In September 1999 a discussion with our Clinical Director about the current ENP role took place. This discussion raised issues, such as role expansion, that would increase the range of conditions managed by the ENP providing obvious benefits for our patients.

One of the areas to consider was the provision of emergency contraception (EC). The proposal was to provide EC out of hours and at weekends, evenings and bank holidays to complement the established sexual health service which is provided on both sites.

If a female presented to the Accident & Emergency (A&E) Department when existing sexual health services were not available and requested emergency contraception she would be offered two options:

1. If appropriate (e.g. within seventy two hours of unprotected sexual intercourse) to attend General Practitioner, local family planning clinic or sexual health department.

2. Or she may prefer to wait for the on-call Gynaecological Senior House Officer to be available and wait on Treeves Ward to be seen.

The results of interviews conducted by Fiona Brundish (A&E Sister) as part of a degree project in April 1999 showed that nursing staff on Treeves Ward and the current Gynaecology Senior House Officer (Gynae SHO) had received no specific training regarding provision of EC. Furthermore they did not feel the distribution of EC from Treeves Ward was particularly relevant and certainly not beneficial to staff or patients. If a woman chose to see the Gynae SHO the waiting time would depend on several variables, for example was the doctor in theatres, A&E, or in the labour ward and consequently called away from existing work commitments.

Once it was established how the existing service was provided, I needed to justify if it was appropriate for the ENP team to provide EC, but above all would our local population benefit if the new service was implemented.

In conjunction with previous work carried out by Fiona Brundish a literature search was undertaken. This will not be discussed in this article however interested readers are provided with a reference list.  

The whole issue of unprotected sexual intercourse (UPSI) and unplanned pregnancy is extremely complex and it became apparent that many interconnected issues require consideration. However, for the purpose of this article, I want to highlight and briefly discuss the pertinent points which formed the framework to justify provision of the service by the ENP team.

The city community:Generally commute into London.Access to GPs limited due to work ethic i.e. reluctant to take time off work.

Multicultural Community:Social and cultural differences regarding use of contraception and family size.

There may be a reluctance to attend GP if well known to other family members.

Transient population:London's diverse and highly mobile population (e.g. students, tourists, homeless) may lack knowledge of local facilities and experience difficulty accessing local primary care facilities.

Conception rates in girls under sixteen is four times higher in inner city areas such as East London, Lewisham, Lambeth and Southwark than outer London when compared with areas such as Barnet and Bromley (Health of Londoners Report 1998). This report also states that there should be wider access to EC.

3. The millennium break

It was felt that due to the additional bank holidays in December 1999 and January 2000 the service should be offered.  We had no statistical data to justify our opinions, but common sense told us that the combination of alcohol, festivities and 'millennium fever' would result in increased UPSI. Conveniently, this provided a dead line with which to work i.e. the service needed to be in place by mid-December. This was to allow for professional training and support to ensure that any problems encountered could be discussed with Trust family planning experts prior to the long holiday break.

The ethos of the new NHS is to provide healthcare that is easily accessible, provision of emergency contraception through the A&E environment is in keeping with this.

I appreciate emergency contraception is an emotive subject due to religious and cultural beliefs and does appear to be low down the list of priorities when working within the high-pressure environment of A&E.  However, taking into account the previous points, I felt that there was a strong argument to facilitate the development of an EC policy.

I had always believed that the Emergency Nurse Practitioner could be well equipped to offer a high standard of service when distributing EC. The ENP team is constant, it does not change every six months as the junior doctors do, consequently the training needs are easier to address, ensuring a high standard of practice.

Once these factors had been recognised and established, we could then move the project forward.

Initially contact was made by telephone, I spoke to colleagues within the Trust who I felt would have a vested interest in the project and on whose expertise I would have to rely on.

During this process I was able to test reactions, gain valuable advice and each telephone call provided me with another contact name.

The following is a list of all personnel that were contacted at various stages throughout the project and prior to the service being commenced :

• Senior Nurse Women's Services;
• Sister, Treeves Ward;
• A&E Clinical Director;
• Senior Nurse Quality;
• Family Planning Team;
• A&E Consultants, Lecturer/Practitioner , Sisters & Charge Nurses;
• Paediatric A&E Sisters & Charge Nurses;
• Pharmacy Department;
• Consultant in Women's Health;
• Consultant Community Gynaecologist;
• Head of Legal Liaison;
• Reception Staff;
• Site Management Team.

It was at this point I made an invaluable contact, Daphne Woodhouse (Family Planning Sister) who informed me that their department had been working on guidelines so the family planning team were able to distribute EC autonomously.

Daphne and I agreed, at this point, to take the project forward together to ensure a unified approach was maintained and duplication did not occur.

Time was of the essence, the new policy documents had to be presented to the Nurse Administration According to Protocol (NAAP) sub-committee at the end of November.  We had to ensure that this was passed first time otherwise I would not meet my deadline for introducing the service by mid-December.

I decided the best way forward was to get all the documentation connected with the new policy prepared in draft form and to circulate it to relevant personnel, all of which are included in the previous contact list, prior to the NAAP sub-committee meeting.  The documentation consisted of:

• Nurse Practitioner Guidelines.
• Patient Information Sheet.
• Two Protocols
• Schering PC4 (Emergency Contraceptive Pill).
• Anti Emetic.
• Proforma.

There was some concern regarding the provision of the service to the under 16 age group.  Ffion Davis, Paediatric A&E Consultant, clarified our position on this issue.  This age formed a large part of our target group and Ffion produced an appendix to attach to the ENP guide lines which proved to be an invaluable resource.

The ENP team approached the concept of this new service with energy and enthusiasm, however, we needed to address our lack of knowledge.

Daphne and Sue Brooks, Family Planning Sister, in the Ambrose King Centre, provided educational sessions for each ENP. We also obtained relevant articles and studies, these were amalgamated and distributed as a self-directed-learning pack.

The learning curve at this point was almost vertical, as always it was rather daunting when one begins to explore the knowledge and expertise possessed by colleagues in other specialities.

Daphne and I attended the NAAP sub-committee meeting in November 1999 and after making final amendments it was agreed that we could take the project forward and implement the new service in our clinical areas.

As planned we were able to facilitate provision of the service on 15^th December 1999, the first woman attended A&E on the 21^st December.  The ENP team saw 27 women, who requested EC, in A&E at the Royal London Hospital between 26^th December - 4^th January 2000.

We had no idea if these figures were high as we had no previous data with which to make comparisons.

An audit proposal has recently been submitted to obtain information on our service provision between 15^th December 1999 - 31^st March 2000.

However, these basic figures are available.

A new type of emergency contraceptive is now available: Levonelle 2, which we hope to provide in the near future as an alternative to Schering PC4.  We will continue to work closely with the family planning services and assist with data collection so that the effectiveness of this new medication may be monitored.

Finally, I would like to express my thanks to all colleagues that assisted me with this project particularly Daphne, without her support and expertise, provision of the service would not have been possible.

References

1. Department Of Health.   The Health of the Nation Key Area Handbook: HIV/AIDS and Sexual Health.  London: HMSO 1993.

2. Department Of Health. Our Healthier Nation: A contract for health.  A consultation paper.  London: Stationary office.1998.

3. Gbolade B, Elstein M, Yates D. UK accident and emergency departments and emergency contraception: what do they think and do?  Journal of Accident and Emergency Medicine, 1999:16; 35-8.

Department of Health. The New NHS: modern, dependable. London: Stationary Office, 1997.

Hearde-Dimyan.  Issue of emergency hormonal contraception through a casualty department in a community hospital.  The British Journal of Family Planning, 1999: 25; 105-9.

McDonald H.  Moral, ethical and professional issues in prescribing emergency contraception.  Emergency Nurse, 1998: 6. 8(Dec/Jan); 28-32.

Roberts R.  Audit of an emergency contraception service. The British Journal of Family Planning, 1995: 21.1 (April); 22-5.