Guidance for outpatient hysteroscopy: Consultation Response (Patient Safety Learning)

Summary

In this blog Patient Safety Learning highlights the key issues included in its recent response to the Royal College of Obstetricians and Gynaecologists new draft guidance for healthcare professionals who are involved in providing outpatient hysteroscopy.

Content

Hysteroscopy is a procedure used as a diagnostic tool to identify the cause of common problems such as abnormal bleeding, unexplained pain, or unusually heavy periods in women. It involves a long, thin tube being passed into the womb, often with little or no anaesthesia.

Concerns about painful hysteroscopy

Patients, patient groups and politicians have raised serious safety concerns about outpatient hysteroscopy procedures for several years, highlighting cases of avoidable harm. Some women have described how the lack of forewarning, coupled with the trauma of the experience itself, left them feeling that both their body and their trust had been violated. Many received little or no pain relief and were not given the information needed to make an informed choice about their own care and their own bodies.

On the hub we have highlighted concerns raised by the patient group the Campaign Against Painful Hysteroscopy[1] and individual patients who have shared their experiences with us. We also have the views of researchers[2] and healthcare professionals[3] on this issue.

Informed by these insights, we identified several key patient safety concerns relating to these procedures in the NHS, around issues of informed consent, access to pain relief and the implementation of good practice guidance.[4] We’ve raised with these issues with the Department of Health and Social Care[5] and Health Ministers in Northern Ireland, Scotland and Wales(6), highlighting several key areas where we believe action is needed to improve hysteroscopy safety:

• National guidance for outpatient hysteroscopy to be consistently applied.
• Women to be provided with information and advice to inform their consent.
• Women to be offered and provided pain relief.
• Significant pain to be considered an adverse event, and recorded and reported as such.
• Research to assess the scale of unsafe care and pain, the extent to which women are suffering, and to inform the implementation of national guidelines.

New guidance for healthcare professionals

This month the Royal College of Obstetricians and Gynaecologists (RCOG) held a consultation on the first edition of new guidance which has been “written for healthcare professionals who are involved in providing outpatient hysteroscopy with the aim of optimising a woman’s experience and clinical outcomes.”[7]

Below we summarise the key points included in Patient Safety Learning’s consultation response. You can find the full consultation document and our response at the end of this blog.

Positive reflections

Given the significant concerns that have been raised by patients about outpatient hysteroscopy in the NHS, we welcome the recognition by RCOG of the need to provide updated guidance to healthcare professionals. We were pleased to see the following included:

• Recognition that for some, this procedure can be an “unpleasant, and even traumatic, experience because of the amount of pain induced” and the importance of having clear and accurate information available so that patients can make informed choices about their treatment.
• Inclusion in the guidance of a specific reference to providing opportunities to reschedule appointments for patients who may have been unaware they had been scheduled for a hysteroscopy procedure, or who need more time to consider the options.
• Reference to ensuring “privacy, dignity and comfort” for patients undergoing this procedure.

However, there were also several areas where we felt this guidance could have been improved.

Patient engagement

Patient engagement is key to improving patient safety. In our report, A Blueprint for Action[8], we identify this as one of the six foundations of safe care. We believe that patients should be engaged for safety at the point of care, if things go wrong, in improving services, in advocating for changes and in holding the system to account.

This is especially important in the case of procedures such as hysteroscopy where patients and patient groups have expressed significant concerns about existing processes. In our response, we queried the extent to which the RCOG had engaged with patients and groups such as the Campaign Against Painful Hysteroscopy to ensure that their views and experiences could help to shape this guidance.

Communication

The guidance emphasises the importance of patients being sent and having access to information and online resources to help inform their decision making. We suggested it would also be helpful to provide this to primary care providers such as GPs. We have heard feedback from both patients and healthcare professionals suggesting that the quality of information currently provided by GPs about hysteroscopy can be variable.

We also underlined the importance of this information being produced to a standard that is easily accessible and understandable for patients, such as the Patient Information Forum’s PIF TICK quality mark.[9]

Resources for healthcare professionals

Discussing the role of safety checks in this procedure, the guidance suggests that healthcare professionals could consider using a specially adapted checklist to ensure that “essential elements such as patient identity checks and pregnancy tests are recorded where appropriate and any medical concerns identified.” We said it would be helpful for RCOG to share a good practice example of this type of checklist.

Patient-reported outcome data

In our response, we highlighted the importance of ensuring that patient-reported outcome data is routinely collected following hysteroscopy procedures to identify any emerging patient safety concerns, and that this is made publicly available. Currently, severe pain after these procedures is not regularly reported by healthcare professionals, nor are there the mechanisms available for patients to share their experience. We are concerned that this may potentially result in under-reporting and this limits our ability to understand the true scale of this patient safety issue.

We also stated our belief that incidences of significant pain should be considered an adverse event, being recorded, reported, and responded to appropriately.

Consent

The guidance places a welcome emphasis on the importance of patients understanding they can stop the procedure at any point. We suggested it may be beneficial to include a reference to the concept of a ‘two-step stop’, which was explained by Dr Saira Sundar in an interview on the hub as follows:

“She can ask for the procedure to pause at any time and then I will tell her what part of the procedure we are at/time left to complete. I then ask her if she would like the entire procedure to stop based on this information.”[3]

Language

We expressed concerns about the some of the language used in this guidance. On several occasions it refers to patients experiencing period-like pain, or a variant of this term. While we appreciate pain is a complex issue, this is quite an imprecise description that some women may not find helpful in making an informed decision about their care, as patients experience pain differently. We believe there needs to be significantly more research into the extent of pain around these procedures, and better ways of describing what the pain might be like without referring to it in such general terms.

We also expressed concerns that in the conclusion it states that “a minority of women will feel severe pain.” The guidance itself acknowledges that one third of women reported pain scores of 7-10 out of 10. While this is technically a ‘minority’, we are concerned that use of this term underplays a significant proportion of women’s lived experiences.

Training

Towards the end of the document, there is a reference to the importance of training for those providing outpatient hysteroscopy services. However, specific training needs are not covered in this guidance.

We believe it is important that staff who undertake these services should receive standardised and regulated training. This should include the risks of severe pain, clinical factors that make someone more susceptible, the limitations of clinician perception in assessing pain, the importance of listening to the patient throughout and the application of consent guidelines. Skills are clearly important, but so are the behaviours that support a patient’s decision making and their confidence in being able to say ‘no’ if they are uncomfortable, in pain and/or anxious.

We believe that it is important that RCOG clarifies where this necessary work will be addressed, as a priority.

Join the conversation

Are you a healthcare worker with insights to share on this topic? Are you a patient who has had a hysteroscopy? Perhaps you are a researcher or have a different perspective to add?

You can join the conversation here or get in touch with us directly by emailing content@pslhub.org

References

1. Campaign Against Painful Hysteroscopy, Open letter to the Department of Health and Social Care, 20 October 2020
2. Dr Richard Harrison, “Pain-free hysteroscopy”, 6 November 2020
3. Patient Safety Learning, Through the hysteroscope: Reflections of a gynaecologist, 26 January 2021
4. Patient Safety Learning, Improving hysteroscopy safety, November 2020
5. Patient Safety Learning, Minister acknowledges patients’ concerns about painful hysteroscopies; but will action be taken?, 20 January 2021
6. Patient Safety Learning, Ministers respond to patients’ concerns about painful hysteroscopies: Northern Ireland, Scotland and Wales, 15 February 2021
7. RCOG, Good Practice Paper: Pain relief and informed decision-making for outpatient hysteroscopy and procedures, February-March 2022
8. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019
9. Patient Information Forum, PIF TICK, Last Accessed 15 March 2022