Introducing a locally designed electronic ureteric stent register

Bwrdd Iechyd Prifysgol Betsi Cadwaladr University Health Board Bwrdd Iechyd Prifysgol Hywel Dda University Health Board

Bwrdd Iechyd Addysgu Powys Powys Teaching Health Board

Introducing a locally designed electronic ureteric stent register Iechyd Cyhoeddus Cymru Public Health Wales

Ymddiriedolaeth GIG Prifysgol Felindre Velindre University NHS Trust

Ureteric stents are inserted in every Ymddiriedolaeth GIG Gwasanaethau Ambiwlans CymruAt Wrexham Maelor Hospital (Betsi Cadwaladr urology unit around the UK on an almost Welsh Ambulance ServicesUniversity Health Board), a simple solution has daily basis. National datasets on the exact NHS Trustbeen designed and implemented to overcome numbers inserted across the UK are not all of the aforementioned issues – an electronic available, but a figure of several thousand ureteric stent register. Alarmingly, to date, there annually would not be an unreasonable are only a few departments in the UK that utilise estimate. an electronic database. These have usually been These stents are inserted for a multitude of developed in-house, with no available published conditions: re-establishing urine flow from the kidney due to obstruction by a ureteric stone; relief of obstruction of the ureter from malignant pathologies; and occasionally prophylactic temporary post-operative urine drainage after successful endoscopic removal of a stone. By far the most commonly used stent is made of a polymer (polyurethane). All manufacturers of this type of stent advise maximal patient indwelling stent time of six months. Depending on patients’ individual circumstances, the urologist may advise removal of the stent in a time period spanning anything from a few days up to the maximum allowed six months. Currently, individual departments rely on their own methods of identifying when stent removal dates are approaching. The standard practice is maintenance of paper-based reminder systems. The British Association of Urological Surgeons (BAUS) recommends the use of a ‘ureteric stent database’ in all hospitals that carry out ureteric stent insertions, but no standardised system exists that can be adopted by all hospitals. Paper records are cumbersome at best. They are prone to getting lost in a vast hospital infrastructure, can degrade over time, may not be accessible in all hospital areas that require stent data recording, rely on dedicated personnel to review and update them regularly, and so on. The ultimate consequence is dire: ‘the forgotten stent’. Any stent that is not removed in the recommended time frame can lead to continued morbidity for the patient (symptoms related to having a ureteric stent), ‘financial morbidity’ for hospitals from recurrent hospital admissions due to stent symptoms, and stents becoming encrusted. The latter can convert a routine outpatient stent removal into a complex urological procedure requiring hospital admission, a general anaesthetic, and specialist endourologists experienced in dealing with the removal of encrusted or ‘stuck’ ureteric stents. www.bcuhb.nhs.wales

information to guide the wider urological community on how to adopt this into their own departments. Here is an insight into Wrexham Maelor Hospital’s electronic ureteric stent register/database and their experience of using it for the past 24 months… Methods:

Concept and database structure

The software used was Microsoft Excel. The database was designed with the central concept of a traffic-light-colour based system. Stent episodes needing removal in >3 months automatically appear green, <3 appear amber, and those past the removal date appear red. Formulas are embedded into the database that automatically calculate this date based on the user’s input of the removal time period required. The described colour code (green/amber/red) then immediately highlights the stent removal data cell, alerting the user of the urgency with which stent removal must be arranged. Once the stent has been removed, the entire field (row) turns ‘blue’ to highlight no further action is required. To comply with audit and clinical governance policies, the database has been amended to prevent accidental deletion of patient episodes and to include other safety measures.

Accessibility

The database is available as a password protected document within a dedicated internal hospital network folder. Password access is only available to urologists who are directly involved in stent insertions. The database can be accessed from any hospital location (e.g. theatre, ward, administrative offices) on a hospitalissued laptop. Through appropriate encryption and hospital IT approved access protocols, the database can also be accessed remotely on hospital laptops if required by urologists. Following approval in a governance meeting, the database was shared with all acute urology sites in the health board and is currently in use across the whole health board.

Governance and monitoring

At the monthly departmental governance meeting, ‘Ureteric Stent Database Review’ is a compulsory agenda item where the previous month’s stent insertions are discussed and all that are close to requiring removal are reviewed. This highlights which patients require urgent dates, if any, and also highlights if any stents are overdue. Two ‘stent officers’ (one consultant and one SpR) are responsible for the maintenance of the database and prepare the monthly presentation for the governance meeting. Results: The database was designed and launched in September 2019. Over the past 24 months, over 300 stent insertion episodes have been logged into the database by 10 Urology doctors (consultants and SpRs). In this electronic stent database era, there have been no overdue stents. This has meant that all patients in the last two years have had their stents removed at the expected time, without delay. Subsequently, there have been no serious complications associated with prolonged stent indwelling time, such as heavily encrusted stents. Conclusion: To the health board’s knowledge, this is the first electronic stent register to be introduced in Wales. Review of practice has shown significant patient benefit through timely stent removal. The hospital has benefitted from a reduction of unnecessary patient admissions which would have arisen from complications of forgotten stents. The team would encourage a Waleswide adoption of an electronic ureteric stent register, in order to improve patient care across the country.