Non-muscle invasive bladder cancer surveillance

Development of the advanced nurse practitioner-led service in Ireland: Preliminary audit results

I was invited to write this article in European Urology Today as a result of my successful presentation at the last International Meeting of the EAUN in Barcelona. I am happy to share with you the developments of the increasing role of the advanced nurse practitioner in bladder cancer care in Ireland.

Bladder cancer in Ireland
Bladder cancer is the 11th most common cancer worldwide, and there are more than 470 new diagnosis in Ireland annually. Approximately 75% of cases diagnosed are non-muscle invasive bladder cancer (NMIBC).  it is one of the most expensive cancers to treat due to high recurrence rates, arduous invasive treatment regimens and surveillance follow-up schedules, which significantly impacts on patients’ quality of life and places a burden on healthcare systems. Ireland’s National Cancer Strategy 2017-2026 emphasises an increased role for the advance nurse practitioner (ANP) in urology to meet the healthcare needs of the  population. Flexible cystoscopy is the cornerstone of non-muscle invasive bladder cancer surveillance. Nurse-led flexible cystoscopy emerged from the UK in the 1990s in response to increasing bladder cancer  workloads of urologists. The role is well established internationally but has not yet been developed in the Republic of Ireland.

For the patient, the benefits of the nurse cystoscopists include continuity of care and the provision of psychological support. Experienced nurse cystoscopists can be involved in training of junior medical staff. The role also offers nurses wishing to remain in clinical practice the opportunity to advance their careers. Data from published service audits in Australia and the UK report that trained nurse specialists can safely and competently carry out this role, patient satisfaction is high and waiting times for access to care are shortened.

Preparing for the role
Preparation for the introduction of the role in Ireland was guided by the tenets of a model of change (adapted from the Health Service Executive Change Model). The ‘initiation and preparation for change’ stage examined the nurse cystoscopist role in the context of the domains of advanced nursing practice, as defined by the Nursing and Midwifery Board of Ireland to ensure congruence.

“…benefits of the nurse cystoscopists include continuity
of care and the provision of psychological support”

The ‘planning’ stage of the process included building commitment, determining the details, and developing an implementation plan. Multidisciplinary stakeholder meetings collaboratively defined the job  description and patient caseload of the candidate advanced nurse practitioner (cANP). Governance structures, such as evidence-based policies, procedures, protocols and guidelines were developed to ensure the delivery of quality and safe service. Formal mentorship for  clinical supervision was agreed with a named consultant urologist, and formal education was embarked upon to Masters level. I also participated in a flexible cystoscopy training workshop at the British Association of Urology Nurses annual conference in  Glasgow in November 2016. Following this, a period of formal flexible cystoscopy training and competency
assessment commenced.

Mainstreaming the role requires its evaluation and ‘making it the way we do business’. Auditing  appropriate measures and disseminating the learning and feeding back to colleagues helps to achieve this aim. Irelands Health Information and Quality  Authority’s (HIQA) ‘National standards for better and  safer healthcare’ aim to improve services and protect patients by placing them at the centre of the care process. Focusing on quality and safety, the standards  are useful for measuring output. The following  standards formed the basis of the audit for the period 23/3/18 to 30/07/18 and are reported below.

Effective care and support

• Measure: Urine for cytology to be sent for all patients with high-grade cancer in alignment  with international best practice guidelines.
• Population: Patients attending the ANP service for surveillance of high-grade bladder cancer.
• Target: 100% will have sample sent for cytology.
• Outcome: 18 out of 20 eligible samples sent: 90% compliance rate.
• Action: A review of the two instances when cytology was not sent, identified that the patients were unable to provide another voided precystoscopy urine sample.
• Plan: In future, patients with high-grade disease will be contacted in advance of their appointment and a 2nd morning voided sample will be requested.

Safe care and support

• Measure: Documented evidence of appropriate antimicrobial stewardship.
• Population: Patients attending the cANP flexible cystoscopy service.
• Criteria: Patient screened and reason for antibiotic prophylaxis identified.Target: 100% documentary evidence.
• Outcome: 100% of patients who received a prophylactic antibiotic (n=62) (18% of all patients attending) had a documented valid reason for administration.
• Action: Target met; continued vigilance required. Antimicrobial stewardship has both clinical and economic benefits.

Use of resources

• Measure: Time to complete an entire episode of care safely (including patient assessment, performance of procedure, care plan, documentation and communication).\
• Population: Patients attending the cANP flexible cystoscopy service.
• Criteria: The standard to be achieved for the ANP is that of a competent urologist.
• Target: Equivalent time to urology colleagues.
• Outcome: No appreciable increase in the average time to complete an episode of care (26 minutes and 27 seconds (cANP) versus 26 minutes 12 seconds (urology colleagues in 2017)).
• Action: Target met; continued vigilance required.

The results of this measure lend support for the introduction of the service on a cost-neutral basis.

Conclusion
International experience of the nurse-led flexible cystoscopy service demonstrates that appropriately trained specialist nurses can deliver a safe and quality patient-centred service. Preparing for the role requires commitment from all multidisciplinary stakeholders to successfully deliver the initiatives. The evaluation of the preliminary introduction of the role in the context of advanced nursing practice demonstrates evidence of compliance with national and international standards, aligned with delivering a safe and high-quality service, providing a tentative framework for its adoption in other centres.

Award
At EAUN19 I presented a poster on the first results of the above audit and was honoured to be awarded the first prize for the Best Practice-development Poster Presentation. I hope to present further results in one of the future meetings. See you in Amsterdam!

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Robert McConkey, RANP, MSc, BSc (Nursing), PGDip. Galway University Hospital, Urology Outpatient Department , Galway (IE), robert.mcconkey@hse.ie