ABSTRACT
ContextNorthern Ireland has five health and social care trusts that provide a Urology service. COVID-19 resulted in the cessation of all but the most urgent elective urological cases. As a result there was an immediate need to enhance current facilities to improve care for our patients. Operations for bladder outlet obstruction, such as transurethral resection of the prostate (TURP), were largely on hold. Men with benign prostatic enlargement continued to suffer in terms of quality of life from symptoms and morbidity from their condition, with subsequent costly attendances through unscheduled care.Issue/ChallengeAs one trust, we had over 100 men active on a waiting list for TURP. We had over 100 patients awaiting a review to decide on surgical management. We had over 400 men awaiting routine assessment through our lower urinary tract symptom assessment clinic.Several surgical options now exist for bladder outlet obstruction. Until this project, TURP was the only option offered to men in Northern Ireland, which is out-with NICE guidance. A TURP has traditionally been an inpatient operation requiring a hospital stay of 2-3 days. During the pandemic and looking to the recovery of services, this was not a viable option.Assessment of issue and analysis of its causesA scoping exercise on where to best place any new service was performed. Key stakeholders included our clinical leaders, management colleagues in the trust and the Department of Health. With successful implementation of a traffic light system for COVID-19, a green pathway for elective surgery had been implemented with great success in our main inpatient Ulster Hospital site. Reflecting on what had been learned in this process, and with a clear need to advocate day-case as default for certain procedures, a regional centre out-with our main inpatient operating theatres was delivered – the Regional Day Procedure Centre (DPC), based at Lagan Valley Hospital.ImpactThe impact has been improved individual patient journeys and improved quality of life for men living with benign prostatic obstruction, with their treatment happening much more promptly, as well as increased staff satisfaction and a saving in theatre costs and bed days.InterventionWe learned and implemented novel bladder outlet techniques;namely Rezum steam ablation therapy to the prostate;green light laser treatment of the prostate (GLLP) and hoImium enucleation of the prostate (HoLEP). We arranged simulation-based training for our Consultant and Speciality Doctor team and mock theatre set up training with the theatre staff to include common pitfalls with equipment. We also arranged simulation-based training for postgraduate surgical trainees, enhancing training during the pandemic.Involvement of stakeholders, such as patients, carers or family members:We engaged and had the support of the clinical and managerial teams from the outset. We opened communication with the day-case unit pre-assessment and anaesthetic teams early. We introduced a new co-located outpatient prostate assessment clinic in conjunction with a nurse specialist.Key MessagesOver the last 6 months we have implemented an all options service for bladder outlet obstruction. We have performed more than 50 day-case Rezum cases, introduced day-case GLLP and inpatient HoLEP. All Rezum and GLLP cases have been day-case with the subsequent personal and institutional savings. We will report our clinical outcomes and reflect on lessons learned.Lessons learntThe introduction of novel bladder outlet therapies has led to improved quality of life for men living with bladder outlet obstruction. We have significantly reduced the waiting list and the waiting time for treatment. We have shown that service development and improvement for benign disease is possible even during a pandemic.Measurement of improvementWe are following up these men with validated symptoms and quality of life scores. We get objective measurement of improvement through repeat flow rate and measurement of post void residual urinary volumes. We have kept a database on key patien parameters and self-reported outcomes. Initial results are promising.Strategy for improvementAs an ongoing and ever evolving project, we use multiple PDSA cycles to improve our service. Weekly team briefs at the end of theatre lists allow feedback from all staff. In particular we have learned from our patients. We have introduced local anaesthetic treatment with Rezum in men unfit for other options. We have contacted other units to share their experience and there has been coverage of our work in our regional media.