Whipps Cross Hospital Botox Service Audit and QIP
BAUS ePoster online library. Barnett H.
Jun 26, 2018; 217785
Heather Barnett
Heather Barnett
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Urinary incontinence is common and has a social, psychological and economic impact on patients. Botox forms part of the MDT approach to OAB. Approximately 200 patients receive botox at WXH per year. We aim to provide a service that is streamlined, patient-centred and guideline led. NICE have clear guidelines on the topic named 'Urinary incontinence in women: management', and EAU also provide a document called 'Urinary Incontinence in Adults'. Although these two documents provide slightly different guidance in some areas (such as PTNS and SNS), they are important frameworks for any botox service to adhere to. This audit assess how the WXH botox service manages OAB in relation to the National guidance provided.

The aims and objectives of this retrospective audit are to review WXH intravesical botox patients who received their injections during the months of October and November 2017, and to assess whether the following national guidelines were adhered to, in addition assessing follow up time and consideration of LA procedures.
1. Ensure patients are willing and able to perform CISC
2. Offer SNS and PTNS to the relevant patients
3. Tell patients how to self-refer if symptoms return following injections

Audit Standards
1. 100% of patients CISC competent or attempted prior to botox
2. PTNS discussed with all suitable patients before deciding on invasive treatments for OAB. SNS should be offered to suitable patients who have failed drugs +/- botox
3. All patients should be offered their repeat botox installation under LA if suitable
4. 100% of patients should know how to self-refer if needed following botox
5. 100% of patients should have follow up arranged after botox treatment. Timing: 6 weeks to 6 months
6. 100% of patients should be offered telephone follow up after botox

Inclusion criteria:
Patients who received intravesical botox injections during October and November 2017.
Exclusion criteria:
Patients who were uncontactable by telephone.

The audit team used the National guidance to decide on aims and standards, before scripting a telephone survey that was used to gather the information from contactable patients. These patients were identified by reviewing theatre lists from October-November and their details found by searching on CRS. Prior to this the audit was discussed with the ethics team, who agreed no formal ethical review was required. A Microsoft Excel Spreadsheet was used to record the audit data.

34 patients were identified as receiving intravesical botox during October-November 2017. 14 could not be contacted, so a total of 20 patient have been included in this audit. Below are the results presented from each question on the telephone survey, with some additional data sourced from CRS.

Although only a third of patients were found to have not been CISC trained, this is significant due to the risk of urinary retention following intravesical botox. It is important that if patients are not suitable for CISC or refuse it, that they are aware before botox, that they may require a LTC. Interestingly, the guidance relating to offering PTNS/SNS was adhered to the least. There may be a number of reasons for this, the EAU and NICE guidance differs on where along the management path they should be offered in relation to invasive procedures and anti-muscarinic agents, so there may be some difference in practice about when it should be offered. 70% of our cohort would consider having the procedure under LA, whereas only 20% did have it under LA. This means that there could be approximately 102 patients a year who may be LA candidates. Using nationally published cost and tariff codes, it is estimated that the potential generated net income per patient for a GA procedure is - £312, and for a LA procedure + £555. Therefore if the potential LA candidates had their next procedure under LA, this could generate £88,434 to the trust. Dedicated LA botox lists run by SpR or specialist nurses could also alleviate the pressure on theatre lists for other GA procedures. Results also highlighted that half of patients feel in general they do not know how to contact the team, which is especially concerning when approximately half do not have any follow-up booked. This means patients in the community may be requiring more botox, or may have had problems following their injections with no way of communicating this to the team other than to attend their GP or A&E. Half of patients reported they would be happy to be follow-ed via telephone, which may be more convenient for the patient and hopefully increase follow up rates. The majority of patients were satisfied with the service and would recommend it, however with further improvements, we aim for 100%.

Although patient satisfaction rates are high, this audit has highlighted that the WXH intravesical botox service does not adequately adhere to the EAU and NICE guidelines, in particular those relating to CISC and PTNS/SNS. MDT input is required to better this service for patients. The audit has also highlighted an opportunity where in converting willing patient's procedures from GA to LA, the trust can be more cost-effective. For patients who undergo multiple botox installations a year, this would not only be money saving; but also prevent patients from having to undergo multiple general anaesthetics a year, and also create more theatre list space for other procedures.

In order for the service to better adhere to the NICE and EAU guidance, a number of interventions have been proposed and actioned.
- All patients should be referred for CISC training before botox injections, specialist nurses are aware and willing to help. If patients are not suitable for CISC it must be discussed and accepted by them that if urinary retention occurs they will require a long term catheter.
- Consultants must discuss the options of PTNS/SNS with the suitable patients. Clinicians should also be aware of and able to offer alternative options to patients, and if not, refer to the Female Urology Specialist Consultant or incontinence MDT.
- Clinicians should discuss LA botox in the first instance, and offer the first installation under GA if fit before converting to LA procedures. They should also be aware there is the option of a 'trial of LA' for nervous patients, where the first LA installation can be done in theatres with the option of GA if not tolerated.
- In order for patients to be able to contact the team with any problems or requests for further botox, contact details will be added to TTAs, and 'business cards' will be distributed. The contact details of one of the WXH specialist nurses are shared to act as the point of contact, and further liaise with the continence team if required.
- In order to catch all follow up appointments the operating surgeon should contact admissions to ensure follow up is booked. Following discussion with the clinic managers, they suggest the most effective method is to email the dedicated bookings team directly. A dedicated telephone clinic should also improve the rates of follow-up for suitable patients for whom this is preferable, to assess response and discuss further injections.

This audit was presented at the WXH Morbidity and Mortality meeting where the North East Thames Urology departments meet on a monthly basis. This presentation was also used to communicate the proposed interventions to the WXH clinicians so they were also aware of how to further improve the botox service delivered to patients.

Future Work
There will be a re-audit of the service in the next three months following new interventions, with an aim to improve adherence to guidelines, patient satisfaction and to also compare net income with the conversion of suitable patients to LA procedures.

In the future, a prospective study of the patients who go on to have LA procedures would be useful to ascertain tolerability and pain scores. An audit of the new outpatient LA botox list should also be carried out in order to assess service delivery and patient satisfaction.
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