Day Case Optical Urethrotomies, Introducing A Pathway
BAUS ePoster online library. Hilbert R.
Jun 26, 2018; 217789
Rebecca Hilbert
Rebecca Hilbert
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Abstract
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Introduction
Urethral strictures are a relatively common cause of bladder outlet obstruction, affecting around 0.6% of the male population with the risk increasing with age (Santucci 2007). Cold knife direct vision or optical urethrotomy is a simple easy procedure that, as a result, is commonly the first treatment for urethral strictures (Tolkack 2017). This is in spite of its low long-term success rates which some estimate to be as low 20-30% (Pansadoro 1996, Santucci 2001).

In our urology department 34 optical urethrotomies were performed last year by eight different surgeons. Patients were most commonly admitted for one night following their procedure.

There remains no consensus in management of post-operative catheter duration with different studies showing there is little difference between leaving no catheter post operatively and leaving the catheter in for up to 14 days where post-operative flow rates are considered (Dahl and Hansen 1986, Hansen and Jensen 1984). A recent study however has concluded that the longer the duration of post-operative indwelling catheter, the greater risk of recurrence (Yuruk 2016). Often the duration of catheter dwell time is at the discretion of the surgeon performing the procedure. Whether the patient is catheterised and the plan for that catheter removal can affect their length of stay in hospital.

Aims
The British Association of Urological Surgeons (BAUS), in their published consent form, describe optical urethrotomies to be 'usually performed on a day case basis' (baus.org.uk). This has not been the standard in our hospital.

In this quality improvement project, we aimed to improve the rate of day case optical urethrotomy to above 90%. As with any day case procedure there will always be some patients who require a hospital stay due to their age, comorbidities or lack of social support.

Measures
An initial audit of the length of stay of patients who had undergone an optical urethrotomy was carried out. The list was generated from an electronic search of the operation database for procedures coded as optical urethrotomy or urethral dilatation from October 2016 to October 2017.

From the initial audit, 34 patients were identified as having had a urethrotomy in one year. Of these, 32 were deemed to be suitable for a day case procedure (one patient was over 85, another had a transurethral resection of the prostate as part of the same procedure). Four (13%) of the 32 patients had been discharged the same day of the operation. The mean average length of stay was 1.1 days. The duration of catheterisation was, on average 2.1 days.

Changes
Following this audit, a protocol (Fig. 1) was devised for patients. Quemby and Stoker 2014 suggest that effective preoperative preparation is essential for the success of day surgery and efficient day surgery processes are facilitated by protocol- driven nurse led discharge. The protocol was devised to fulfil both these criteria.







Method
The protocol was circulated in the department both to the medical staff, who have the responsibility of booking and performing the procedure, and to the nursing staff whose responsibility it is to take the catheter out following the procedure. The new protocol (fig 1.) was discussed at the morbidity and mortality meeting of the department.

There already existed a day case pathway for patients to have their trial without catheter (TWOC) day 1 following Holmium Laser Enucleation Prostatectomy (HoLEP). There is a dedicated urology department in our hospital with specialist urology nurses who are used to this pathway. The new pathway for optical urethrotomies was to take the same pattern of the HoLEP patients.

The same method was then used to collect a list of patients who had undergone the same procedure after the pathway had been used for 5 months.

Results
Following the implementation of the pathway 17 patients had an optical urethrotomy from October 2017 to March 2017. One of these patients was as not suitable for a day case (hypertensive in recovery and admitted for monitoring) and therefore excluded from the audit. Out of 16 patients, 8 had a day case procedure, the average length of stay was 0.5 days. The average length of catheterisation was 4.2 days.












So far, 50% of patients have been discharged the same day of their procedure. This is an obvious improvement from 13% discharged home the same day before the pathway was implemented.

Reassessment
Although a lag is to be expected, 50 % is well below the aim of 90%. The cause for discrepancy is likely to be the surgeons' lack of knowledge of the new pathway both when booking the procedure and also when carrying it out. Habit of the medical staff is likely to also play a role; it has been the case for a long time that these procedures were performed on an inpatient basis.

Interestingly the length of catheterisation time has increased from 2.1 days on average to 4.2. This is likely to reflect the fact that prior to implementation of the pathway patients' catheters were taken out day one post operatively while they were still an inpatient. In spite of the protocol recommendations that patients should have their catheters removed day one post operatively or at 1 - 2 weeks only six of the 16 patients had their catheters removed day one and of these six, five had remained as inpatients and so had their catheter removed as an inpatient. Two of the 16 patients waited over 2 weeks for their TWOC. It is not known if increased duration of catheterisation is post optical urethrotomy is to the detriment of the patients' long-term outcomes; multiple studies have yielded differing results2,5,6,7. It does however highlight that there is a lack of compliance with the pathway even when these operations are being done as a day case. It is not known whether this lack of compliance is due to lack of knowledge of clinicians of the pathway or it to a lack of capacity when booking patients to come in for their trial without catheter.

Action
To further improve the adherence to the pathway these results will again be discussed at the departmental morbidity and mortality meeting. The protocol can also be re-discussed and any problems associated with its use identified.

It needs to be identified whether failure to adhere to the pathway is a result of the medical staff not being aware or having problems with the new protocol, or it is the nursing staff who have responsibility for admitting and discharging the patient. If both the medical and nursing staff have a good awareness of the protocol then even if a patient has been admitted as an inpatient the nursing staff can be empowered to use the protocol and raise the possibility of same day discharge.

The capacity in TWOC clinic also needs to be assessed as inability to book patients into TWOC clinic could explain why catheter dwell time has increased.

An area in which further improvements can be made would be in adding intermittent self-catheterisation to the pathway. It has been shown in previous trials that one way to improve the success rates from optical urethrotomies and urethral dilatations is to teach the patient intermittent self-dilatation post operatively (Lauritzen 2009). This is treatment some our or patients are already getting but is not standardised in the pathway and should be added in an attempt to improve success rates.

Summary
It has been shown that following the implementation of a pathway for day case optical urethrotomy the rates of same day discharge improved from 13 to 50%. There is still work to be done in facilitation of the pathway and clinician education to improve this percentage to above our target of 90%. The pathway can be improved by adding intermittent self-dilatation to the patient journey.

The pathway should be audited again in 6 months' time to assess the change in compliance.
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