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 Irritative symptoms

Hesitancy Nocturia

Weak stream Frequency

Straining Urgency

Prolong micturition

Intermittent stream

Post void dribbling

Sense of incomplete emptying

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)

0

1000000

2000000

3000000

4000000

5000000

6000000

7000000

8000000

2006 2011 2016

No.

of

pers

ons

(pop

ulat

ion)

male female

Male 60+/65+(2016 Population By-census)

0

100000

200000

300000

400000

500000

600000

2006 2011 2016

No.

of

pers

ons

(pop

ulat

ion)

60+ 65+

4/2016-1/2017 AROU Hospitalization (male)

0

20

40

60

80

100

120

20 30 40 50 60 70 80 90

No.

of

pati

ents

Age distribution

9/2016-1/2017 ATOC program (male)

0

5

10

15

20

25

40 50 60 70 80 90 100

No.

of

pati

ents

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

0

10

20

30

40

50

60

70

80

90

100

Hospitalization (4/16-1/17) ATOC (9/16-1/17)

Succ

ess

wea

n of

f fo

ley

(%)

Comparisons before and after ATOC Program

Hospitalization Before ATOC (5 months)

Hospitalization After ATOC (5 months)

ATOC clinic (5 months)

No. of bed days 669 402 0

No. of patient 176 112 69

Mean length of stay

3.8±1.8 3.6±1.3 0

Mean catheterization day

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)

19584 18618 3578.9

Success rate of wean off foley

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

Reference

1. Emberton M, Anson K (1999). Acute urinary retention in men: an age old problem. BMJ 318(7188): 921-925

2. Choong S, Emberton M (2000). Acute urinary retention. BJU, 85(2), 186-201

3. Berry SJ, Coffey DS, Walsh PC, Ewing LL (1984). The development of human benigh prostatic hyperplasia with age. J Urol, 132(3), 474-479

4. Nicola J & Gail MP (2008). The success of a nurse-led, one-stop suspected prostate cancer clinic. Cancer nursing practice, 7(3), 28-32

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)