40% 15 30% 10 20% 5 10% 0% 0 Apr 2016 May 2016 Jun 2016 Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017 Mar 2017 Urgent Ref Count Urgent w/in 30 Days
Gynae Elective Surgery Waiting List 200 180 160 140 120 100 80 60 40 20 0 Apr 2016 May 2016 Jun 2016 Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017 Mar 2017
Documentation / communication • Obstetrics – VMR • Gynae – letters dictated Impact of EMR (due for implementation within next 12 months)
Questions??
EARLY PREGNANCY ASSESSMENT Dr Sarah van der Wal – O+G Staff Specialist
Services offered at Bendigo Health 1. Early Pregnancy Assessment Service 2. Choices Service
Early Pregnancy Assessment Service • Runs daily • Both for Initial Assessment and Follow up • Staffed by Registrar or Senior Resident supervised by Staff Specialist
Scope of Practice of EPAS • Early Pregnancy Loss • Pregnancy of Unknown Location • Early Fetal anomalies
Referrals • Accept internal and external referrals • Triaged according to risk • Information required: – Last Menstrual Period – All serum bhCGs performed – Any US performed – Any significant Medical/Surgical History
Early Pregnancy Loss • Miscarriage – Threatened – Missed – Incomplete – Complete • Pregnancy of Unknown Location • Ectopic Pregnancy
Diagnostic Guidelines – Early Pregnancy • 1 st Trimester scans should be performed using ASUM guidelines (2015) • Gestation sac should usually be visible from 4 weeks and 3 days by TV scan • Must be eccentrically placed and surrounded by echogenic ring – not intra-cavity fluid (pseudosac) • Fetal heart visible from 2-6 weeks with a high resolution TV scan, may need to be 3-4mm CRL however
Early Pregnancy – Diagnosis • bhCG >1200-1500 for TV scanning • bhCG >3000 for TA scanning
Miscarriage • Transvaginal Scan: • MSD (mean Sac Diameter) > 25mm with no visible fetal pole • CRL >7mm but no fetal heart movements for >30 seconds • Any doubts – a second scan in 1 week
Miscarriage - Treatment • Conservative/Expectant – – Reduced risk (surgical) – More days of bleeding and greater amount of bleeding – Approximately 10% of women will require subsequent surgical management – Efficacy is lower and may take several weeks if intact sac
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