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
Redevelopment Project of Kwong Wah Hospital
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
ATOC program Co-operation between Surgery and Emergency Department Develop ATOC protocol Selected Acute Retention Of Urine (AROU) patients Ambulatory care PWH, UCH
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
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
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
Benign prostatic hyperplasia (BPH) Majority of male AROU associate with BPH (2) Over 50% male population aged 50-60 yrs had BPH (3,8) Age Incidence of BPH 40-50 yr 20 % 50-60 yr 50 % 60-70 yr 55 % 70-80 yr 80 % 80-90 yr 90 %
Hong Kong Population (2016 Population By-census) 8000000 7000000 No. of persons (population) 6000000 5000000 4000000 3000000 2000000 1000000 0 2006 2011 2016 male female
Male 60+/65+(2016 Population By-census) 600000 No. of persons (population) 500000 400000 300000 200000 100000 0 2006 2011 2016 60+ 65+
4/2016-1/2017 AROU Hospitalization (male) No. of patients 120 100 80 60 40 20 0 20 30 40 50 60 70 80 90 Age distribution
9/2016-1/2017 ATOC program (male) No. of patients 25 20 15 10 5 0 40 50 60 70 80 90 100 Age distribution
ATOC program Objective: reduce unnecessary hospitalization and reduce bed occupancy Manage AROU patient and try without catheter in outpatient setting Analyze the economical outcomes
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
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
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
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
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
Success wean off catheter Home Bladder diary Arrange uroflow before next Urology FU IPSS on the day of uroflow Telephone FU
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
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%
Success rate of wean off catheter Success wean off foley (%) 100 90 80 70 60 50 40 30 20 10 0 Hospitalization (4/16-1/17) ATOC (9/16-1/17)
Comparisons before and after ATOC Program Hospitalization Before ATOC (5 months) Hospitalization After ATOC (5 months) No. of bed days 669 402 0 No. of patient 176 112 69 Mean length of stay Mean catheterization day 3.8±1.8 3.6±1.3 0 ATOC clinic (5 months) 3.4±3.4 3.3±1.2 6.8±2.4 Mean age 77.3±8.5 77.3±7.9 79±10.5 Total cost per patient (HKD) Success rate of wean off foley 19584 18618 3578.9 60.2% 52.3% 62.3%
Estimated cost from HA Annual Report 2015-2016 Cost per A&E attendance (HKD): 1230 Cost of hospitalization per day (HKD): 4830 Cost per SOPD attendance (HKD): 1190
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: 248.4 days Total cost per patient: 4830 x 3.6 + 1230 = 18618 (HKD) Total cost of all patients: 18618 x 69 = 1284642 (HKD) Total cost reduction: Total cost of all ATOC patients total cost in ATOC program: = 1284642 246950 = 1037692 (total cost saving in 5 months)
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
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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Reference 5. Wright L (2006). Sonographer or nurse-led transrectal ultrasound (trus) and biopsy. Synerygy,, 24-27. 6. Hospital authority annual report 2015-2016 7. 2016 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 (pp1429-1452)