Abstract
The first part of this chapter has been written with the patient’s journey in mind: from the time of presentation to the general practitioner (GP) with a problem such as abnormal uterine bleeding, through referral to secondary care for investigation, including hysteroscopy if appropriate, and to treatment as indicated. We hope this approach will clarify what is involved in providing such a service. In the second half of the chapter, the equipment required for providing hysteroscopy services is described in detail, making extensive use of published standards and guidelines for gynaecology and hysteroscopy specifically.
3.1 Introduction
The first part of this chapter has been written with the patient’s journey in mind: from the time of presentation to the general practitioner (GP) with a problem such as abnormal uterine bleeding, through referral to secondary care for investigation, including hysteroscopy if appropriate, and to treatment as indicated. We hope this approach will clarify what is involved in providing such a service. In the second half of the chapter, the equipment required for providing hysteroscopy services is described in detail, making extensive use of published standards and guidelines for gynaecology and hysteroscopy specifically.
3.2 Infrastructure
3.2.1 Referral Mechanisms
‘Infrastructure’ means the systems and processes necessary to offer and run a hysteroscopy service. It starts with the referral mechanism, either from the GP or from within the gynaecology service. Many hospitals offer specific clinics for menstrual disorders or post-menopausal bleeding that include the option of hysteroscopy; the latter is usually part of a fast-track service for suspected cancer. Access may be online with the ‘Choose and Book’ system, though the standard paper referral system remains available.
Scrutiny of hospital referrals to gynaecology with subsequent allocation to a specific clinic ensures that patients see the most appropriate clinician at the first visit, and that they are offered the most relevant investigations, including hysteroscopy when indicated. A pelvic ultrasound scan, if not available as part of the hysteroscopy service, can be arranged and co-ordinated with the hysteroscopy clinic appointment. The aim is to provide prompt access to a service with efficient assessment and treatment.
3.2.2 Patient Information
Patients facing hysteroscopy experience high levels of anxiety [1], which can be reduced by understanding the procedure in advance [2]. Comprehensive, clear and simply written patient information should be provided with the appointment letter, and also be available online, so that the patients can read it before attending. Also, providing a brief summary of the procedure and advice about analgesia at the start of the document may be helpful for patients who do not want detailed information.
The information provided will vary according to local circumstances and the type of services offered, but should support patients in making informed choices about their care and management. It should give details about having an outpatient diagnostic hysteroscopy, and whether immediate treatment is offered, as with ‘see-and-treat’ services. Informed choice is facilitated when information is provided about the venues for hysteroscopy, and the potential treatments available. The Royal College of Obstetricians and Gynaecologists (RCOG) Patient Information Committee, in conjunction with the British Society for Gynaecological Endoscopy (BSGE) Hysteroscopy Subcommittee, have developed a generic outpatient hysteroscopy patient information leaflet (PIL) based on the RCOG/BSGE Green-top Guideline No. 59, Best Practice in Outpatient Hysteroscopy (PIL available at www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/gynaecology/pi-outpatient-hysteroscopy.pdf).
Advice about taking simple analgesics, such as 1 g paracetamol and/or 400 mg ibuprofen about one hour before the scheduled appointment time, should be included in the patient information. Some patients may benefit from taking an anxiolytic beforehand; a small dose of diazepam or temazepam can be beneficial. The use of local anaesthesia should be described, and whether there is the option for using nitrous oxide.
Outpatient hysteroscopy is acceptable to many patients, but not to all, so the option of inpatient investigation and treatment needs to be clear from the outset [3]. It is apparent from the online comments of some patients that their outpatient hysteroscopy experience was far from acceptable or satisfactory, with severe pain being one of the commonest complaints [4, 5]. Patients who opt for an outpatient investigation need to be aware that the procedure can be stopped at any time; clinicians, including the nursing staff, must be prepared to listen and stop when asked.
Some hospitals, such as the Royal Victoria Infirmary in Newcastle, UK, offer conscious sedation instead of general anaesthesia. Patients attend the outpatient clinic on a specific day and at an allocated time, and receive their treatment with intravenous sedation and analgesia, and are discharged within two hours of arrival. Details of the service and analgesia regime are described in Chapter 6.
Additional leaflets covering the investigation of post-menopausal bleeding (PMB), see-and-treat endometrial polypectomy and the treatment of HMB may be useful when sent with the first appointment letter. Also helpful are specific leaflets covering endometrial ablation and myomectomy.
3.2.3 RCOG Standards
In 2016, RCOG produced a set of 92 standards for gynaecological care [6] that built upon the previous standards published in 2008 [3]. They provide a framework for the provision and delivery of a quality gynaecological service, and focus on patient safety, clinical effectiveness and the patient experience.
When setting up or developing an outpatient service that includes hysteroscopy and outpatient procedures, the RCOG standards suggest considering the following indicators alongside a well-developed clinical governance structure for a well-functioning service:
Clear pathways for referral into the service and between services
Care pathways that are described in evidence-based clinical guidelines and benchmarked against national guidance such as that from the National Institute for Health and Care Excellence (NICE) and RCOG
Patient-centred care as evidenced by the involvement of women in all aspects of their care and the decision-making process
Evidence of multi-disciplinary care and team working
Awareness of complication rates from therapeutic interventions.
The 92 standards cover all aspects of gynaecology care and many are relevant across inpatient and outpatient services. It is advisable that individual departments benchmark their own services against these standards; this will facilitate the delivery of quality improvement programmes. The following points give examples of how the standards may be relevant to diagnostic and operative hysteroscopy services:
The need for interpreting services should be identified at the point of referral. If needed, arrangements should be made for appropriate interpreting services to be available at all appointments, without reliance on family members.
If treatment is planned, women should receive comprehensive verbal and written information regarding the procedure, including options for other treatments as well as the proposed procedure. This may be by leaflet or reference to the organisation’s website where leaflets have been uploaded. The information they have received should be documented in their notes.
For procedures performed in outpatient clinic areas, there must be adequate nursing support with at least two additional staff members in the procedure room; this will be a mix of qualified nurses, healthcare practitioners and associate practitioners.
3.2.4 The Clinical Team in the Outpatient Setting
According to the joint guideline by RCOG and BSGE, Best Practice in Outpatient Hysteroscopy [7], there will generally be a complement of three support staff, in addition to the hysteroscopist, consisting of at least one registered nurse and two healthcare assistants. One of the healthcare assistants will support the nurse and the other the patient, accompanying her throughout her clinic journey; the role of this healthcare assistant is to be the ‘vocal local’, communicating with the patient to help alleviate her anxiety, thereby minimising embarrassment and pain.
3.2.5 Clerical Support
A reception area with administrative and clerical staff is needed to meet and greet patients, confirm and enter their demographic details, access their records and guide them to the waiting area or ultrasound department for pelvic ultrasound before the hysteroscopy. Secretarial staff are important in the timely typing and sending of patient correspondence to GPs and keeping track of all investigations and results.
3.2.6 Outpatient Facilities
Outpatient hysteroscopy should be performed in an appropriately sized and fully equipped treatment room with a couch suitable for hysteroscopy (Figure 3.1). The room may be in a dedicated hysteroscopy suite or a multi-purpose facility. It should be patient-friendly and provide privacy with an adjoining changing area and, ideally, a toilet.
The availability of a hoist should be considered. A risk assessment of the clinical environment and couch is recommended, to assess suitability for hoisting patients; if deemed suitable, then appropriate equipment and staff training are required. Adequate resuscitation facilities must be readily available, with access to oxygen and a means of monitoring blood pressure, pulse and oxygen levels. These are not specific to hysteroscopy, being also required in colposcopy clinics and when fitting intrauterine contraceptive devices.
The recovery area should be separate from the waiting area to enable patients to recover with privacy, if required (Figure 3.2). It needs to be furnished with comfortable reclining chairs and a bed so that the patient can lie flat, which is sometimes necessary following treatment or a vasovagal episode.
3.2.7 Ergonomics and Hysteroscopic Procedures
Ergonomics is the study of the interactions between people and other elements of a system; its goal is to optimise human wellbeing and overall system performance [8]. As with any other activity involving people and equipment, the principles of ergonomics apply to hysteroscopy so that it is undertaken efficiently and safely, both for patients and for clinical staff, including managing patients with limited mobility.
Assessing the working environment is embedded in our practice, with well-developed assessment processes to reduce the risk of harm from needlestick injury, infection, slips, trips and falls, and exposure to substances hazardous to health. Less well established, however, is assessment in relation to work-related musculoskeletal disorders, even though they are well documented in the literature, with risk assessment tools available on the Health and Safety Executive (HSE) website [9]. Musculoskeletal injuries – any injury of the joints or other tissues in the limbs or the back – are the most common reason for occupational ill-health in the UK. There are many causes of musculoskeletal injuries; the most common are incorrect manual handling and repetitive motions.
Back pain and other musculoskeletal disorders account for approximately 18% of all sickness absence in the NHS [10], resulting in a cost of around £200 million each year [11]. The HSE defines manual handling as transporting or supporting a load, including lifting, lowering, pushing, pulling, carrying or moving. For some members of staff, manual handling accidents can result in long periods of sick leave; for others, it can end their career. It is therefore vital that all clinical areas are risk-assessed in relation to manual handling requirements and that all staff have completed local manual handling training.
When performing any risk assessment, consideration must be given to moving patients within the outpatient clinical setting and what aids will be used. Some patients with minimal mobility will require a hoist (Figure 3.1); those able to stand may find a short-distance transfer platform useful for transferring from a wheelchair to the examination couch (Figure 3.3). Ideally, the patient’s needs should be assessed before they arrive in the outpatient clinic.
Another group of patients who require a different approach to examination, for their own safety as well as that of the hysteroscopy team, are women who are too heavy for the standard examination couch, particularly those who weigh over 200 kg. An option in these circumstances is for the patient to lie on her left side, with knees bent, on the edge of a bariatric bed. This avoids the patient being placed in a precarious position, enables her to feel safe and physically supported, while facilitating hysteroscopic examination, endometrial sampling or insertion of a hormone-releasing intrauterine device.
Repetitive strain injury (RSI) describes the pain felt in muscles, nerves and tendons caused by repetitive movements and overuse. Symptoms range from mild to severe and usually develop gradually, mostly affecting the forearms, elbows, wrists, hands, neck and shoulders. As well as repetitive activities, poor posture or activities that require working in an awkward position are risk factors [12]. Consequently, poor arrangements in the hysteroscopy room will increase the risk of RSI.
Several studies have looked at the prevention of work-related musculoskeletal injuries, specifically in relation to clinicians performing endoscopic procedures [13]. The ergonomic principles to avoid work-related musculoskeletal injuries are transferable to hysteroscopic practice and include:
Assessing the clinical area to ensure ergonomic practice is observed. This includes ensuring that the height of the patient chair/couch is adjustable, and that consideration is given to the type of chair used by the clinician, and to the position of monitors and foot pedals.
Educating staff in ergonomic techniques.
Contributing to research on the modification and development of ergonomic hysteroscopic equipment. Some clinicians develop pain in their hands due to the weight of the hysteroscope plus the camera head and additional therapeutic devices.
3.3 Instrumentation
There is a wide array of equipment available for hysteroscopic procedures, including portable all-in-one cameras, monitors and light sources, as well as the traditional stack systems. Miniature hysteroscopes are particularly useful when only a diagnosis is required; larger scopes also offer a therapeutic option suitable for a ‘see-and-treat’ service. Most hospitals in the UK already offer an outpatient hysteroscopy facility; changes in clinical practice may lead to an increase in services, particularly in the community, where flexible use of facilities makes smaller portable equipment advantageous. The equipment that is readily available in the UK is discussed below.
3.3.1 Camera Stacks
Stack systems include the mount for the camera control unit, an external cold light source (xenon lamp, 175–300 W), a video monitor and a printer (Figure 3.1). Still images and video recordings can be archived for auditing and teaching purposes.
Where space is limited, compact, mobile all-in-one units can be used, such as the TELE PACK X LED (Karl Storz, Tuttlingen, Germany) (Figure 3.4) and the THS® tower-free hysteroscopy system (Hologic, Inc., Marlborough, MA, USA). These consist of an integrated camera, LED light source, 15-inch monitor, integrated data management system and USB ports, and fit in even the smallest examination room.
Another portable hysteroscopy system is the UBIPack GYN (SoproComeg, La Ciotat Cedex, France), which contains a camera and a light source. It has no monitor, but the image can be viewed on a laptop or standard personal computer via a 3 m cable with a USB connection. The system can be used with flexible or rigid endoscopes and with regular or pendulum camera heads. The camera type is recognised by the Intelligent Control Endoscope (ICE) software provided. Additional software (Sopro Imaging) provides patient management screens and enables printing of medical reports.
More recently, miniature integral hand-held systems have become available; these will be discussed in Chapter 19.
3.3.2 Diagnostic Hysteroscopes
Diagnostic hysteroscopes can be flexible, rigid or semi-rigid and are available in a variety of sizes. Most have a viewing angle of 30° at the tip of the scope, but some with viewing angles of 0° and 12° are in use in clinical practice. Diagnostic hysteroscopes with a 30° viewing angle allow for a thorough inspection of the entire uterine cavity including the uterine walls, cornual recesses and tubal ostia, with minimal pressure applied to the cervix.
The type of hysteroscope to use in practice is a choice for the clinician to make. Its size (for the comfort of the patient) must be balanced with the clarity of the image obtained and the possibility of immediate treatment. The type of lens system in the hysteroscope makes a significant difference to the quality of the image. In rigid hysteroscopes, between the objective and the distal lens of the hysteroscope are densely packed, small-diameter glass rods (Hopkins rod lenses). In semi-rigid or flexible hysteroscopes, there are flexible plastic fibres. The rod lens system produces a better quality image than that produced using flexible fibres. Also, image resolution is lower with the flexible scopes as the fibre optic bundle carries both the light and the image, whereas the rigid hysteroscopes have a separate image bundle (rod lens) and fibre optic light bundle.
Flexible Hysteroscopes
Flexible hysteroscopes (Figure 3.5) vary in diameter from 3 to 5 mm, with a viewing angle of 0° and working length of 230–290 mm. They are associated with less pain during outpatient hysteroscopy than rigid hysteroscopes, but are more expensive and tend to have inferior image resolution. Flexible hysteroscopes cannot be autoclaved and therefore require specific facilities for cleaning and disinfection. Rigid hysteroscopes, though less comfortable, may be more cost-effective, with better images, fewer failed procedures and shorter examination time.
Semi-rigid Hysteroscopes
The term ‘semi-rigid’ refers to hysteroscopes that use semi-flexible fibres for light transmission instead of the standard rod–lens system. This enables the production of very narrow hysteroscopes, such as the Alphascope™ which is only 1.8 mm in diameter. This is used with a disposable single-use Versascope™ sheath (Figure 3.6). This sheath is curved with a collar that rotates 360°, allowing visualisation of the entire cavity. The sheath features an expandable operating channel down which 5 and 7 Fr instruments can be passed, including the 5 Fr Versapoint™ bipolar electrodes.
Related posts:
Chapter 2 – Anatomy and Physiology of the Uterus
Chapter 6 – Analgesia and Anaesthesia for Hysteroscopy
Chapter 8 – Hysteroscopic Electrosurgery
Chapter 10 – Hysteroscopic Endometrial Polypectomy
Chapter 17 – Audit, Data Collection and Clinical Governance in Hysteroscopy
Chapter 18 – Training in Hysteroscopic Skills
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