My role as a Urology Nurse Practitioner involves assessing individuals and delivering treatment plans, autonomously and collaboratively, in the context of many urological conditions including recurrent urinary tract infections; renal and ureteric calculi; flexible cystoscopy for haematuria diagnosis; and bladder cancer surveillance.
In the last edition of the European Urology Today, I shared some session highlights from my attendance at the British Association of Urological Surgeons Limited (BAUS) conference held late June 2018. In this column, I would like to highlight other interesting topics from the poster section of the conference. One such poster described the first experience of using the novel treatment Uromune® (sublingual vaccine) in men with recurrent urinary tract infections (UTIs) in the United Kingdom.
The study followed 22 men with proven UTI and clinical symptoms, with a mean age of 65 years. They each received three months of Uromune® vaccine with 21 men successfully completing the treatment protocol. Results indicated that 17 men did not develop UTI during the treatment period, but longer term follow-up showed that the vaccines effect wore off after around 14 months, with the UTI returning. The authors concluded Uromune® to be safe and effective, and a viable alternative to long- term antibiotics. A randomised controlled trial is planned.
A second poster reported on a prospective clinical study examining if it is safe to carry out flexible cystoscopy when urinary dipstick is positive for “infection”. The driver for the study was the observation that one in six patients was having their cystoscopy appointments cancelled on the day due to positive urine dipstick result. This resulted in considerable underutilisation of clinic resources. The primary aim of the study was to identify the risk of UTI or urinary sepsis within two weeks of cystoscopy, when pre-cystoscopy urinalysis was positive for infection (positive leukocytes or nitrites).
In the study, all patients had a cystoscopy even if they had positive urine dipstick results. Patients considered high risk for UTI, and those with the positive results were given a single dose of prophylactic prior to cystoscopy.
In a six-month period, 1,625 participants were recruited and 18.25% had a positive urine dipstick result wherein a third had a proven urine culture as well. Results indicated that the overall risk of developing a post-cystoscopy UTI in this cohort was slightly higher, but remained low overall. They felt the risk cceptable and resulted in significantly less procedures being rescheduled.
Another interesting poster reported on a prospective audit designed to measure if a 90-minute, weekly virtual stone clinic had improved patient care at a reduced cost. It described how a new patient care pathway was introduced in response to pressure on outpatient clinic appointments. The pathway ensured that all stone patients were reviewed by the stone team and triaged to the appropriate stream of care.
Three hundred stone referrals were received and 65 (21.6%) had consultations via a virtual clinic with no appointment needed; 45 (15%) were changed to nurse-led telephone appointments; the appointments of 127 patients (42.3%) were changed to specialist nurse outpatient appointments; and 63 (21%) were seen in a consultant-led outpatient clinic. The poster concluded that the virtual stone clinic had improved patient management while saving significant resources, in terms of time and money. The data showed that outpatient clinic pressures were significantly reduced, patient care expedited where appropriate and last-minute cancellations were prevented.
“The poster concluded that the virtual stone clinic had improved patient management while saving significant resources, in terms of time and money.”
Another interesting session reported on a survey undertaken to ascertain physician views on Multidisciplinary Team (MDT) Meetings. The NHS Cancer Plan stated that “the care of all patients with cancer should be formally reviewed by a specialist team to ensure that patients have the benefit of the range of expert advice needed for high-quality care.” The practice of regular MDT meetings has been developed to formalise this consultative process.
An MDT meeting consists of a group of professionals from one or more clinical disciplines who make the decisions together regarding recommended treatment of individual patients. It is intended that an MDT meeting must consider the patient as a whole, not just focus on recommendations for optimal medical treatment.
The physician survey findings indicated a common viewpoint that too many routine decisions are made at MDT meetings. The speaker commented that the requirement to present all cases at MDT meetings is training doctors to feel unable to make their own decisions, in partnership with their patients.
Survey respondents reported an increasing recognition that mandatory attendance of around 15 health professionals at an MDT session may be an inefficient use of a medical professional’s time. One NHS Trust indicated that 48% of their patients were discussed for less than two minutes and two thirds were discussed for less than three minutes at an MDT. There was a feeling that a lot of time was spent rubber stamping straightforward cases limiting time and energy for discussing complex cases. The speaker noted that NHS England plans to implement recommendation 38 of the NHS Cancer Strategy*: to streamline MDT processes, and will produce guidance to Cancer Alliances in support of this.
There is likely to be a shift in focussing time and resources on identifying and prioritising those patients whose diagnosis falls outside of established treatment pathways or normal parameters. The discussion was fascinating from a New-Zealand perspective as we have followed the NHS lead, formally incorporating MDT into our cancer care pathways over the last few years. The model of MDT adopted where I work in urology follows these recent recommendations, focusing energy and resources on the more complex cases.
I left the BAUS conference with plenty to report back to colleagues. I have enjoyed sharing some of my conference highlights with you through these columns. As I headed home, I was keen to spend some time refocussing our efforts to establish a virtual stone clinic process at my workplace, as well as, examine our flexible cystoscopy infection data, to see what stories lie within. This newfound inspiration is a hallmark of a worthwhile event.
* Reference: https://www.england.nhs.uk/wp-content/uploads/2016/05/cancer-strategy.pdf
Sue Osborne, Urology Nurse Practitioner, Auckland (NZ), email@example.com