A quality improvement project: Rapid Access Hysteroscopy Clinics with nurse pre-procedural telephone support in the outpatient setting

Endometrial cancer (EC) is the most common gynaecological cancer in women in Aotearoa New Zealand and is increasing in incidence each year.^1,2 This upward trend is believed to be closely linked to an increasing prevalence of risk factors such as obesity, diabetes and an ageing population.^1,2 While the risk of developing EC is growing among post-menopausal women, there is a concerning rise in the number of pre-menopausal women diagnosed with EC.² These women are broadly classified as having abnormal uterine bleeding (AUB), often belonging to the Pacific peoples ethnic group.^1,2

Hysteroscopy is the gold standard investigation for women with post-menopausal bleeding (PMB).³ It allows for the visualisation of any abnormalities inside the uterine cavity and identification of endometrial polyps (which may be missed if only a pipelle biopsy is obtained).⁴ Waiting to attend hysteroscopy after a first specialist appointment (FSA) can not only cause delays to diagnosis but anxiety for patients.³ Rapid access pathways for hysteroscopy are well stipulated in the literature to expedite time through cancer pathways for women.^3,5 Rapid access clinics (RAC) are safe, cost effective and efficient, however they are not yet widely adopted as a “one-stop shop” service across Aotearoa New Zealand for diagnostic investigation for women with a high suspicion for gynaecological cancers.^3,4,6

Prior to 2014, Counties Manukau District Health Board (DHB) offered direct access hysteroscopy for women referred by their general practitioners (GPs). However, an audit revealed that a considerable number of these women subsequently required general anaesthetic (GA) hysteroscopy, primarily due to issues like cervical stenosis or polyps. Additionally, flaws in the triaging process resulted in inappropriate clinic attendance by women that had undergone prior hysterectomies, experienced difficulty tolerating a speculum during GP visits, or were not sexually active.

To address these challenges, the clinics were changed to a two-step process involving an FSA followed by a hysteroscopy. Criteria for the follow-up hysteroscopy included the patient’s tolerance of a pipelle biopsy. While hysteroscopy was suitable for an OP setting, many follow-ups continued to be scheduled as GA procedures, with little oversight of wait times, thereby increasing clinical risk. In 2016, MyoSure and local anaesthetic blocks were introduced at Counties Manukau, enabling the removal of polyps in the outpatient (OP) setting and significantly reducing subsequent GA hysteroscopy cases.

The Health New Zealand – Te Whatu Ora Faster Cancer Treatment (FCT) indicators aim for 90% of high suspicion of cancer (HSC) patients with confirmed cancer to receive treatment within 62 days of referral.⁷ Between July 2020 and September 2021, the rolling average of compliance of gynaecology patients to be treated within the 62-day target was 41.5% in the Counties Manukau district. This prompted the Women’s Health department to engage with Ko Awatea, Counties Manukau’s Centre for Innovation and Improvement. Our project targeted the front-end of the FCT pathway where there was an appetite to re-trial a Rapid Access Clinic (RAC) to expedite time from referral to diagnosis. The aim of this project was to increase the number of HSC women to receive earlier access to hysteroscopy through RAC by June 2023.

Methods

The existing standard process from referral to first treatment was mapped by key stakeholders working in the FCT gynaecology pathway (Appendix 1 Figure 1). Retrospective wait time data was collected between key pathway steps and shared with clinicians across three workshops where they brainstormed reasons and root causes for delays.

Stakeholders brainstormed change ideas that would help to reduce time in the pathway and prioritised the ideas with the highest perceived impact. A RAC for hysteroscopy with pre-procedural nurse telephone support was identified as a key change idea to test, and it was hypothesised that such clinics would reduce wait time between referral and provisional diagnosis.

A project team of senior gynaecologists, a clinical nurse specialist (CNS), women’s health service manager and an improvement advisor were assembled to set up and test RAC for OP hysteroscopy.

Criteria were developed to assist clinicians in grading patients into RAC, which included:

• Abnormal uterine bleeding (AUB) or post-menopausal bleeding (PMB)
• Post-menopausal—recent ultrasound scan demonstrating an endometrial thickness of ≥5mm
• Pre-menopausal—recent ultrasound scan demonstrating an endometrial thickness of ≥20mm or evidence of polyp or mass
• Pre-menopausal identified as high risk with BMI >35, haemoglobin <100, diabetes, failed hormonal management, Tamoxifen or known genetic risk, e.g., Lynch syndrome
• Ability to tolerate a speculum examination
• High suspicion of cancer

A RAC-specific waiting list and clinic template were created on the patient management system to ensure that HSC women were prioritised over those requiring routine OP hysteroscopy.

The project team developed a telephone script (Appendix 2 Figure 1) to assist the gynaecology CNS in conducting phone consultations up to a week prior to the patient’s clinic appointment. The patient’s medical history and hysteroscopy counselling were documented on an electronic clinic template in Clinical Portal and could be reviewed by a gynaecologist prior to the appointment. Following the phone consultation, a hysteroscopy information leaflet was emailed to the patient, providing supplementary information about the procedure.

We used Plan-Do-Study-Act (PDSA) cycles to test the RAC model.

The first pilot began in late October 2022 with four patients scheduled for RAC each week. CNS time of 0.1 FTE was allocated to conducting and documenting pre-procedural phone consultations. The benefits of RAC were recognised in the early weeks of the pilot by the senior gynaecologists, which led to waitlist numbers exceeding the planned clinic capacity by the end of November. Following the Christmas break, a second pilot explored the use of cancelled operating theatre lists to supplement the four weekly RAC slots on an ad-hoc basis. Although repurposing the theatre capacity worked well initially, it was not a sustainable long-term solution. To cater to the growing clinic demand, we increased the number of available RAC slots to 10 per week by March 2023. This expansion also required an increase in CNS time to 0.2 FTE per week to accommodate the growing demand.

A dashboard of referral and clinic demand and a written guideline about RAC were implemented to help sustain these changes.

Quantitative data of the RAC were collected between 20 October 2022 and 31 May 2023 and statistically analysed to understand changes in median wait time pre-RAC and during the trial. Thirty women or a whānau member rated their experience of the pre-procedural nurse phone call on a five-point Likert scale, justified their rating and identified any further opportunities for improvement. To ensure objective and unbiased responses, surveys were completed by Ko Awatea, independent of the Women’s Health team. Responses were de-identified to ensure participant anonymity. Ethical principles were observed throughout the survey process. Participants were fully informed about the purpose of the survey, provided their consent and were informed of their right to withdraw from the survey at any stage if they chose to do so.

The cost reduction benefit for the patient was calculated based on distance travelled from the patient’s home address to the outpatient department. Standard car petrol usage was used to calculate petrol costs. The travel time was based on off peak traffic volumes to calculate a conservative estimate of time saved. Hospital cost–benefit analysis was calculated by using standard costs and times for senior medical officers and hysteroscopies, as provided by the local Population Health department and via a time and motion study that was part of this project.

Attendance

Between 20 October 2022 and 31 May 2023, 231 women attended RAC with only one non-attendance. FSA clinic attendance rates improved from 91% pre-RAC to 99% with RAC. The improvement of attendance during the trial was of high statistical significance (p=0.00).

A total of 207 (89.6%) patients successfully tolerated RAC hysteroscopy, while 24 (10.4%) patients were required to complete the procedure under general anaesthetic.

View Table 1–3, Figure 1–4.

Wait time outcomes

The lead time between FSA and OP hysteroscopy reduced from 25 days (SD: 21 days) to 0. Wait time from referral to provisional diagnosis increased from 26 days (SD: 30 days) to 31 days (SD: 15 days) following implementation of 10 RAC slots. Wait time between referral to grading and grading to provisional diagnosis remained relatively unchanged. There was a reduction in the standard variation of wait time, with the largest impact between grading and FSA, demonstrating an improvement in process stability at this step.

Histology outcomes

We were able to diagnose 13% (27/207) of women with EC through RAC, up from 6% (18/308) diagnosed in the previous 9 months at FSA. This increase was attributed to more diagnostic hysteroscopies being performed, allowing for more opportunities to undertake endometrial sampling. One hundred and eighty women that did not have EC were removed from the FCT pathway once this result was determined.

Patient experience

Thirty women were surveyed about their experience of the pre-procedural CNS phone consultation. Twenty-six women rated the nurse phone consultation positively, noting that the information they were given about the clinic and procedure was explained well, as reflected in feedback from a patient and a whānau member:

“She [the nurse] explained everything I needed to know, everything was very clear. I wasn’t expecting that kind of procedure.” – Cook Islands Māori patient

“The nurse painted a thorough picture of what would take place, describing the position that my mum’s legs would need to be in to ensure she could have the procedure. It was really good to get an idea of what was going to happen, i.e., local anaesthetic, tools that would be used. The experience couldn’t get better than this. This is a lot better than other appointments.” – Tongan family member

Of the four women who rated their experience as “okay”, two women wanted further information about what to expect during the procedure and how to adequately manage their pain post-procedure. All women felt that their concerns and questions were adequately answered by the nurse.

Benefits

The RAC pathway has made it possible for more HSC women to receive hysteroscopy in a timely manner, improving patient safety. Of the women that were referred for RAC, 89.6% (207/231) successfully underwent the OP hysteroscopy procedure. These women saved one additional trip to the Manukau SuperClinic and reduced median wait time from FSA to hysteroscopy from 25 days to 0. The combined appointments saved our patients a total of NZ$35,959 in travel costs. The reduction in the number of visits has also led to a significant decrease in CO₂ emissions (-1,782kg), which is equivalent to the amount of CO₂ offset by 71 trees.

Financial impact

The annual number of HSC hysteroscopies has increased by 456%, from 70 to 359. Cancelled theatre slots repurposed for RAC made up 43% of the RAC slots delivered across the trial. The cost of delivering these procedures has increased accordingly from NZ$86,529 to NZ$364,745 (NZ$278,215 increase). However, this increase in cost is due to past underperformance. Counties Manukau Women’s Health clinical governance expects all eligible women with a high suspicion of cancer to receive rapid access to hysteroscopy.

RAC delivery is also more cost effective when compared with the previous pathway. Based on the new number of referrals, by having direct access to OP hysteroscopy, the Women’s Health Service saved nearly NZ$62K per year due to increased clinic session productivity, with an additional hysteroscopy patient seen by a gynaecologist per FCT FSA session (from four to five).

Discussion

Rapid access clinics (RAC) have been explored across various outpatient services; however, they have not consistently been adopted across Aotearoa New Zealand to support the diagnosis of women with a high suspicion for EC.³ Our project is the first to report on the outcomes of RACs for hysteroscopy with embedded pre-procedural CNS support. RACs are patient-centric, allowing for one less clinic visit, which reduced the time patients and whānau needed to take away from work or other priorities and results in savings in travel costs.^5,6 Furthermore, system cost savings due to increased productivity meant that gynaecologists and nursing staff could see patients in other clinics.

While the RACs did not reduce overall wait time from referral to provisional diagnosis, there was an improvement in process consistency, indicated by a reduction in the number of outliers and standard variation (from 30 days to 15 days), notably between grading and FSA. Flow through the rapid access pathway was in part hindered by a small number of clinicians grading incoming gynaecology referrals. This resulted in delays in scheduling appointments and subsequent consultations with gynaecologists for patients. In response, we recently trained and expanded the scope of several CNSs to support our gynaecologists with the grading of incoming referrals. We are yet to determine the impact of this on time to FSA and whether this could subsequently expedite time to diagnosis, but it is likely the allocation of additional resources to grading would help to make this part of the process quicker.

We provided RACs through a combination of planned OP clinics slots and capacity from cancelled operating theatre lists. This allowed our team to perform more pipelle biopsies and, subsequently, diagnose more women with EC. In some cases, where a polyp was solely identified during hysteroscopy, the patient could be treated immediately and discharged to her GP, avoiding the need for an additional clinic visit or GA hysteroscopy.

Pacific peoples made up approximately 22% of the Counties Manukau catchment area in 2021–2022.⁸ In our trial, Pacific women (41%) had the highest incidence of EC compared to any other ethnic group accessing RAC. These findings are consistent with previous studies that demonstrate that Pacific women are disproportionately affected by EC, likely due to the effects of socio-economic deprivation and obesity with associated diseases.²

Pre-procedural nurse telephone consultations are widely used in practice to reduce day-of-surgery cancellations and improve patient experience by ensuring patients are fully informed about their procedures.⁹ We adapted a similar premise in the outpatient setting tailored to RAC. In our project, telephone consultations also served to verify the suitability of women graded into RAC, ensuring that those with specific requirements received adequate support. Women deemed unsuitable were referred for hysteroscopy under GA. Pre-procedural telephone consultations also improved clinician productivity by enabling the CNS to undertake medical histories and provide explanations of the procedure to patients and whānau in advance. This gave clinicians more time to perform hysteroscopies, increasing the number of procedures from four to five per session.

Overall, patient and whānau feedback regarding the RAC pre-procedural telephone consultation was positive and was believed to have played a key role in enhancing attendance rates from 91% to 99%. This improvement was further supported by the proactive assistance of clinic schedulers and nurses, who liaised with patients to allocate them into preferred clinic times. Where appropriate, Māori and Pacific peoples CNSs also offered tailored support to RAC patients from these ethnic groups to attend appointments.

Furthermore, the functioning and speed of RAC for hysteroscopy is dependent upon multiple factors including the availability and skill-mix of both medical and nursing staff, the physical space of procedure and clinic rooms, equipment and sterilisation services.^10,11 Effective communication between care providers and the capacity of other services, such as radiology and pathology, are also integral components to ensuring timely care through the FCT pathway.^10,11

Strengths and limitations

Clinician buy-in and collaboration drove and enabled successful implementation of RAC. We applied the Awareness Desire Knowledge Ability Reinforcement (ADKAR) Model to engage with relevant clinicians.¹² Initially, senior clinicians resisted participating in quality improvement activities due to feelings of frustration resulting from a lack of transparency and feeling unheard by the management team. Despite our initial analysis identifying the greatest opportunity to reduce wait time variation was between decision-to-treat and first treatment, we prioritised the RAC testing with support from senior clinicians, aligning with the “desire” element of ADKAR.¹² The pilot of RAC boosted clinician morale, as they witnessed its benefits for women, which was reinforced by positive feedback from patients and other staff in the clinic.

Our initial baseline quantitative data analysis was undertaken during the COVID-19 pandemic. Wait times for FSA, pathology, radiology and surgery were significantly impacted by COVID-19 pandemic-related lockdowns. The analysis revealed significant variation in wait times between decision-to-treat and first treatment. This indicated a need for further improvement initiatives to expedite activities in the latter stages of the pathway to ensure timely treatment.

Although we gathered patient experiences of the pre-procedural phone call, it would be valuable to collect further insights about the entire RAC experience. Anecdotal reports from clinicians suggest improvements in their experiences, however conducting further surveys among them would help to strengthen this work.

Conclusions

The implementation of RAC for women with a high suspicion of gynaecological cancer has demonstrated valuable benefits for both patients and clinicians. While it has not yet demonstrated wait time reductions from referral to provisional diagnosis, the clinics have demonstrated patient-centric values, reducing the number of visits to clinic saving time from work and associated cost savings. Additionally, patients felt well-supported and informed of their hysteroscopy through the CNS pre-procedural phone consultation. RAC facilitates an earlier shift to focus care on those with cancer and expedites the removal of patients without cancer diagnoses from the FCT pathway.

This model of care is straightforward and can be easily replicated in other Women’s Health services across New Zealand and adapted for various specialty outpatient clinics.

View Appendix.