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Pregnancy Testing Before Planned Surgery in young people under 18 years of age V2.0 10th March 2016 Table of Contents 1. Introduction ..................................................................................................................... 3 2. Purpose of this Policy/Procedure .................................................................................... 4 3.Scope .................................................................................................................................. 4 4. Definitions / Glossary .......................................................................................................... 4 6. Standards and Practice ................................................................................................... 6 7. Dissemination and Implementation ................................................................................. 1 8. Monitoring and effectiveness ........................................................................................... 1 9. Updating and Review ...................................................................................................... 2 Equality Impact Assessment ............................................................................................... 2 Appendix 1. Governance Information ..................................................................................... 3 Appendix 2. Initial Equality Impact Assessment Form ............................................................ 5 Summary The possibility of pregnancy should be considered in all relevant female patients before surgery which could pose risks to mother or foetus. Therefore Pre-operative pregnancy testing should be carried out in all females between the ages of 12 years and 55 years. 1. Introduction 1.1. The possibility of pregnancy should be considered in all relevant female patients before surgery which could pose risks to mother or foetus. 1.2. Offering pregnancy testing to females less than 18 years of age needs to be undertaken in a sensitive and confidential manner and may lead to safeguarding children concerns. 1.3. In some instances, the need to share information may need to override the duty of confidentiality. 1.4. There is evidence that some treatments can carry the risk of spontaneous abortion, prematurity and intrauterine growth restriction. 1.5. Patient history of menstrual period, contraception, sexual activity and the possibility of pregnancy could be unreliable. 1.6. In order to reduce the risk to any unborn foetus/baby, it has been agreed that all females 12 to 55 years should be routinely be offered a pregnancy test in the 24 hours prior to surgery being undertaken under general anaesthetic. 1.7. This will be obtained on the day of operation. 1.8. Written information about this test should be given to the patient and parents as far in advance as possible, such as when surgery is agreed at out-patients, or when the young person attends for pre-operative assessment so that the patient and/or parents can have any relevant discussion between themselves and any outside agencies and take appropriate action prior to admission. 1.9. If a previously unknown pregnancy is detected, the risks and benefits of surgery can be discussed with the patient. 1.10. If a previously unknown pregnancy is detected, the appropriate Safeguarding Children actions can be instigated. 1.11 .This policy states the responsibilities of the multidisciplinary team when caring for females of 12 to 18 years of age who are to undergo an anaesthetic. It conforms to guidelines and documents as identified within Appendix 1: Governance Information 1.12. This version supersedes any previous versions of this document. 2. Purpose of this Policy/Procedure 2.1. The purpose of this policy is to outline the Trust policy for Pregnancy Testing prior to Surgery of Young People less than 18 years of age and to protect the child/young person from the risk of undergoing surgery when pregnant. 2.2. To assist staff in the process of offering pregnancy tests and dealing with safeguarding children issues that may arise from that process. 2.3. To ensure that any information collected from the young person and parent/carer follows a standardised format, which is agreed by the multidisciplinary team. 2.4. To ensure that appropriate action is taken if a positive pregnancy test result is discovered in the 12 – 18 year old female according to statutory obligations. 3. Scope 3.1. This policy applies to all staff members, and their line managers who are involved with the management of females of 12 to 18 years who are to undergo anaesthesia. 4. Definitions / Glossary 4.1. POA – Pre Operative Assessment – a clinic where the pre-operative needs of patients are identified and initial actions and investigations are performed to identify risk and outline care to be provided during the forthcoming hospital stay. 4.2. OPD – Out Patient Department – an initial assessment clinic where the young person is reviewed by a consultant on the referral from General Practitioner. From this OPD clinic, the young person is listed for procedure requiring an anaesthetic. 5. Standards and Practice 5.1. Role of Managers Line managers are responsible for: Ensuring staff receive appropriate training 5.2. Role of Individual Staff To ensure they are aware of the policy 5.3. Staff who are involved in the management of females of 12 to 18 years are required to follow this policy and be clear with regard to their individual roles and responsibilities within the process. 5.4. Role of the Consultant Medical Staff and Medical Team The consultant staff and those to whom they delegate duties: Must discuss with the parents and young person the reason for their admission to hospital/contact with the service, the treatment involved and likely outcome including the need for anaesthetic. Will be responsible, in consultation with other members of the multidisciplinary team, for deciding which professionals need to be involved in the management of females of 12 to 18 years who require an anaesthetic. Anaesthetist must ascertain that the pregnancy status has been clarified prior to giving anaesthetic Should inform the female of 12 to 18 years who requires an anaesthetic a test is performed to ascertain pregnancy status. 5.5. Role of Nursing Staff The Nursing Staff involved in management of females of 12 to 18 years are responsible for: At pre-operative assessment clinic (POA), or at time of admission if not attending POA clinic clearly document accurate information relating to the 12 – 18 year old female menstrual cycle. This information will form the basis of decision regarding the need for a pregnancy test on day of anaesthetic. At pre-operative assessment clinic, or at time of admission if not attending pre op assessment clinic, should provide an information sheet: Pregnancy Testing Before Planned Surgery. On the day of admission ask the patient to provide a specimen of urine to enable a pregnancy test to be carried out according to RCHT Pregnancy Testing Protocol (2010) Be responsible for documenting that the pregnancy test has been performed and document the result of the test in the medical notes. 6. Standards and Practice 6.1. Most young people under the age of 18 years will have an interest in sex and sexual relationships. 6.2. All staff coming into contact with children and young people have a duty to safeguard and promote their welfare and should know what to do if they have concerns. 6.3. Cases of underage sexual activity are likely to raise difficult issues and should be handled particularly sensitively. 6.4. This means when offering routine pregnancy testing prior to surgery, the reason for it should be explained in a sensitive and confidential way, but it will have to be made clear to the young person that if sexual activity is disclosed, that absolute confidentiality cannot be guaranteed, as there may be circumstances where the needs of the young person can only be safeguarded by sharing information with others (Working Together to Safeguard Children 2010) 6.5. Age 13 years and under: A child under 13 years is not legally capable of consenting to sexual activity. Any offence under the Sexual Offences Act (2003) involving a child aged under 13 years is very serious and should be taken to indicate that the child is suffering, or is likely to suffer, significant harm (Working Together to Safeguard Children 2010). These cases should always be discussed with a nominated child protection lead in the organisation. 6.6. Over 13 – 16 years olds: Sexual activity with a child under 16 years is an offence. Where it is consensual it may be less serious in cases than if the child were under 13 years, but may have serious consequences for the welfare of the young person. Consideration should be given in every case of sexual activity involving a child aged 13-15 as to whether there should be a discussion with other agencies and whether a referral should be made to children’s social care. 6.7. 16 – 18 year olds: Sexual activity with 16 – 18 year olds may involve harm or the risk of harm, although it is unlikely to be an offence. 6.8 The process of offering pregnancy testing to under 18 year olds 6.8.1 Written information is given as far in advance as possible to the patient and parents such as when surgery is agreed at out patients, when the young person attends for pre-operative assessment or when prior to obtaining consent for the operation in the Emergency Department. Patient being admitted on the day of surgery are asked to provide a sample of urine on arrival to the ward/unit. 6.8.2 When the young person is admitted to the ward or Emergency Department, they must be asked if menstruation has commenced. Pregnancy test should be performed in all cases. 6.8.3 The patient and parents are asked if they are aware that RCHT pregnancy testing as a routine on all pubertal females. If they are not, why pregnancy testing is offered as part of routine procedure prior should be explained to the young person and accompanying adult in manner. undertake the reason to surgery a sensitive 6.8.4 Informed consent must be obtained prior to pregnancy testing being carried out and documented in medical notes. 6.9 Cases where consent for pregnancy testing is obtained: 6.9.1 Lot/Batch number of test and the result should be recorded in the medical notes and in t he peri-operative document pre op checklist with the batch number and the result 6.9.2 If the result is negative, pre-operative procedure should be continued. 6.9.3If the result is positive, pre-operative procedure should be discontinued and the relevant surgeon informed immediately and a discussion with the Safeguarding team should be initiated. For additional guidance, reference should made to www.SW.CPPorg.uk http://www.swcpp.org.uk/. A referral to the Genito-Urinary- Medicine Clinic should be made and discussed with the young person (Appendix 4). 6.11 Cases where consent for pregnancy testing is refused: 6.11.1If consent for pregnancy testing is refused by the parent or young person, the possible dangers to the young person’s health should be discussed in a sensitive manner 6.11.2Where possible the issue should be discussed with the young person on their own 6.11.3If pregnancy testing is still refused, this should be discussed with the relevant surgeon and written refusal to consent obtained from the parent and young person. The parent or young person should sign the peri-operative document checklist if the pregnancy test is declined. 6.12 All cases: 6.12.1At all stages the young person should be reassured that this is a routine procedure for all pubertal females. 6.12.2A record of the pregnancy test result or refusal to consent to the test must be made in the young persons’ medical record. In cases where the result is positive, steps should be taken to deal with the issues that arise, together with discussion with Safeguarding Children team, which should be recorded. 7. Dissemination and Implementation 7.1. Ward and Department Managers are responsible for ensuring adequate dissemination and implementation of the policy within their own areas. 7.2. All managers will be aware of the contents of the policy and will ensure that their staff have read and understood the procedures and processes related to the management of pregnancy testing prior to anaesthetic for all 12 to 18 year old female patients. 8. Monitoring and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Completion of documentation Recording of pregnancy test results Timeline of documentation for all interactions with young person Ward Manager or designated deputy An agreed audit tool developed by the Directorate, to include all elements as described above. An agreed audit tool developed by the Directorate, to include all elements as described above. Audits will be reported via the Divisional Audit and Guidelines meeting in the Directorate. Action plans, incidents and complaints related to discharge and transfer will be brought back to the directorate via Clinical Governance meetings. Reports should be discussed at the appropriate Operational Board Reports should be discussed at the appropriate Operational Board, with any high risk areas highlighted and action plans developed to address any gaps identified. Change in practice and lessons to be shared Lessons will be shared with all the relevant stakeholders by Presentation at Child Health audit and guidelines meetings and via Child Health risk management newsletter. Following liaison with relevant stakeholders, any required changes to practice will be discussed at Directorate Clinical Governance meetings, prior to being reflected in this policy and implemented clinically. 9. Updating and Review 9.1. This policy will be reviewed by the author at least every 3 years reflecting changes in legislation as necessary. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website. Royal Cornwall Hospitals NHS Trust is committed to a Policy of Equal Opportunities in employment. The aim of this policy is to ensure that no job applicant or employee receives less favourable treatment because of their race, colour, nationality, ethnic or national origin, or on the grounds of their age, gender, gender reassignment, marital status, domestic circumstances, disability, HIV status, sexual orientation, religion, belief, political affiliation or trade union membership, social or employment status or is disadvantaged by conditions or requirements which are not justified by the job to be done. This policy concerns all aspects of employment for existing staff and potential employees. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 2 of 14 Appendix 1. Governance Information Document Title Policy for pregnancy testing prior to surgery of young people under the age of 18 years of age Date Issued/Approved: March 2016 Date Valid From: March 2016 Date Valid To: March 2019 Directorate / Department responsible (author/owner): Yvette Williams; Tabitha Fergus Contact details: 01872 253911 Brief summary of contents Policy and guidance for the management of 12 to 18 year old females who require pregnancy testing prior to anaesthetic Suggested Keywords: Pre surgery pregnancy testing Target Audience RCHT PCH CFT KCCG Executive Director responsible for Policy: Medical Director Date revised: March 2016 This document replaces (exact title of previous version): Policy for Pregnancy testing prior to surgery of young people under the age of 18 years of age Paediatric practice development forum Sexual Health Hub Safeguarding Children’s Team Audit and guidelines Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Tim Mumford Name and Post Title of additional signatories None Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Signature of Executive Director giving approval Publication Location (refer to Policy on Policies – Approvals and Ratification): Document Library Folder/Sub Folder {Original Copy Signed} Name: {Original Copy Signed} Internet & Intranet Paediatrics Page 3 of 14 Intranet Only Links to key external standards GOSH Related Documents: DoH: Working Together to Safeguard Children (2010) DoH: Information Sharing: Pocket Guide (2008) Responsibilities of Doctors in Child Protection Cases with regard to Confidentiality (2004) The Sexual Offences Act (2003) DoH: NSF for Children and Young People and Maternity Services (2004) Children Act (2004) RCHT Pregnancy Testing Protocol (2010) NSPA Rapid Response Report. NSPA/2010/RRR011 Training Need Identified? No Version Control Table Date 1st October 2012 10th March 2016 Version No Summary of Changes V1.0 Initial Issue V2.0 2nd Issue minor no changes. Changes Made by (Name and Job Title) Ann Houlston Ward manager then Yvette Williams Yvette Williams Delegated to Yvette Tabitha Fergus Williams Willisam All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 4 of 14 Appendix 2. Initial Equality Impact Assessment Form Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): Policy for pregnancy testing prior to surgery of young people under the age of 18 years of age Directorate and service area: Is this a new or existing Policy? Directorate and service area: Nursing Existing Midwifery and Allied Health Professional Name of individual completing Telephone: 01872 253911 assessment: Yvette Williams This policy has been developed to support Trust staff in the 1. Policy Aim* management of pregnancy testing prior to anaesthetic in the Who is the strategy / 12 to 18 year old female patient. policy / proposal / It is a requirement of NPSA Rapid Response Report service function NPSA/2010/RRR011 to have in place a policy that meets the needs aimed at? specific to this group. 2. Policy Objectives* To ensure the safe management of 12 to 18 year old females who require an anaesthetic. 3. Policy – intended Outcomes* Safe management of 12 to 18 year old females who require an anaesthetic. 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? Annual audit of documentation RCHT staff and 12 to 18 year old female patients Nursing Staff Consultant Anaesthetists Consultant Surgeons Consultant Gynaecologist Consultant Sexual Health Children’s Services Integration Group Paediatric Practice Development Forum b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Age Yes yes No Rationale for Assessment / Existing Evidence All female patients from 12 to 55 years require pre-anaesthetic pregnancy testing Page 5 of 14 Sex (male, female, trans- no gender / gender reassignment) Race / Ethnic communities /groups no Disability - no Learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs no Marriage and civil partnership yes All female patients from 12 to 55 years require pre anaesthetic pregnancy testing Pregnancy and maternity yes Sexual Orientation, yes All female patients from 12 to 55 years require pre anaesthetic pregnancy testing All female patients from 12 to 55 years require pre anaesthetic pregnancy testing Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked “Yes” in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major service redesign or development Nox 8. Please indicate if a full equality analysis is recommended. Yes 9. If you are not recommending a Full Impact assessment please explain why. Signature of policy developer / lead manager / director Y.williams Names and signatures of members carrying out the Screening Assessment Date of completion and submission March 2016 1. 2. Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust’s web site. Signed __Y.Williams/ T.Fergus_____________ Date ___March 2016_________ Appendix 4 -Sample of leaflet given to children and young people. Page 6 of 14 Appendix 3- Sample of Information given to children and young people. Pregnancy testing before planned surgery When you come into hospital for your operation you will be asked to give a urine sample for a pregnancy test on the morning of the operation. This is something hospitals all across the country are doing and specifically has been recommended as a way of enhancing safety. Why am I being asked to do this? Pregnancy testing before surgery is recommended for all female patients aged 12 – 55 years of age. It has no relation to any individual’s circumstances. I am sure I’m not pregnant. Must I have the test? Nobody is compelled to have a pregnancy test. If you decide not to be tested you will be asked to sign a note to say that you have made that decision. This may be the obvious thing to do for some people such as those who have had a hysterectomy. We would recommend that even people confident about their contraception check with a pregnancy test. Why is it important? The very early stage of pregnancy, maybe even before the pregnancy has been recognised, is the time when an embryo may be most vulnerable to ill effects of medicines, X-rays and anaesthetics. Operations on the abdomen and pelvis can directly affect the womb and even operations (or occasionally complications) on other parts of the body may involve medicines that can affect pregnancy. If I’m pregnant, will my operation be cancelled? Pregnancy is just one factor in your decision to have an operation. If you are pregnant you should talk to the doctors looking after you about whether there are any additional risks involved with your operation. You will be able to decide together whether you should go ahead, consider another treatment or delay treatment. I don’t think this is right for my daughter We hope you will understand that it is better to test every female patient of child bearing age rather than discriminate by asking personal questions, especially for very young patients. When girls are mature enough to understand and weigh up information to help them make decisions, they can (legally) determine their health care even when not yet 16 years of age. Therefore if a young patient under the age of 16 is having an operation she will often be asked to either have a pregnancy test or sign herself that she does not want to do so (and takes responsibility for that decision). If it is not appropriate for her to do so herself, the person with parental responsibility who signs the consent form would also be asked to consent to pregnancy testing. Page 7 of 14