Shared learning database

 
Organisation:
Frimley Health NHS Foundation Trust
Published date:
August 2016

Having taken part in a trial, which compared the UroLift system with TURP, the team championed UroLift as an intervention that should be routinely offered to NHS patients. A lead project team was established, which consisted of a consultant urological surgeon, a nurse specialising in lower urinary tract symptoms and a deputy directorate manager.

Offering the UroLift procedure is in line with NICE MTG26 and its recommendations which state that the UroLift system should be considered as an alternative to current surgical procedures for use in a day case setting in men with lower urinary tract symptoms of BPH. This case study has been adapted from the ‘NICE medical technology adoption support for UroLift for treating lower urinary tract symptoms of benign prostatic hyperplasia – insights from the NHS – insights from the NHS

Does the example relate to a general implementation of all NICE guidance?
Yes
Does the example relate to a specific implementation of a specific piece of NICE guidance?
Yes

Example

Aims and objectives

Aims:

Enhance the quality of care offered to men with BPH by making available an additional option for surgical management

Objectives:

• Offer men in whom it was clinically indicated, the option of the UroLift procedure, in addition to all other clinically appropriate options

• Increase capacity for surgical interventions for BPH by introducing UroLift

• Reduce the number if inpatient bed stays for patients undergoing surgical management of BPH

• Offer a management option for men who wish to preserve their sexual function


Reasons for implementing your project

The urology department at Frimley Park Hospital comprises 4 consultant urological surgeons. The team offers TURis, the GreenLight laser and the UroLift procedure as options for men with BPH. The hospital does 250–300 surgical interventions per year for BPH. Having taken part in the BPH6 trial1, which compared the UroLift system with TURP, the team championed UroLift as an intervention that should be routinely offered to NHS patients. A lead project team was established, which consisted of a consultant urological surgeon, a nurse specialising in lower urinary tract symptoms and a deputy directorate manager. At the end of the trial the team developed a business case to approve the use of the UroLift system on a routine basis. Although the national tariff is likely to change in the future, the 2015/16 national tariff system (2015/16) does not cover the full cost of the UroLift system so the business case needed to emphasise the clinical and financial benefits for the trust and men before final approval was given.

The business case focused on the following:

• that the procedure can be done as a day case

• UroLift is associated with low readmission rates

• careful patient selection (suitable for daycase, prostate size). The UroLift procedure is done in the operating theatre by the consultant urological surgeon with the support of the theatre staff, meaning that training is needed for everyone involved. The manufacturer organised and funded the surgeon’s training at the start of the trial, which involved:

• watching at least 2 cases

• practising on a simulator and model

• undertaking cases in theatre at Frimley Park under the mentorship of a manufacturer representative.

• The manufacturer also trained theatre staff in ordering and handling the single-use delivery device and implants.

The surgeon aims to carry out a number of UroLift procedures in the same theatre session in order to maximise capacity. The number of UroLift procedures that can be done in a single session is limited by the number of tailored scopes available in the hospital (each of which needs to be sterilised between use). 1 Sønksen J, Barber NJ, Speakman MJ, et al. (2015) Prospective, randomized, multinational study of prostatic urethral lift versus transurethral resection of the prostate: 12-month results from the BPH6 study. European Urology.


How did you implement the project

The surgeon who was trained for participation in the trial started to offer the UroLift procedure to NHS patients in October 2014. As the surgeon became more confident the team moved from using general anaesthesia and urinary catheterisation to doing the procedure under sedation and without urinary catheters. All UroLift procedures at Frimley Park are done by 1 trained surgeon, so there are enough cases to allow the development of expertise in this procedure. On average, the surgeon uses 3 implants per procedure. At Frimley Park Hospital the procedure is generally only done on prostate sizes 60ml or less. The surgeon noted that as their experience has increased, they have needed to use slightly fewer implants per procedure. Men are selected (that is, they are suitable for a day-case procedure) and identified for the procedure using the existing care pathway for BPH, although the team have made some changes to the pathway to better incorporate the UroLift system (see below). This involves a nurse specialist and a GP with special interest or a consultant urological surgeon assessing all men referred to secondary care. Men at the surgical stage of the pathway (that is, where symptoms are severe and conservative management has failed or is inappropriate) for whom surgery is an option are given information about all appropriate surgical options, including the UroLift procedure. They are then seen by a consultant urological surgeon to discuss these options in more detail. Men who choose the UroLift procedure are generally those who wish to preserve their sexual function or do not want TURP. There is currently demand for the procedure from men outside the hospital’s usual catchment area. This is provided for those who have funding agreed from their local clinical commissioning group.

The team has made a number of changes to the care pathway for BPH to incorporate the UroLift system, including:

• Assessing the size of the prostate and the presence of a middle lobe by cystoscopy (or in some cases ultrasound). This often means an additional outpatient appointment and is not part of the routine pathway for BPH.

• After confirmation that the UroLift procedure is appropriate, the patient follows the same day-case pathway as all other urological day-case procedures, including the GreenLight laser.

• Following patient discharge, the nurse follows up by phone at 3 weeks and again at 3 months.


Key findings

The nurse specialist collects post-procedure data including symptom scores and patient satisfaction, in line with the BPH 6 trial.

Table 1 BPH procedures done in Frimley Park Hospital

Procedure

Number of procedures: September 2014 to September 2015

Admission status

Estimated theatre time (minutes)

UroLift

75

 

Day case

25

TURis

190

Inpatient

60

GreenLight

80–90

Day case

60

 

The team concluded that compared with TURP, using the UroLift system:

• reduces the number of formal follow-up appointments (of the 75 procedures done, only one needed a subsequent clinic appointment)

• may increase the number of interventions done in 1 theatre session because of a faster procedure time

• improves post-procedure symptoms and patient satisfaction with respect to quality of recovery and preservation of sexual function

• reduces readmission rates particularly for urosepsis and bleeding.

The adoption of the UroLift system at Frimley Park Hospital has been driven by the urology surgeons’ view that patient satisfaction and quality of life for men at the surgical stage of the pathway will be enhanced if they are offered more choice about management of their symptoms. The team plan to explore how a specific UroLift procedure pathway can be developed, including how it could be offered in an ambulatory setting alongside other simple urological procedures.


Key learning points

This case study has been adapted from the ‘NICE medical technology adoption support for UroLift for treating lower urinary tract symptoms of benign prostatic hyperplasia – insights from the NHS – insights from the NHS which presents adoption experiences at 2 NHS sites. Overall key learning for both sites were:

• Before implementation, collect baseline data on current surgical interventions and develop data collection mechanisms to monitor how the technology affects quality and safety, patient experience, productivity and improved clinical outcomes.

• Ensure that care pathway mapping has been done to identify where the technology would fit into the proposed patient pathway. Clearly define the selection criteria and how many men will be expected to benefit from the introduction of the procedure.

• Providers and commissioners will need to agree a local tariff for the procedure that supports adoption.

• Oversee a trial period for training before doing the procedure independently to increase clinical confidence and efficiency.

• Develop robust protocols for procedure competence and ensure local governance arrangements are in place.


Contact details

Name:
Dr Neil Barber
Job:
Consultant urological surgeon
Organisation:
Frimley Health NHS Foundation Trust
Email:
Neil.Barber@fhft.nhs.uk

Sector:
Secondary care
Is the example industry-sponsored in any way?
No