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Improving a nurse-led flexible cystoscopy service through audit

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Karen Kilburn, BSc (Hons), RN.

Urology Nurse Practitioner, University Hospital of North Tees, North Tees and Hartlepool NHS Trust, Stockton

Around 13 200 new cases of bladder cancer are diagnosed each year, making it the fifth most common cancer in the UK (Cancer Research Campaign, 2000). To meet a service need and to improve the continuity of patient care, the urology team at the North Tees and Hartlepool NHS Trust discussed the possibility of developing the nurse practitioner role to include carrying out flexible cystoscopy on patients already diagnosed with transitional cell carcinoma of the bladder or kidney.
Around 13 200 new cases of bladder cancer are diagnosed each year, making it the fifth most common cancer in the UK (Cancer Research Campaign, 2000). To meet a service need and to improve the continuity of patient care, the urology team at the North Tees and Hartlepool NHS Trust discussed the possibility of developing the nurse practitioner role to include carrying out flexible cystoscopy on patients already diagnosed with transitional cell carcinoma of the bladder or kidney.

It has already been demonstrated that nurses with a special interest in this field can develop the skills necessary to carry out flexible cystoscopy and become competent in detecting recurrent bladder cancers (Gidlow et al, 2000).

The Department of Health document on waiting times for cancer patients or patients with a suspected cancer states that there should be a maximum one-month wait from urgent referral to first treatment by 2005 (DoH, 2001).

The local situation
The increasing incidence of bladder cancer was having an impact on waiting times for the procedure at the author's trust. Patients already diagnosed were given a slot on the flexible cystoscopy list for their routine follow-up. New patients needing a diagnostic cystoscopy to investigate their lower urinary symptoms were put on a waiting list and given an appointment when one became available.

Waiting times for non-urgent flexible cystoscopy were around nine months, and six months for urgent cases. One of the main goals the urology team and trust wanted to achieve from this service was to greatly reduce the waiting times for both urgent and non-urgent flexible cystoscopy.

The nurse practitioner is a named person patients can contact if they are concerned about their condition. Anecdotal evidence suggests that patients are reassured that the nurse practitioner will be available to give advice when needed. This system ensures a seamless service where both the patient and nurse practitioner are aware of the patient's history and treatment plan.

The trust has supported this development, empowering the nurse practitioner to undertake this clinical skill by adopting some of the key roles set out by the Chief Nursing Officer (Box 1) (DoH, 2000).

Literature review
Medline, UKCC, Department of Health and NHS Executive databases were searched for the years 1995 to 2002 using the key words 'audit', 'protocol', 'nurse-led' and 'practice development'. Most searches referred to areas of nurse development outside their traditional roles but few were specifically related to flexible cystoscopy. There were no definite recommendations on treatment patterns for patients with transitional cell carcinoma of the bladder. One document did relate to the training required to undertake this role and this was a draft document from the British Association of Urological Surgeons, which discussed recent developments and clinical skills required.

Physiology of bladder cancer
In adults the bladder lies deep in the symphysis and is pear shaped. It can be felt when it becomes more oval shaped as it fills with urine. It rests on the prostate in men and, in women, on the anterior wall of the vagina. The bladder is separated from the rectum by a double layer of peritoneum, which is fused together (the facia of Denonvilliers). This layer forms a barrier that can prevent bladder cancer spreading to the rectum or prostate gland (Blandy, 1998). The bladder acts as a reservoir for urine. In adults with an intact nervous system, the rising pressure associated with a full bladder signals impulses to be sent to the brain that the person needs to pass urine (micturate). If the nervous system is fully developed, micturition can be delayed until it is convenient (Blandy, 1998).

The urinary bladder is lined with urothelium and neoplasms that develop there are usually transitional cell carcinomas (Blandy, 1998). The urothelium can, however, undergo changes in some patients due to chronic infection or inflammation, and this may lead to the development of squamous cell carcinomas or adenocarcinomas (Blandy, 1998). Beta-naphthylamine and benzedine are chemicals present in tobacco and substances formerly used in the rubber and coal industries. Heuper et al (1938) first demonstrated that these two substances were extremely influential in causing bladder cancer and, although they are no longer used in industry, their presence in tobacco means that smoking continues to be the greatest contributing factor in the development of transitional cell carcinoma of the bladder (Blandy, 1998; Trotto, 2000).

Bladder tumours can be singular or multiple and usually present as a solid lump, an ulcerated area or a 'cauliflower-like' growth.

Nurse cystoscopy
Flexible cystoscopy is a procedure used to enable the nurse practitioner or doctor to examine the internal surfaces of the bladder and urethra. A local anaesthetic gel is instilled into the urethra and the flexible cystoscope is passed along the urethra and into the bladder. Sterile water is run through the cystoscope to distend the bladder, ensuring that all surfaces can be examined. The nurse practitioner or doctor will examine the urethra, sphincter, prostatic urethra (in men) and bladder neck as the cystoscope is introduced. The flexibility of the instrument allows the examination of the bladder and an internal view of the bladder neck and, in men, the prostate.

This procedure is used extensively to detect the recurrence of bladder tumours in people diagnosed with transitional cell carcinoma of the bladder or kidney. Traditionally, this has been carried out by a doctor at senior house officer level or above after training in the procedure. The rising incidence of bladder cancer has increased the need for monitoring using flexible cystoscopy (Parkin et al, 1992).

The Department of Health suggests that nursing practices must develop and expand to meet the changing needs of the health service (DoH, 1999; DoH, 2000). Extending nurses' roles to carry out procedures such as flexible cystoscopy is supported by The NHS Plan (DoH, 2000), which states that nurses will take responsibility for their individual practices and ensure that high standards of practice are set and delivered.

Development of nurse cystoscopistsThe NHS Plan states that patients recognise that developing nursing skills and new roles can reduce waiting times and give them speedier access to the services they need and they are supportive of this (DoH, 2000). Thus flexible cystoscopy is an area in which extending nursing skills could achieve these goals.

The lack of a recognised training course for nurses in this area meant that the proposed and current training was 'in house'. This type of training is recognised by the British Association of Urological Surgeons (BAUS). The Guidelines for Nurse Cystoscopists (BAUS, 2000) recommend the development of local policies that should specify the training required and undertaken and the competencies achieved by the practitioner, and this is firmly supported by the author's trust.

The nurse practitioner has a legal obligation to ensure that the flexible cystoscopy will be performed to the same standard as any competent cystoscopist and the current post-holder feels confident to carry out the procedure without supervision. The nurse practitioner and consultant are aware that carrying out flexible cystoscopy is a responsibility 'beyond the traditional boundaries of practice' (UKCC, 1996) and ensure, by reflection and clinical supervision, that the six principles of the Scope of Professional Practice (UKCC, 1992) are upheld.

The NHS modernisation agenda set out in The NHS Plan (DoH, 2000) has empowered nurses to introduce service and role developments that focus on the patient. Traditionally, nurses, midwives and health visitors have demonstrated an ability to positively adapt and develop their roles in relation to patient need. Making full use of their knowledge and advancing their skills through evidence-based practice (NHSE, 1998) now means that their roles have developed and expanded to enable medical, nursing and other colleagues to work alongside each other. This multidisciplinary approach enables agreed protocols to be used across professions, ensuring a consistently high level of practice is maintained to the full benefit of the patient (DoH, 1999).

Service development
The urology nurse practitioner at this trust carries out flexible cystoscopy on 12 patients a week in the day-case unit.

The consultant and the nurse practitioner designed a protocol for carrying out this procedure. A lack of national guidelines on how often patients should have their bladder checked meant that the protocol had to be based on consensus of opinion from consultants and their urology teams across the area. The original protocol outlined the recommended frequency of flexible cystoscopy dependent on the initial tumour grade, and any other investigations that the patient may need to monitor progress.

One year after introducing the service and using this protocol, the urology team audited the protocol to see if it was effective (Table 1).

Clinical audit is a clinically led initiative that seeks to improve the quality and outcome of patient care (NHSE, 1998). In this case, the nurse practitioner examined her own practice and patient treatment plans against a set protocol. This encouraged the team to critically analyse the protocol and review its validity, resulting in revision of the protocol and the formulation of guidelines for the follow-up of patients diagnosed with transitional cell carcinoma of the bladder. The aims of the audit were:

- To review the clarity and ease of use of the protocol

- To determine whether the protocol was being followed with regard to the frequency of patient checks and investigations.

The format used to gather the information needed followed the clinical audit process key stages highlighted by the National Centre for Clinical Audit (1997) (Box 2).

Data collection The data collection was carried out between May and December 1999 and was a retrospective audit of case notes. Data on what had happened at patients' most recent flexible cystoscopy was collected from their case notes, together with operation notes, histology results, and radiological investigation results. All patients who underwent a check flexible cystoscopy during that time were entered into the study and every fourth person was randomised for inclusion (this number was chosen by throwing a dice). There were no exclusions and the audit department - using a Microsoft Access database - processed the final results as independent auditors to verify the results.

Results Results are shown in Figures 1 and 2. Sixty patients were included in the study:

- Eleven were female and 49 were male

- Six patients were under 55 years of age; the remainder of the group were aged between 60 and 94 years

- All patients had previously been diagnosed as having transitional cell carcinoma of the bladder

- There were no cases of transitional cell carcinoma of the kidney, although such patients would have been included if selected

- All had had a flexible cystoscopy at least once during the time span, with no patient having had more than two.

The original protocol (Table 1) specified how often flexible cystoscopy should be carried out, dependent on the grade of tumour.

Of the 60 patients included in the study, 25 (42%) did not comply with this protocol:

- 32% (19) patients had not had an intravenous urogram (IVU) in the past five years (Figure 2)

- 3% (two) patients had an original diagnosis of carcinoma in situ and should have been reviewed by rigid cystoscopy by the consultant (Figure 2)

- 7% (four) patients with Grade 1 tumours were being checked every three months instead of annually (Figure 2).

The urology team agreed that a review of the protocol was needed to ensure that all patients would have the same standard of treatment and investigation. Their treatment plan would be decided by the grade of tumour at last biopsy and would not be influenced by age, ethnicity or where the patient lived. The consultant and nurse practitioner agreed that the last positive biopsy result taken from the bladder would be the basis on which the next flexible cystoscopy was planned.

There needed to be more clarity on how often patients should attend for flexible cystoscopy and by simply re-wording the document and reinforcing treatment patterns the protocol became easier to follow.

Changes following audit
Table 2 shows the revised protocol now in use. Notes were added to ensure that all patients were offered the same investigations and that there were guidelines to follow if any difficulties were encountered during the procedure (Box 3). The team is aware that the nurse practitioner or doctor carrying out the procedure may in some cases need to deviate from the protocol if this is in the best interests of the patient.

As a result of the audit the following changes have been made:

- Patients are now on a regular programme of check cystoscopy as highlighted in the revised protocol and not called more often than necessary

- Following the protocol ensures that investigations are not being missed and treatment can be initiated if needed

- Patients are aware of how often they need to be seen and can contact their practitioner if they are concerned.

Although beyond the scope of this audit, the feedback from patients tells us that they are very satisfied with the service and we will be auditing this in the near future.

The approved protocol was re-audited one year after implementation and the results were very pleasing, with 98% of patient treatments complying with the revised protocol. A small group of 44 patients were selected using the same data collection methods as previously. There were six female and 38 male patients.

Thirty-nine patients' treatment plans complied with the protocol. The exceptions were:

- Two patients with Grade 1 and two with Grade 2 tumours were having check cystoscopy more often than the protocol stated for clinical reasons

- One patient with a Grade 1 tumour was being rechecked six monthly rather than yearly for no apparent reason

- No patient had missed their routine IVU.

This innovation in nursing practice is an example of how meeting demand for a service can greatly impact on the quality of care offered to patients. Developing protocols and regular audit is essential to meeting the needs of patients and the agenda of clinical governance to have continuous quality improvement programmes in place (Elcoat, 2000). It is hoped that other trusts may adopt this protocol if they feel that it would help meet the needs of their patients.

Blandy, J. (1998) Lecture Notes on Urology (5th edn). Oxford: Blackwell Science.

British Association of Urological Surgeons. (2000) Nurse Cystoscopy. London: BAUS.

Cancer Research Campaign. (2000) Facts about Bladder Cancer. London: CRC. Available at:

Department of Health. (1999) Making a Difference. London: The Stationery Office.

Department of Health. (2000) The NHS Plan: A plan for investment, a plan for reform. London: The Stationery Office.

Department of Health. (2001) Cancer Waiting Times: Achieving the NHS Cancer Plan waiting times. London: The Stationery Office.

Elcoat, C. (2000) Clinical governance in action: key issues in clinical effectiveness. Professional Nurse 15: 10, 622-623.

Gidlow, A. (2000) National guidelines for nurse cystoscopy. Professional Nurse 16: 3: 992-993.

Heuper, W.C., Wiley, F.M., Wolfe, H.D. (1938) Experimental production of bladder tumours in dogs by administering beta-naphthylamine. Journal of Industrial Hygiene and Toxicology 20: 46.

National Centre for Clinical Audit. (1997) Clinical Audit Action Pack. Version 2. London: The Stationery Office.

NHS Executive. (1998) Achieving Effective Practice. London: The Stationery Office.

NHS Management Executive. (1990) A Guide to Consent for Examination or Treatment. London: The Stationery Office.

Parkin, D., Muir, C., Whelan, S. (1992) Cancer Incidence in Five Continents (vi: 120). Lyon, France: International Agency for Research on Cancer.

Trotto, N.E. (2000) Contemporary management of bladder cancer. Patient Care 34: 7, 72-82.

UKCC. (1992) The Scope of Professional Practice. London: UKCC.

UKCC. (1996) Guidelines for Professional Practice. London: UKCC.
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