Is it possible to perform all Diagnostic Hysteroscopies in the Outpatient Hysteroscopy Clinic?

Objectives: To assess the viability of increasing the proportion of diagnostic hysteroscopies performed in an outpatient setting (OPH), versus those under general anaesthetic; and to establish factors which may determine the choice of operative setting. Method: A comparison of two audits of theatre hysteroscopy procedures (at Whipps Cross University Hospital), with an assessment of the trend in the use of both outpatient and theatre hysteroscopies. Results: Between April-2012 and October-2015 3381 patients underwent hysteroscopies, with a relatively consistent number of procedures per month (average 79.5). There was a significant (P=0.001) change in how diagnostic hysteroscopies were performed (OPH rose by 65.5% and in-theatre hysteroscopies fell by 42.6%). In a one-month audit of patients who underwent theatre hysteroscopies in 2012, 50 patients underwent the procedure of which: 6 (12%) met the exclusion criteria and were unsuitable for OPH; 44 (88%) had no factors that met the exclusion criteria (disregarding patient preference or a failed OPH); 36 (72%) met the inclusion criteria and could have received OPH. In a further audit conducted over two months in 2015, of the 42 patients who underwent theatre hysteroscopies 20 (47.62%) met the exclusion criteria for OPH. Of the remaining 22 (52.38%); nine (21.43%) were unsuitable due to patient preference, for five (11.90%) no reason was recorded and eight (19.05%) were booked under general anaesthetic to prevent breaches of suspected cancer targets. Conclusions: Hysteroscopies have been performed in the outpatient setting in increasing numbers, resulting in reduced risks to the patient, faster, cheaper treatment, and shorter recovery times. There has been a marked improvement in documenting the justification for the chosen referral option. This suggests an increased awareness of the inclusion and exclusion criteria for OPH by staff and promotion of OPH to patients. This improvement was achieved by betterpatient awareness of OPH, and changing the attitudes of clinicians. More could be done to increase further the number OPH referrals, including providing dedicated time in clinic for treatment where cancer is suspected, and further normalisation of OPH for patients. Consideration could be given to introducing a see-and-treat clinic model, and requiring the reasons for general anaesthetic referral to be recorded.