An Inventory of VHA Emergency Departments’ Resources and Processes for Caring for Women

In summary, our inventory of VHA EDs revealed that most have access to resources and processes needed for delivering emergency care to women Veterans. However, as hypothesized, EDs with lower demand for female-specific services (i.e., fewer encounters by women) and EDs that are smaller and located in less complex facilities in non-metropolitan areas are more likely to lack such resources and processes. We nonetheless also identified some higher-demand, larger EDs, and EDs in complex metropolitan VAs, with potentially important gaps.

Overall, we found that many VHA EDs have gaps when compared to the resources recommended by a 2007 American College of Emergency Physicians (ACEP) policy statement.10 With respect to obstetrics and gynecology, ACEP recommends that all EDs should have gynecologic examination tables; specula of various sizes; emergency obstetric instruments and supplies; sexual assault evidence kits (as appropriate); qualitative and quantitative pregnancy testing; blood cross-matching capabilities (which includes Rh Factor); Chlamydia testing (DNA probe versus culture not specified); Rho(D) immunoglobulin; oral contraceptives; and “emergency ultrasound services for the diagnosis of obstetric/gynecologic… conditions.” ACEP also asserts that “The ED should be designed to protect, to the maximum extent reasonably possible … the right of the patient to visual and auditory privacy.” Further, the hospital “must provide to the ED a list of appropriate ‘on-call’ specialists who are required to respond to assist in the care of emergency patients within reasonable established time limits.” Currently, to our knowledge, no other national ED inventories have been conducted against which we could compare our VHA results. This gap in knowledge of how U.S. emergency care is organized and delivered warrants further study. More research related to the costs and feasibility of achieving the ACEP standards with varying facility and community characteristics, as well as the quality and outcomes of care they afford, is also needed.

Absence of ED equipment and supplies for emergency gynecologic care may potentially result in care delays and sub-optimal outcomes. Having gynecologic examination supplies stocked in the ED decreases the likelihood of delays secondary to waiting for supplies. Where supplies and expertise are not available, women may need to be transferred to neighboring facilities to receive needed care. EDs without gynecologic examination tables may use those in nearby primary care or women’s clinics, but this may mean that the patient leaves the monitored ED area to complete the examination and access to these areas may be more difficult, or not available, after hours. Pelvic ultrasound is also a key component in evaluating a pregnant woman presenting with abdominal pain or vaginal bleeding.11 Therefore, any ED without pelvic ultrasound access should transfer to other facilities all pregnant women Veterans with abdominal pain or vaginal bleeding. Similarly, any woman with a suspected gynecologic emergency presenting to an ED without available specialty consultations may need to be transferred to another facility with this capability. The time it takes to transfer these women, and arrange for the transfer where expedited acceptance agreements are not in place, will extend the time to treatment of time-sensitive conditions. While national VA policy references the need to effectively treat women Veterans under emergent conditions, 12‐14 more specific guidelines may be needed so that consistent resources and processes are available across VHA EDs, and/or, if these resources or processes are not available, expedited arrangements are in place to provide women Veterans with the timely care they need.

Although all VHAs contract with other facilities for obstetric care, women may present to VHA EDs with pregnancy-related emergencies. Some of these emergencies, such as miscarriages and ectopic pregnancies, may occur without the patient having previous knowledge of the pregnancy. The ED needs to have a mechanism for women who have Rh-negative blood type to receive Rh Immunoglobulin within 48 h. In the event that Rh Immunoglobulin is not administered when indicated, a woman’s future pregnancies may be negatively affected. Although uncommon, women may present to VHA EDs later in pregnancy as well, and VHA EDs need to be prepared for these situations, at least with policies and procedures for rapid transfer to facilities that do deliver obstetric care.

Almost all VHA EDs report adherence with VHA’s directive on caring for acute sexual assault victims, stating that all EDs must “have plans in place to appropriately manage the medical and psychological assessment, treatment, and collection of evidence from male and female Veterans who are victims of alleged acute sexual assault.” 14 However, 41 % of VHA EDs reported not having the capacity to arrange for mental health follow-up within 24 h, which is also part of this policy. The importance of urgent follow-up mental health care for sexual assault victims has been well-documented.15

Our findings must be interpreted in light of several limitations. First, the data are facility-reported without independent verification of accuracy. If responses reflect social desirability, we posit that gaps may be broader than reported. Second, our measures of ED structure and processes vary with respect to levels of evidence linking them to care quality. For example, although there is evidence about the importance of follow-up for medical and psychiatric care for sexual assault victims,12 we do not know how having a gynecologic examination table within the ED, rather than in a nearby clinic, impacts care quality. Thirdly, we were unable to find a similar inventory of resources and processes for non-VA EDs, and therefore we do not know how our findings compare to community EDs. An investigation of community ED adherence to ACEP recommendations is needed. Finally, all resources and processes can only impact the care of patients to the extent to which they are actually used and used appropriately. One of the most significant factors impacting the care of women for these conditions is the knowledge and skills of the ED providers, and the gender-sensitivity with which they deliver care, neither of which were captured in our inventory approach. All of these limitations should be addressed in future investigations.

Over the past decade, VHA has devoted considerable effort to improving the care it provides to women Veterans. However, this inventory revealed that gaps remain with respect to resources and processes for their emergency care. Exploration of facilitators and barriers to addressing these gaps, such as logistical considerations, is needed. Despite their growing numbers, women Veterans still represent a relatively small proportion of the overall patient population and therefore providing them with efficient, timely, and consistently high-quality care is an organizational challenge. Future work should seek creative solutions to this challenge to further the goal of VHA achieving standards of gender equity across all services delivered.