North Wales CHC Urology & Catheterisation Review

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1 North Wales CHC Urology & Catheterisation Review Urinary catheterisation is not a treatment. Catheterisation can only be a temporary measure for male patients suffering urinary obstruction Introduction This review was undertaken by Jackie Allen (CHC Chair) and Christine Evans (retired Urological Surgeon) following concerns expressed by male urology patients and their families. A male urinary catheter is painful and has a profound effect on quality of life. Catheters are prone to blockage, inevitably cause infections and urethral strictures and preclude sexual activity. Most male catheters are unnecessary and can be avoided by prompt prostatic surgery to remove the obstruction. Patients with chronic retention can be helped to self-care by teaching Clean Intermittent Self-Catheterisation (CISC) to patients and carers. The practice of maintaining patients on catheters rather than undertaking prompt TURP/Prostatic Ablation is returning to the situation that applied in North Wales prior to Urological surgeons at that time made a concerted effort to end the practice and benefits were felt across the health care system in terms of reducing infection and blocked catheters. The benefits for patients in terms of reduction in pain and discomfort were immeasurable. The Community Health Council strongly believes that we should not return to this situation. A summary of the key action points is set out below. The detailed visit reports are on the following pages. Summary of Key Action Points We have found that all Acute Hospital Urology departments and Emergency departments are aware of the problem of patients being inappropriately and unnecessarily maintained on catheters for extended periods of time. All departments are making some efforts to correct this problem. We were both very pleased with the enthusiasm of the staff and their commitment to improve the care of patients. The equipment in all the departments is excellent. Patients with an indwelling catheter should be rapidly identified, treated as priority and admitted within 3 months. Routine TURP wait is currently1 year because cancer cases take priority Too many catheterised patients are lost to the system and simply attend when they have an emergency, the emergency is treated and they are lost again 1

2 It is unacceptable that so little is known about the patients awaiting effective treatment. It has not been possible to determine how long patients have been catheterised, why they are catheterised, whether they are known to the Urology Department or the District Nursing Service, which waiting list (if any) they are on or even their gender. More work should be done to identify the reasons for long term male catheterisation A digital Catheter Register is long overdue and urgently required The biggest request from Urology staff was for more operating lists and more ring-fenced beds. Four urologists, in each centre, cannot manage with 6 beds especially when major cancer work is being performed as well. The lack of beds leads to many last minute cancellations this is demoralising and distressing for patients We commend the Waiting List initiatives but more are needed to ensure that all patients currently being inappropriately managed on catheters are treated rapidly Further development of Rapid Access Clinics More day case lists with General Anaesthetic It is disappointing that catheterisation has become the standard mode of care when TURP and Laser Ablation are so rapid, effective and have dramatically reduced In Patient stays. It may be beneficial to allocate work differently; for example, Wrexham Maelor has the shortest waiting list and does not undertake urgent cancer surgery so perhaps they should take over more of the benign surgery from the centre. There is a needed for more Urology Nurse Specialists especially in the centre where they have disappeared. These are very valuable workers who can replace the middle grade doctors in many areas There is much good practice and this should be standardised across the three areas; for example, the East Nurses are more organised with their catheter register. Training and Confidence is a major issue for both nursing and WAST staff all staff should be able to undertake catheter re-insertion and bladder washouts. WAST staff are being re-trained in the West. Increase the use of self-care by training patients in CISC (Clean intermittent catheterisation) whenever appropriate. End the practice of requiring patients to endure two Trials Without Catheter (TWOC). It unnecessarily delays timely treatment for patients and prolongs pain and infection risk. Improve compliance with the Catheter Insertion Bundle. Forms should be completed for every patient. 2

3 Unannounced Visit 11 th May 2016 Urology Department, Ysbyty Glan Clwyd The CHC team initially visited the Diagnostic Department and discussed the management of catheters with the Sister and the Urodynamic Nurse Specialist. They were informed that if a male patient is catheterised anywhere in the hospital, including the Emergency Department (ED) and all other wards, they are admitted for trial without catheter (TWOC) within two weeks after having been prescribed Tamsulosin (an alpha blocker) to relax the prostate urethral muscles and Finasteride (a prostate shrinker) for two weeks. The outliers i.e. those not from the urology department, tend to become lost to the system and linger at home unrecorded. The Trial Without Catheter (TWOC) patients are admitted to the diagnostic unit. If this fails they are re-catheterised and rebooked for another TWOC. Christine Evans believes that this is second TWOC unnecessarily delays appropriate treatment and recommends that the practice should cease. If the first TWOC is unsuccessful then the patient should be immediately listed for Trans-Urethral Prostatectomy (TURP) or Prostatic Ablation. If the patient s second TWOC fails, only then is a referral made. This means that the patient will have been catheterised for a minimum of four weeks. Often it is a great deal longer than this. The catheters are looked after in the community by the district nurses. Blocked catheters are generally dealt with in ED, Diagnostics or even by surgical admission. The CHC Team asked why community nurses and paramedics did not deal with blocked catheters. They were informed that, despite having received appropriate training, community based staff appeared to lack the confidence to deal with these emergencies. This means that a patient with a blocked catheter and a painfully distended bladder is assessed by district nurse or paramedic and then sent for treatment at YGC, enduring painful and unnecessary travel and waiting. The CHC Team also spoke with the Urology Consultant, Ross Knight, and asked; Who sends for the patients and deals with the waiting lists? How are the catheterised patients identified? They were informed that Mr Knight and Mr Toussi manage their lists personally and Mr Srinivasan s is managed by his secretary. Mr Knight identifies his catheterised patients by computer but this does not seem to be a pan-north Wales system. We understand that there is a catheter audit being undertaken at the moment but the information will not be generally available. We have been informed that the waiting list for benign disease is currently over twelve months. This is not good news for patients with a catheter. Conversely, the delays come at a time when the operative procedure for prostate resection is infinitely safer, with very little blood loss and far fewer complications. Normally, there is only a 24 to 48 hour stay for most patients. 3

4 A key factor behind the increasing wait for surgery is that the Urology Department have lost lists. They now have only two half days per week run as a full day. This is a marked reduction from 10 years ago. There is no GA day case list, these patients fill the main theatre lists. There is no dedicated Urology ward - just beds on Ward 5 and these are no longer ring-fenced. The Urology Department in YGC is overstretched as they are doing most of the radical prostatectomies and radical cystectomies in North Wales. Mr Srinivasan has a 6 month waiting list for radical prostatectomy (for operable prostatic cancer); this is unacceptable as the cancer may spread in that time. Having regard to the long waiting times and the complex cancer related case mix at YGC, we strongly suggest that BCUHB provide increased capacity in the form of increased lists, dedicated beds and additional facilities. An alternative would be to refer routine prostate and other surgery to Wrexham or Bangor. There are now three separate waiting list managers, one for each hospita, so is there communication and a willingness to help each other out? Other suggestions is the need for YGC Action Points 1. The YGC Urology service cannot cope with volume of cancers currently presented to them; they need two sites. 2. Develop a Catheter book - like there is a stent book 3. More main theatre lists 4. Develop use of Cystodiathermy for bladder tumours under local anaesthetic (we are informed that a bid for equipment has been made). 5. Limited GA in Diagnostic Unit setting up discussions with anaesthetists 6. Get the GA list back from Llandudno, it is not in use at the moment. These sessions could be used for the fourth Urologist who is now in post. 7. Protected Urology beds 8. Laparoscopic assistant for Mr Toussi 9. Replace Urology Nurse Practitioners lost through vacancy control - using nurse practitioners means there is less need for the middle grade registrars. 4

5 Catheter Presentations to Emergency Department Group CHC Attendance at the meeting on 20 th May 2016 at YGC Chaired by Nia Baldwin other attendees included ; Adam Griffith (Head of Nursing ED), Liz Greaves and a WAST representative. Key discussion points Over the past 2 years 187 patients came in to ED with catheters in, and they were unknown to their GP or the district nursing service Most catheters in ED are inserted without rectal examination and patients are sent home without Urology department knowledge. This group have put together a catheter pathway. On this pathway, if a patient has a blocked catheter a District Nurse is sent within 2 hours. A digital catheter register is being developed for all catheters as well as certain patients who must be seen by the Urology department... We then discussed CISC (Clean intermittent catheterisation) in certain cases Currently being considered is Trial Without Catheter (TWOC) at home with the District Nurse rather than have to go to Urology diagnostics. The CHC strongly commends this initiative. There needs to be a method of identifying patients with catheters on the WL Many nurses don t like to do the first catheterisation and have never done it. This seems to be a confidence/training issue. Some nurses don t like to do the first catheter change. This needs to be addressed urgently It would be very helpful to know what number/proportion of patients manage to pass urine after their first TWOC It would be helpful to know how many calls to WAST are for blocked catheters. There is poor compliance with the Catheter Insertion Bundle. Forms should be completed for every case presenting at ED. This is not done consistently and the form should be sent to the GP and District Nursing Service We need to know the causes of catheter insertion i.e. retention of urine/ incontinence It should be made clear to all staff that the catheter IS NOT the treatment. The treatment is dealing with the obstruction by TURP or other appropriate procedures. 5

6 District Nursing Services - Central 25 th May 2016 Jackie and Christine met with Nia Boughton, (Head of Nursing - Central) to find out whether district nurses were replacing catheters and doing bladder washouts, thus avoiding the need for male patients having to go to ED at YGC. It was found that nurses in the community can only do repeat catheterisations and some are more prepared to insert catheters and undertake bladder washouts than others - depending on their training and confidence. This situation must be addressed and all staff should be undertaking the full range of catheter care. Catheter care accounts for one in every five 5 district nursing visits. There were 43 blocked catheter callouts in January 2016 in Central area alone. Nia informed the CHC team that a digital/electronic catheter register for the whole of North Wales was essential for effective management but that this was at least six months away. Nia highlighted the difficulties in relation to Welsh Ambulance Service Trust teams being called out to blocked catheter emergencies. WAST staff capability to undertake catheter care has been limited by training and confidence. There is currently a pilot in the west, where an advanced nurse practitioner goes out with ambulance crew to attend blocked catheter call-outs. An extension of hours for District Nurses is being considered. This would provide for overnight presence. At the moment District Nurses are on duty 8am -10pm, 7 days a week. 6

7 Unannounced Visit - 24 May 2016 Urology Department - Ysbyty Wrexham Maelor Christine Evans and Jackie Allen met with Christian Siepp, Consultant Urologist, Kelly Price, Urology Nurse Specialist (UNS) and Hazel Allen, Sister in Charge, to discuss the management of catheters and the Urology Waiting List. There are plans to set up an emergency access service for urology in normal working hours so that patients with catheter problems will not need to go to ED or SAU (Surgical Admissions Unit) except when Out Patients is closed. We were informed that Out Patients Sister changes catheters up to three times and then refers the patient to the District Nurse. Trial without catheter (TWOC) is unsuccessful in approximately 50% of cases. The Department teaches patients CISC - especially for chronic retention Findings Diagnostics are done in Out-Patients; they have Ultrasound, Flexible Cystoscopy and Trans Rectal Ultra Sound. Urodynamics and ESWL are done in X-ray department. Prostates are dealt with by TURP, bipolar and laser. Radical and pelvic surgery are not done at the Maelor Each consultant has 2 lists a week plus some day case lists where general anaesthetic can be given The main reported problem is the lack of Urology beds (on Lister and Glyndwr). These beds are not ring-fenced; so patients are often cancelled at the last minute for lack of a bed. In the week previous to this visit, the Consultant could not find a bed after a penile prosthesis operation because the bed, he had booked before the operation, had been filled. Currently the waiting time for benign disease is one year, for Urgent treatment it is eight months. The day case lists are currently filled with botox treatment (for hyperactive bladder). There is a 7 month wait for cystoscopies for bladder tumours. Patients with recurrent bladder tumours requiring treatment with Mitomycin and Bacillus Calmette-Guerin (BCG) do get in BUT with difficulty. YWM - Action Points 1. The Diagnostic Unit should be all inclusive. It should not be based Out Patients. This was determined over five years ago and plans were started but no action furtherhas been taken. 2. There are too many unnecessary admissions which should go to the Surgical Admissions Unit and not Urology beds e.g. scrotal pain and loin pain yet to be investigated 3. Further development of Rapid Access Clinics currently one day per week 4. More day case lists with General Anaesthetic currently only three per month 7

8 Unannounced Visit 25 th May 2016 Urology Department, Ysbyty Gwynedd This was the third and last visit to Urology departments in BCUHB to discuss the increasing number of male catheterised patients and to talk about remedying this unacceptable situation. Jackie and Christine met with Sue Harrison (Urology Nurse Practitioner) and Alexandru Kyriakos (Consultant Urologist). We were well received by the staff who are anxious to improve the service The situation is similar to the other two DGHs, there are currently 4 consultants, doing both cancer and benign work. The new consultant Mr Kotb has taken over the cancer work from Ernst Ahiaku who has reduced his sessions, and also taken back the operating list used by Mr Srinivasan from YGC. The other consultant Mr Thankavelu does renal work. Most of the prostates are done by TURP with a typical post-operative stay of 2 days because there is no laser available at YG. There is a diagnostics unit where flexible cystoscopies and urodynamics are done, Trans-Rectal Ultra Sound (TRUS )is done in Endoscopics and Extracorporeal shock wave lithotripsy (ESWL) has gone but is planned to return. There is no urology ward now, the Department has access to up to 6 beds on Tegid ward but these beds are not ring fenced. Day surgery is also done from Tudno ward. The lack of a urology ward has meant the nurses are now more generalised and are not necessarily good at post op bladder washouts. The specialist trained nurses were excellent at this but all of these well trained nurses have left to go into the community. It is interesting that we expect our surgeons to become more specialised but our nurses more generalised. As far as catheters are concerned, insertion can be undertaken anywhere in the hospital(although patients are not always examined rectally) or recorded on the catheter insertion bundle. YG Action Points 1. Ring fenced beds 2. More operating sessions although waiting initiatives on a Saturday are starting 3. More specialist nurses to do the cancer work and replace Registrars 4. Additional District Nursing training in catheter care. Currently catheters are inappropriately managed in the district. Nurses won t change catheters if they don t know the patient. This may be a confidence issue. In the daytime catheter problems go to Urology department and at night they go to ED 5. There is a new template guided biopsy facility at Llandudno Hospital (bought by charitable donation for 60,000). It needs to be shared with YG as there are up to 49 patients waiting up to 7 months for template biopsy of prostate 6. Patients with an indwelling catheter should be rapidly identified, treated as priority and admitted within 3 months. Routine TURP wait is currently1 year because cancer cases take priority 8

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10 Meeting with Jayne Sankey - East Community Services 22 nd June 2016 The purpose of this visit by Jackie Allen and Christine Evans was to ascertain what the District Nursing Services were in the east for the patients with indwelling catheters - especially male patients. Jayne Sankey is the Lead Nurse in the East. This area has had a catheter pathway with a catheter register for many years. The register states clearly the reason for fitting the catheter. East Community Services have 598 patients with indwelling catheters both male and female. District Nurses provide a full service for catheter patients in this area (if they are informed about the patient) and will change and washout blocked catheters. The Out of Hours Service will also provide this care to patients known to the District Nursing Service. With the help of the Wrexham Maelor ED consultant, Dr Hywel Hughes, the number of patients going ED with a blocked catheter has been reduced from three to one per week. The situation in West and Central is very different and we strongly suggest that all areas adopt this best practice. Action Points The doctors in ED and the wards need re-education and supervision to make sure the Catheter Insertion bundle sheet is filled in and sent to the DN /GP. There is some IT support needed to improve the usability of the Register The District Nurse Liaison Team should continue to go on daily ward rounds to pick up catheterised patients. Patients are going to ED and not the Surgical Admissions Unit because there are rarely beds available in SAU More work should be done to identify the reasons for long term male catheterisation Discharge letter summary for the GP needs to go home with the patient Patients awaiting surgery need identified and known to the Urology Department and others providing care. Admission for surgery for patients with catheters should be expedited. An increase in the numbers of Consultant Urologist, combined with waiting list initiatives should make this possible. 10