A fellowship exchange at UZ University Hospital Ghent, Belgium
I visited the UZ University Hospital in Ghent last 24 to 27 November as part of a fellowship programme of the European Association for Urological Nurses (EAUN). The EAUN, which sponsors the travel, accommodation and daily allowances, offers two application rounds per year.
In my daily work at the Centre for Continence Disorders, we provide urological nursing to a diverse group of patients. We see men suffering from Hypertrophia prostatae who have an indwelling catheter following a period of urinary retention. We see the same group of patients for urodynamic examinations in order to establish which treatment is more suitable for each individual. Another large group are younger patients suffering from various continence disorders. It is particularly satisfactory when we succeed in helping this group of patients getting back to everyday life with “normal” urination, which many of them have never previously experienced.
Another group of patients which I am specifically interested in are those suffering from “Bladder Pain Syndrome.” Sometimes it is possible to treat these patients with the instillation of Chondroitin sulphate, either by self-instillation or by receiving the treatment at the hospital. The so-called “neuro-patients” who are suffering from spinal cord injury, patients who have had a Clam operation and where the bladder is enlarged and with Mitrofanoff / Monti operations – are another important group of patients.
It is a great challenge to help these patients get competent care and assistance. In our small unit there is a very good collaboration with our secretary and the doctors in charge of the patients suffering from highly complex continence disorders and from spinal
cord injury.
Urodynamic examinations
During my time at the Centre for Continence Disorders, I was interested in experiencing and learning how the nursing of comparable patients is conducted at another university hospital in Europe. I chose Gent since the group of patients matched that of the Centre for Continence Disorders.
Annette Hjuler with host Ronny Pieters
My contact point, Ronny Pieters, helped me find accommodation near the hospital, which was very comfortable. I spent a weekend as a tourist in Ghent with its historical centre and the many beautiful canals.
The first day of the week, I observed the daily routine of Ronny who is a clinical urological nursing specialist. He workes full days at the hospital where he supervises nurses in the outpatient clinic, the recovery room and the ward. In addition, staff from other departments called him for assistance such as providing training for clean intermittent catheterisation.
I was also present during several urodynamic examinations of children, men, women and “neuropatients.” Technically, the examination is conducted a bit differently from the way we do it in Denmark. A three-way catheter is used, with the urethral sphincter examined during filling. EMG (electrodes for measuring muscle activity) is not used and a profile is not established as we do it back home. An X-ray is made in order to control the position of the catheter and a picture is made of the urination to help improve diagnose and if the patient suffers from cystocele and reflux. Provided that the patient is sufficiently stable to stand up, both sitting and standing filling is made and “cough leaking” is also tested.
The bladder was not emptied in case of residual urine before the second filling; instead it was noted that the filling had started with X ml. The “neuro-patients” were examined in the same manner as we do it. All examinations were observed by a doctor and the patient got feedback and treatment was initiated immediately after the examination. Treatment with anticholinergics, Betmiga (Beta 3 agonist) and clean intermittent catheterisation training is initiated with the same indications as we use; however the approach is less pedagogical – often basic assessment has not been made prior to the urodynamic examination resulting to instances when patients are sent home to fill in liquid/urination scheme and, in rare instances, the use of diapers.
An annual subsidy of 150 euros for buying diapers etc. is provided for all patients suffering from continence disorder, including the period prior to the medical intervention. When the medical assessment has been finalized and diapers are established as one of the remedies to treat the condition, the patient will receive a 100% refund of the cost. As for catheters, the public funds will cover four catheters per day and in case of a need to extend the frequency, the patient must rely on the catheter manufacturer to donate the rest. To my understanding, it is possible for each individual patient to choose the best fit among available catheters.
At the operation ward I observed how test electrodes for InterStim Neurostimulation Therapy were placed by sacral nerves 2-3. This method is applied to different kinds of continence disorders, but the best results are observed with patients suffering from an overactive bladder. The test period is between one to four weeks and if the patient period is satisfactory to lessen the patient’s symptoms, a small battery box is inserted into the right part of the loin. Once the box is adjusted, the patient should go to the toilet based on the need and the problem is solved. Later, when the patient is in the recovery room, Ronny Pieters – as part of his supervisory tasks – comes by and adjusts the intensity of the electricity with a small remote control. Hexvix (Blue-light cystoscopy), instilled about one hour before trans resection of the bladder, is also used as well as the instillation of Mitomycin C in the bladder after resection. It is given when the urine is nearly clear, and the procedure as done in the recovery room by Ronny Pieters.
Catheter removal
Nephrostomy catheter removal is done in the outpatient clinic. The new catheter is guided by ultrasound and guidewire. A plaster is placed on the catheter where it meets the skin which makes it easy to detect if it is displaced; a thread fixed to the skin is also used. The bandage is placed over the catheter as we know it, but in order to avoid pulling and cracking of the hose, it does not cross the abdomen. The hose is placed over the hip and along the outer side of the leg which makes it impossible to lie on the side without irritation. The patient also has a supra-pubic catheter which was changed in the same session – the nurse made the necessary preparations, pulled out the old catheter and the doctor inserted the new one- a very smooth procedure.
Several unsuccessful attempts were made at changing a double J catheter via a urostomy, despite the involvement of several doctors. But fortunately we have an operation ward! Suprapubic catheters were placed as well; when the patient’s bladder does not contain sufficient urine, salt water is instilled by catheter. The balloon contains 10 ml water and when there is a sufficient volume in the bladder, the nurse draws it to prevent the water from leaking in case of bladder cramps. At the same time, the bed was elevated at the feet end and the doctor placed the catheter easily and quickly.
At the ward, nurses are responsible for everything relating to patient car. The nurse has a mobile rack containing utensils that might be needed, the patients’ medicine and a computer. One nurse is responsible for four to eight patients but depending on the demands of the individual patients.
The week concluded with a visit to the Rehabilitation Centre, comparable to Centres for Brain Damage and Centre for Spinal Cord Injuries in Denmark. Patients are admitted immediately following an accident/injury. The rehabilitation is conducted similar to our practice in Denmark and patients are hospitalised as long as necessary. The centre has “test” apartments where patients can live, including with family, one month prior to being discharged. If any aspects of managing everyday life requirements appear difficult for the patient to handle, there is time to address them. There is also a small garden with a greenhouse where training can take place as well as a car where patients can train how to get in and out and how to place the wheelchair, among others.
In conclusion, I benefited from a good and useful experience regarding specialised nursing practice in another country. I would encourage colleagues to take the same opportunity since it provides a great chance to reflect, learn and gain inspiration. And my thanks to Ronny Pieters who guided me during the wonderful fellowship in Ghent.
Annette Hjuler, Rn, Centre for Continence Disorders, Århus University Hospital, Århus (DK), annehjul@rm.dk