Implementation of the “Pregnancy Reasonably Excluded Guide” for Pregnancy Assessment

Abstract

OBJECTIVE: Preoperative evaluation for pregnancy at our institution lacked standardization among individual health care providers and surgical services. This pilot project aimed to improve assessment for pregnancy before scheduled outpatient gynecologic surgical procedures. The Pregnancy Reasonably Excluded Guide incorporates historic, evidence-based criteria to facilitate identification of patients with a higher chance of pregnancy. METHODS: We retrospectively reviewed documentation for women undergoing gynecologic surgery at an outpatient surgical center from March through September 2016, before and after implementation of the pregnancy assessment protocol. After implementation, all eligible women (aged 18–50 years, not undergoing an emergent or pregnancy-related procedure) were assessed using the Pregnancy Reasonably Excluded Guide on arrival to the preoperative area. The Pregnancy Reasonably Excluded Guide checklist uses traditional and World Health Organization criteria for reasonable exclusion of pregnancy. Nursing staff reviewed responses with patients and pregnancy tests were completed as indicated by patient responses. Women who were unable to read, understand, or freely respond to the checklist received pregnancy testing. Pregnancy assessment, testing, results, and delays were recorded. This project was deemed exempt by the institutional review board. RESULTS: Two hundred thirteen eligible patients underwent outpatient gynecologic procedures during the study period (excluding a 2-week washout period at implementation). In the preimplementation period, 93 of 136 patients (68%) had pregnancy risk documented; 73 of 77 (95%) had documentation in the postimplementation period (P≤.01). Pregnancy tests were completed in 45 preimplementation patients (33%) and 16 postimplementation patients (21%) (P=.06). No pregnancy test results were positive. No procedural delays were associated with pregnancy assessment. CONCLUSION: Patient-centered assessment using the Pregnancy Reasonably Excluded Guide at presentation for outpatient gynecologic surgery significantly improved evaluation and documentation of pregnancy status before scheduled procedures without increasing the number of pregnancy tests or causing procedural delays.

Indicators and predictors modifiable by the nursing department during the preoperative period: A scoping review

“…Other potential indicators/predictors fall under the heading of standardisation and include aspects such as unification and structuring by creating standard elements and instruments for use in health care and by establishing protocols for each of the processes involved. Unifying the questionnaires used in healthcare practice would help identify possible complications in the preoperative phase by avoiding data heterogeneity (Pettersson et al, 2017; Wyatt et al, 2018). Moreover, it would facilitate the compilation and analysis of strategies and protocols, and enable planners to modify those not meeting criteria of efficiency and effectiveness (Ayyadhah Alanazi, 2014; Dries, 2018; Vogl et al, 2015).…”

“…Among the articles reviewed, the two most frequent years of publication were 2018 (Brown et al, 2018;Dries, 2018;Wyatt et al, 2018) and 2020 (Derseh et al, 2020;da Silva Schulz et al, 2020;Vogl et al, 2015) (n = 3), followed by 2012 (Husted, 2012;Johansson Stark et al, 2014), 2015 (Crump et al, 2015;Liederbach et al, 2015) (n = 2), 2011 (Papadopoulos et al, 2016), 2014 (Ayyadhah Alanazi, The articles reviewed were conducted in 18 countries and five continents. By location, the largest number of articles originated from the United States (17%), followed by Germany (10%), Australia, Brazil, Canada, United Kingdom and Sweden (7% each) and Austria, China, Denmark, Spain, Ethiopia, Finland, France, Islamic Republic of Iran, Iceland, Japan and Norway (3% each) (Figure 3).…”

Pregnancy Reasonably Excluded Guide (PREG) Evaluation of Pregnancy Status Before Contraceptive Procedures: Improved Availability of Same-Day Insertion

“…PREG has now been implemented successfully in several settings at Mayo Clinic. 5,6 Patient-physician review and discussion of pregnancy exclusion criteria remained important to improve the validity of the assessment and further ensure that the woman was a candidate for screening alone (ie, asymptomatic) vs requiring a diagnostic evaluation (eg, abnormal menses or acute pelvic pain).…”

“…3 Inconsistent ordering may delay contraceptive procedures the preoperative setting and has the potential to be used in additional health care areas. 6 PREG uses traditional criteria to identify cases in which hCG measurement is not indicated, plus items modified from a checklist by Stanback et al 7 for ruling out pregnancy among family-planning clients. The checklist by Stanback et al, 7 supported by the World Health Organization and Centers for Disease Control and Prevention, has a greater than 99% negative predictive value for pregnancy.…”

“…4,8 Criteria from the Stanback et al 7 list incorporated into PREG were being within 7 days before the onset of normal menses, having had no intercourse since normal menses, and correct and consistent use of contraception. 6 Being limited to hormonal contraception, the contraceptive use criteria in PREG are more conservative than those used by Stanback et al 7 Traditional criteria that indicate a negative result on screening for pregnancy without hCG 7 or PREG. Previously, no formal process had been used at our institution to exclude pregnancy in the primary care setting.…”