Ambulatory Try off Catheter (ATOC) Program for the Patient with Acute Retention of Urine Outpatient Service

Transcription

1 Ambulatory Try off Catheter (ATOC) Program for the Patient with Acute Retention of Urine Outpatient Service Mr. Tang, Chi Chiu Kevin (APN) Urology Center Department of Surgery Kwong Wah Hospital

2 Redevelopment Project of Kwong Wah Hospital

3 Redevelopment Project of Kwong Wah Hospital Phase I and II Total ~ 10 years till 2025 Department of Surgery 4 wards > 2.5 wards inpatient services > outpatient services

4 ATOC program Co-operation between Surgery and Emergency Department Develop ATOC protocol Selected Acute Retention Of Urine (AROU) patients Ambulatory care PWH, UCH

5 AROU Definition Sudden and painful inability to void voluntarily (1) Mx: bladder decompression Urethral catheterization/ Suprapubic catheterization Conventionally, Hospitalization x observation Costly, hospital-acquired infection Average 3-4 days Try without catheter (TWOC) during admission If failed, may need to re-admit for next TWOC

6 Benign Prostatic Hyperplasia (BPH) Age and male hormonal stimulation Increase cell number Epithelial and stromal proliferation or impaired programmed cell death leading to cellular accumulation (8) Obstructive and Irritative symptoms

7 Benign Prostatic Hyperplasia (BPH) Obstructive symptoms Hesitancy Weak stream Straining Prolong micturition Intermittent stream Post void dribbling Sense of incomplete emptying Irritative symptoms Nocturia Frequency Urgency

8 Benign prostatic hyperplasia (BPH) Majority of male AROU associate with BPH (2) Over 50% male population aged yrs had BPH (3,8) Age Incidence of BPH yr 20 % yr 50 % yr 55 % yr 80 % yr 90 %

9 Hong Kong Population (2016 Population By-census) No. of persons (population) male female

10 Male 60+/65+(2016 Population By-census) No. of persons (population)

11 4/2016-1/2017 AROU Hospitalization (male) No. of patients Age distribution

12 9/2016-1/2017 ATOC program (male) No. of patients Age distribution

13 ATOC program Objective: reduce unnecessary hospitalization and reduce bed occupancy Manage AROU patient and try without catheter in outpatient setting Analyze the economical outcomes

14 ATOC Program Method: ATOC Program established in 9/2016 Recruit 69 males selected AROU patients Data collected from 9/2016 1/2017 Data Compared before and after established ATOC program

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16 ATOC program Medication prescribe in A&E Harnal OCAS 0.4mg daily Current on Hytrin, consider increase dosage, max: 6mg Already on max dose, continue current dose

17 ATOC clinic in Urology Center Mx in ATOC clinic: Detail history?side effect on medication, dizziness Vital sign Explanation of the pathophysiology of AROU Male urinary system and anatomy D/S PR if no B.O. 2 days Try wean off foley Physical exam and DRE Phimosis, Paraphimosis, hernia, prostate nodule, hard prostate

18 ATOC clinic in Urology Center Health education and counseling Fluid management Bladder training Life style modification Uroflow and PVRU Repeat at least 2-3 times Interpretation and explanation

19 ATOC clinic in Urology Center Nurse led TRUS sizing (4,5) Increase job satisfaction (4,5) Releases medical staff for other activity (4,5) Early detection on BPH Shorten waiting time compare with x ray department

20 Success wean off catheter Home Bladder diary Arrange uroflow before next Urology FU IPSS on the day of uroflow Telephone FU

21 Failed wean off catheter Failed to void Large RU, risk explanation, i.e. renal impairment Counsel x learn CISC Foley reinsertion if failed or not fit for CISC Poor premorbid and advanced age, counsel x long term Foley or SPC Refer CNS x Foley care Urine x R/M, C/ST Counsel x TURP Video, pamphlet, Blood taking, CXR, KUB, ECG Arrange early Urology FU

22 No. of 30 days readmission in ATOC program AROU x 3 Suicidal idea?due to Foley insertion x 1 Haematuria x 2 Unplanned readmission rate: 8.7%

23 Success rate of wean off catheter Success wean off foley (%) Hospitalization (4/16-1/17) ATOC (9/16-1/17)

24 Comparisons before and after ATOC Program Hospitalization Before ATOC (5 months) Hospitalization After ATOC (5 months) No. of bed days No. of patient Mean length of stay Mean catheterization day 3.8± ±1.3 0 ATOC clinic (5 months) 3.4± ± ±2.4 Mean age 77.3± ±7.9 79±10.5 Total cost per patient (HKD) Success rate of wean off foley % 52.3% 62.3%

25 Estimated cost from HA Annual Report Cost per A&E attendance (HKD): 1230 Cost of hospitalization per day (HKD): 4830 Cost per SOPD attendance (HKD): 1190

26 Estimated cost reduction and bed days after establish ATOC Program If all ATOC program patient need admission The mean length of hospital stay: 3.6 days Total saving bed days: days Total cost per patient: 4830 x = (HKD) Total cost of all patients: x 69 = (HKD) Total cost reduction: Total cost of all ATOC patients total cost in ATOC program: = = (total cost saving in 5 months)

27 conclusion The ATOC program is effective Reduce unnecessary hospitalization Reduce bed occupancy in surgical ward Reduce cost Increase job satisfactory Early detection on BPH Early suitable Tx to patient Increase patient satisfaction

28 Discussion Currently one ATOC session/week The duration of the catheterization Mean catheterization day: 6.82±2.41 (range from 1-13) Future may increase two session/week May be regular audit/meeting for discuss the case pathway for recruit more patient Not enough patient: due to pilot phase, some patient refuse, not all the physician refer patient to ATOC

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30 Reference 1. Emberton M, Anson K (1999). Acute urinary retention in men: an age old problem. BMJ 318(7188): Choong S, Emberton M (2000). Acute urinary retention. BJU, 85(2), Berry SJ, Coffey DS, Walsh PC, Ewing LL (1984). The development of human benigh prostatic hyperplasia with age. J Urol, 132(3), Nicola J & Gail MP (2008). The success of a nurse-led, one-stop suspected prostate cancer clinic. Cancer nursing practice, 7(3), 28-32

31 Reference 5. Wright L (2006). Sonographer or nurse-led transrectal ultrasound (trus) and biopsy. Synerygy,, Hospital authority annual report Population By-census 8. McConnell, J (1998). Epidemiology, Etiology, Pathophysiology, and Diagnosis of Benign Prostatic Hyperplasia. In Walsh, P., Retik, A., Vaughan, D. & Wein, A. (Ed.), Campbell s Urology (pp )