Improving follow-up utilizing Plan-Do-Study-Act cycles and a texting intervention for patients with pregnancy of unknown location

Pregnancy of unknown location (PUL) describes a clinical condition in which a patient has a positive pregnancy test, but no visible pregnancy on ultrasound. Patients with PUL must be tracked carefully until the final diagnosis is confirmed, to exclude an ectopic pregnancy which can lead to morbidity and mortality for the patient if unrecognized. The aim of this quality improvement study was to improve follow-up care and communication for patients diagnosed with PUL. Our study was conducted from October of 2019 to January of 2021. Our cohort consisted of patients diagnosed with PUL who were followed until a final diagnosis was established. We used Plan-Do-Study-Act (PDSA) cycles to improve patient follow-up and patient-to-provider bidirectional communication. Our main metrics were the proportion of patients returning at 48-h for their blood draw, rate of 5-day delay in care, and number of patients lost to follow-up (those who did not follow up within 2 weeks of their anticipated follow up). PDSA cycles were compared using run charts. Following implementation through PDSA of a text-based follow-up program for patients with pregnancy of unknown location, the proportion of patients who were lost to follow-up decreased from 25% to 12.5%, as did the proportion of patients experiencing delays of 5 days or more during follow-up, from 41% at baseline to 33% at the time of the last PDSA cycle. However, our lost to follow-up rate reduction was not maintained in our final cycle and rose again to 30%.