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Flexible Cystoscopy
THE BRITISH ASSOCIATION UROLOGICAL SURGEONS OF Flexible Cystoscopy Performance Criteria, Training and Assessment Logbook November 2012 1 Tristel has provided an unrestricted educational grant for this independent publication Flexible Cystoscopy Performance Criteria, Training and Assessment Record Trainee Name Title of Trainee NMC Number Supervisor Name Title of Supervisor Name of Assessor Title of Assessor NHS Trust/Employing Organisation Date Training Commenced Date Assessment Completed 1 1 Contents Reflective Diary Contents Contents Skills for Health Standards for Flexible Cystoscopy 3 ReflectiveReflective Diary Diary Performance Criteria for Undertaking Flexible Contents Cystoscopy 5 Skills for Health Standards for Flexible Cystoscopy Skills for Health Standards for Flexible Cystoscopy Contents Reflective Diary Observation of Cystoscopy Aims and Objectives 7 Performance Criteria forCriteria Undertaking Flexible Cystoscopy Performance for Undertaking Flexible Cystoscopy Reflective Diary Skills forofHealth Standards for Flexible Observation Cystoscopy Training Record Cystoscopy Observation of Cystoscopy Aims and Aims Objectives 9 Observation ofUndertaking Cystoscopy andCystoscopy Objectives Skills for Health Standards for Flexible Cystoscopy Performance Criteria for Flexible Withdrawal of Flexible Cystoscope Aims and Objectives Observation of Cystoscopy Training 11 Observation ofUndertaking Cystoscopy Training Record Performance Criteria for Flexible Cystoscopy Observation of Cystoscopy Aims andRecord Objectives Withdrawal of Cystoscope Training Record Withdrawal of Aims and Aims Objectives 12 Withdrawal ofCystoscope Flexible Cystoscope and Objectives Observation of Flexible Cystoscopy Aims and Objectives Observation of Cystoscopy Training Examination of Bladder Urothelium UsingRecord a Flexible Cystoscope Aims And Objectives Withdrawal of Training Record 13 Withdrawal ofCystoscope Cystoscope Training Record Observation of Cystoscope Cystoscopy TrainingAims Record Withdrawal of Flexible and Objectives Examination of Bladder Urothelium Training Record Examination Bladderof Urothelium Usingand a Flexible Aims AndAims Objectives Examination Bladder Urothelium Using aCystoscope Flexible Cystoscope And Objectives 14 Withdrawal ofofCystoscope Flexible Cystoscope Aims Objectives Withdrawal of Record Insertion of Flexible CystoscopeTraining Aims and Objectives Examination Bladder Training Record Examination ofUrothelium Bladder Training Record Aims And Objectives 15 Withdrawal ofof TrainingUrothelium Record Examination ofCystoscope Bladder Urothelium Using a Flexible Cystoscope Insertion of Flexible Cystosope Training Record Insertion of Flexible Aims and aAims Objectives Insertion ofCystoscope Flexible Cystoscope and Objectives 16 Examination of Urothelium Using Flexible Cystoscope Aims And Objectives Examination of Bladder Bladder Urothelium Record Flexible Cystoscopy Full Procedure AimsTraining and Objective Insertion of Flexible Training Record Insertion ofCystosope Flexible Cystosope Training Record 17 Examination of Bladder Urothelium Training Record Insertion Flexible Cystoscope Aims and Objectives Performance ofofFull Procedure Training Record Flexible Cystoscopy Full Procedure Aims and Objective Flexible Cystoscopy Full Procedure Aims and Objective 18 Insertion of Flexible Cystoscope Aims and Objectives Insertion of Flexible Cystosope Training Record Summary of Training Record Performance of Full Procedure Training Performance ofProcedure Full Procedure Training Record 19 Insertion of Flexible Cystosope TrainingRecord Record FlexibleofCystoscopy Full Assessment Flexible Cystoscopy SkillsAims and Objective Summary of Training Record Summary Training Record 20 Flexible Cystoscopy Full Procedure Aims and Objective Performance of Full of Procedure Statement of Competence to PerformTraining FlexibleRecord Cystoscopy Assessment of Flexible Cystoscopy Skills of Flexible Cystoscopy Skills of Assessment 21 Record Performance of Full Procedure Training Record ofStandards Training Record SkillsSummary for Health for Removal of Ureteric Stent Using a Flexible Cystoscope Statement ofof Competence to PerformSkills ofRecord Competence toFlexible PerformCystoscopy Flexible Cystoscopy 23 Summary Statement of Training Assessment Flexible Cystoscopy Performance Criteria for Undertaking Removal of Ureteric Stent Skills for Health Standards for Removal UretericofStent Using a Flexible Skills for Health forof Removal Ureteric Stent Using aCystoscope Flexible Cystoscope 24 Assessment Flexible Cystoscopy Skills Statement ofofCompetence toStandards Perform Flexible Assessment of Ureteric Stent Removal Skills UsingCystoscopy a Flexible Cystoscope Performance Criteria forCriteria Undertaking Removal of Ureteric Performance for Undertaking Removal ofStent Ureteric Stent Cystoscope Statement of Competence tofor Perform Flexible Cystoscopy 25 Skills forCompetence Health Standards Removal Ureteric Stent Using a Cystoscope Flexible Statement of to Remove UretericofStents Using a Flexible Assessment ofCriteria Ureteric Skills Using aStent Flexible Assessment ofStent Ureteric StentRemoval Removal Using aCystoscope Flexible Cystoscope Skills for Health Standards forRemoval Removal of Ureteric Using a Flexible Cystoscope 26 for ofSkills Ureteric Stent SkillsPerformance for Health Standards to Undertaking Use Cystodiathermy Via a Flexible Cystoscope Statement ofof Competence to Remove Stents a Flexible of toUreteric Remove Ureteric Using aCystoscope Flexible Cystoscope Performance Criteria forCompetence Undertaking Removal of Ureteric Stent Statement Statement of Competence Remove Ureteric Stents Using aStents Flexible Cystoscope 27 Assessment Ureteric Stent Removal Using a Using Flexible Cystoscope Assessment of Cystodiathermy Skills UsingSkills a Flexible Cystoscope Skillsfor forHealth Health Standards to Use Cystodiathermy a Flexible Skills for Health to Use Cystodiathermy aCystoscope Flexible Cystoscope Assessment Ureteric Stent Removal Skills Using a Using Flexible Cystoscope Skills Standards -Standards Use cystodiathermy viaVia flexible cystoscope 28 Statement ofofCompetence to Remove Ureteric Stents a Via Flexible Cystoscope Statement of Competence to Perform Cystodiathermy Using a Flexible Cystoscope Assessment Cystodiathermy Skills Using a Flexible Cystoscope Assessment of Undertaking Cystodiathermy Skills UsingUsing ausing Cystoscope Statement ofofCompetence totoRemove Ureteric Stents aaFlexible Cystoscope Performance Criteria for Cystodiathermy Flexible Cystoscope for Health Standards Use Cystodiathermy aFlexible Flexible Cystoscope SkillsSkills for Health Standards to Undertake Biopsy Using aVia Flexible Cystoscopy Statement ofofCompetence totoPerform a Flexible Statement of Competence toCystodiathermy Perform Cystodiathermy Using aCystoscope Flexible Cystoscope Skills for Health Standards Use Cystodiathermy ViaUsing a Flexible Cystoscope 31 Assessment Cystodiathermy Using a Flexible Cystoscope Assessment of Biopsy Skills Using aSkills Flexible Cystoscope Skills for Health Standards toPerform Undertake Biopsy Using a Flexible Skills for HealthtoStandards to Undertake Biopsy Using aCystoscopy Flexible Cystoscopy Assessment Cystodiathermy Skills Cystodiathermy Using a Flexible Cystoscope 33Statement Statement ofofCompetence Using aCystoscope Flexible Cystoscope of Competence to Undertake Biopsies Using a Flexible Assessment Biopsy Skills Using a Flexible Assessment of Biopsy Skills Using aCystoscope Flexible Statement ofofCompetence totoPerform Cystodiathermy a Flexible Cystoscope 35Background Skills forReading Health Standards Undertake Biopsy UsingUsing aCystoscope Flexible Cystoscopy Cystoscope and References Statement ofof Competence totoUndertake Biopsies Using Flexible Statement of Competence Undertake Biopsies UsingCystoscope aCystoscope Flexible Cystoscope Skills for Health Standards Undertake Biopsy Using Flexible Cystoscopy 37 Performance Criteria for Undertaking Biospsies Using a aaFlexible Assessment Biopsy Skills Using atoFlexible Cystoscope Background Reading References Background Reading and aReferences Assessment Biopsyand Skills Using Flexible Cystoscope 39 37 Statement ofof Competence to Undertake Biopsies Using a Flexible Cystoscope 29 41 39 Statement of Reading Competence to Undertake Biopsies Using a Flexible Cystoscope Background and References 42 41 Background Reading and References 42 2 2 2 2 2 Prompts to structure reflection: Reflective Diary Reflective Diary • to Write a description of a significant cystoscopy procedure. Prompts structure reflection: •• What issues seemedofsignificant? Write a description a significant cystoscopy procedure. •• How was I feeling what made me feel that way? What issues seemedand significant? •• What was was II feeling trying to achieve? How and what made me feel that way? •• Did I respond effectively and in tune with my values? What was I trying to achieve? •• WhatI respond were theeffectively consequences onvalues? the patient, others and me? Did and of in my tuneactions with my •• How were feeling and what them that way? What were others the consequences of mymade actions on feel the patient, others and me? •• What were factors influenced I was feeling, thinking or responding? How others feelingthe andway what made them feel that way? •• To what extent did I act for What factors influenced the the waybest? I was feeling, thinking or responding? •• How doesextent this situation with previous experiences? To what did I act connect for the best? •• How does mightthis I respond more effectively given this situation again? How situation connect with previous experiences? •• What might wouldI the consequences be of alternative How respond more effectively given thisactions? situation again? •• How do I now about this experience? What would thefeel consequences be of alternative actions? •• Am I do now able feel to better myself and others better as a consequence? How I now aboutsupport this experience? •• Am II now now able moretoable to work with patients the better team toashelp them meet their needs? Am better support myself andand others a consequence? • (Johns 2006) Am I now more able to work with patients and the team to help them meet their needs? (Johns 2006) 3 3 3 Reflective Learning Log (cont.) 4 4 B CYST1 - Undertake diagnostic and surveillance CYST1 - Undertake diagnostic and surveillance cystoscopy using a flexible cystoscope. cystoscopy using a flexible cystoscope OVERVIEW This standard covers the use of a flexible cystoscope to examine the interior of the bladder and urethra and the identification and recording of normal and abnormal findings. This standard covers the use of flexible cystoscopy for adults only. Paediatric services are excluded. Users of this competence will need to ensure that practice reflects up to date information and policies. Version No 1 KNOWLEDGE AND UNDERSTANDING You will need to know and understand: 1. National and local cystoscopy policies and guidelines 2. National and local infection control policies and guidelines 3. National and local policies and guidelines for used equipment and waste handling and disposal 4. National and local policies and guidelines for consent to cystoscopy 5. National and local policies and guidelines for patient identification 6. National and local policies and guidelines for patients’ records, their storage and confidentiality of information 7. The range of information which should be made available to the patient 8. National and local policies and guidelines appertaining to the examination report 9. The normal anatomy and physiology, normal variants and anatomical relationships of the lower urinary tract 10. The abnormal anatomy, pathology and physiology visible through cystoscopy and the significance of such abnormalities 11. The cystoscopy blind areas and techniques for visualising these 5 5 12. The clinical conditions appropriate for cystoscopy 13. The indications and contra-indications for cystoscopy 14. The medical terminology relevant to the procedure 15. The common pathologies of the lower urinary tract 16. The signs and symptoms of the patient's physical and emotional status 17. The complications of cystoscopy and remedial strategies 18. The range of local anaesthetics for use in cystoscopy, their specifications and possible side effects 19. The function, specification and performance characteristics of the equipment to be used in cystoscopy 20. The impact of equipment controls on the visual image 21. The safe operation of cystoscopy equipment 22. The importance of timely equipment fault recognition and local procedures for dealing with these 23. Equipment capabilities, limitations and routine maintenance 24. The preparation of environment and equipment for cystoscopy 25. The roles and responsibilities of other team members 26. The limits of one’s own knowledge and experience and the importance of not operating beyond these 27. Audit data to reflect on own practice and maintenance of competence in accordance with national and local policies and guidelines ADDITIONAL INFORMATION This National Occupational Standard was developed by Skills for Health. This standard links with the following dimension within the NHS Knowledge and Skills Framework (October 2004): Dimension: HWB6 Assessment and treatment planning Reproduced with kind permission of Skills for Health 6 6 Performance Criteria for Undertaking Flexible Cystoscopy Action Rationale Verify correct patient with correct notes for correct procedure To ensure that the correct patient has the correct procedure performed Check that the patient has no relevant allergies To avoid adverse reaction to medication/latex used prior to or during procedure. Explain procedure including risks and benefits to patient and obtain informed written consent To comply with DH (2009) recommendations on consent and to ensure patient is prepared for procedure Prepare patient for procedure: To ensure clear view of bladder urothelium • empty bladder Flexible cystoscopy should be avoided in patients with a UTI • urine dipstick recorded To avoid spillage of irrigation fluid on to patient clothing Patient to undress from below the waist ,,ensure ensure patient dignity is maintained If patient has an artificial urinary sphincter implanted, ensure that it is deactivated To avoid adverse incident Communicate with patient throughout the procedure To confirm understanding of procedure, provide patient with reassurance and answer patient questions or concerns Cover patient from waist down with sterile drapes To reduce the risk of patient developing a healthcare acquired infection Clean penis/vulva and urethral meatus with sterile sodium chloride 0.9% To reduce the risk of patient developing a healthcare acquired infection Instil local anaesthetic lubricant gel into urethra with minimum discomfort to patient To allow smooth passage of cystoscope into bladder and cause minimum discomfort to the patient Check cystoscope and processor in working order To avoid harming the patient and to ensure that the procedure is performed safely. Introduce flexible cystoscope into the urethra Urethra under direct vision using deflection and inflection of the tip to maintain urethral lumen within the centre of vision ,with minimum discomfort to the patient, ensuring irrigation fluid is continuously running To reduce the risk of trauma to the urethra and minimise patient discomfort 7 7 Performance Criteria for Undertaking Flexible Cystoscopy Action Rationale Fill bladder with irrigation fluid with minimum discomfort to the patient To allow complete examination of bladder urothelium Aspirate fluid from the bladder/washout the bladder via the cystoscope if view is poor due to debris or bleeding To improve vision Using rotation, deflection and inflection (including J/U manoeuvre) of the flexible cystoscope tip, systematically examine the bladder urothelium, trigone, ureteric orifices and bladder neck To ensure thorough examination of bladder urothelium Withdraw flexible cystoscope under direct vision using deflection and inflection of the tip to maintain urethral lumen within the centre of vision with minimum discomfort to the patient, ensuring irrigation fluid is continuously running To examine the urethra whilst minimising the risk of trauma and causing minimum patient discomfort Clean any surplus lubricant from patient and ensure that they are dry before dressing To maintain patient comfort and dignity Ask patient to empty their bladder before leaving the department To ensure patients are able to void Explain findings and management plan to patient and confirm understanding To ensure patient remains informed Reminds patientof ofexpected expectedurinary urinarydiscomfort/ Remindpatient patient of expected urinary Remind discomfort/bleeding risk of urinary tract infection and bleeding risk of urinary tract infection and to ensure to ensure good fluid intake following procedure. good fluid intake following procedure. Ensures patientisisisaware awareof actionto takenin the of Ensure patient patient aware ofofaction action totobe bebetaken taken ininevent Ensure event of complications arising. complications arising To avoid unnecessary patient anxiety, reduce the risk of urinary tract infection and to ensure patient is aware of when and who to contact in the event of complications arising. Discard rubbish in accordance with local health and safety at work waste management policies and procedures Safe disposal of waste Ensure used flexible cystoscope is reprocessed in accordance with Infection Control Services Ltd (2007) decontamination policy, manufacturers instructions and local health and safety at work policies and procedures To avoid cross infection and prevent avoidable damage to cystoscope Document Documentsprocedure procedurein incase casenotes notesand andcommunicates communicates result to the patients General Practitioner To ensure everyone involved in the patient pathway is informed that the procedure has been performed and of the result to maintain continuity of care Arrange any necessary follow up appointments To maintain continuity of care 8 8 Aims and Objectives Aims and Objectives ctives Observation of Flexible Cystoscopy Aims and Objectives Aims and Objectives Aims and Objectives Observation of Flexible Observation Cystoscopy of Flexible Cystoscopy Flexible Cystoscopy Minimum 10 (five male and five female) Observation of Flexible Cystoscopy 10 (five Minimum male and10five (five female) male and five female) five male andMinimum five female) The aim of10 a period of observation is to allow the trainee to become familiar with the Minimum (five male and five female) The aimis of period The aim observation ato period isof to observation allow the trainee is the to to become the trainee familiar to become with technique performing aofflexible cystoscopy and for theallow Supervisor to verify thatthe thefamiliar traineewith the eriod of observation toofaallow theof trainee become familiar with ainee to become the technique ofawith performing technique a the flexible ofand performing cystoscopy a flexible andtrainee for cystoscopy the Supervisor and for tothe verify Supervisor thatthe theto trainee verify that the trainee fulfils the skills knowledge. erforming a flexible cystoscopy and Supervisor to verify that theto trainee Thefamiliar aim ofprerequisite period of for observation is to allow the become familiar with or the Supervisor verify thatfulfils the trainee the prerequisite skills the prerequisite and knowledge. skills and equisite skills fulfils and to knowledge. technique of performing a flexible cystoscopy andknowledge. for the Supervisor to verify that the trainee fulfils prerequisite skills and knowledge. To observe the the explanation of flexible cystoscopy to thetopatient and and • the To listen listen and to and observe explanation of flexible cystoscopy the patient of observe towelling and sterile precaution techniques taking of informed informed consent •of flexible To listen to and observe Toconsent listen the toTo and explanation observe of the flexible explanation cystoscopy of flexible to the cystoscopy patient and to the patient and en to and observe•thetaking explanation cystoscopy to the patient and Aims and Objectives To observe towelling To the observe and sterile towelling precaution sterile techniques precaution taking of to informed taking consent ofthe informed consent the technique of inertion of the urethra observe towelling and sterile precaution techniques of informed consent flexible cystoscopy patient and •• toTo Tothe listen and observe explanation ofinto flexible cystoscopy to and the patient and techniques elling andtechnique sterile precaution techniques technique of To inertion ofofthe • into To consent observe the technique ofinto inertion of the the the urethra into the urethra insertion the cystoscope into urethra • of To observe the anatomy and endoscopic appearances lower urinary as seen erve the inertion the the urethra observe towelling and sterile precaution techniques taking ofof informed Flexible Cystoscopy nto observe the • circuit anatomy To observe and the endoscopic anatomy appearances and endoscopic of the appearances lower urinary of the as lower seen through closed television ervethe theurethra anatomy ••andTo endoscopic appearances of lower asthe seen To observe the technique of the inertion ofurinary the into urethra urinary as seen pearances of thefive lower urinary as seen through closed through television closed circuit television Identification bladder landmarks, verification of knowledge of anatomy and hfive closed television • female) To observe theofcircuit anatomy and endoscopic appearances of the lower urinary as seen malecircuit and Identification Identification bladder landmarks, oftract bladder landmarks, of knowledge verification of of anatomy knowledge and of anatomy and physiology of•of the lower urinary and identified pathologies ication of bladder •landmarks, verification oftelevision knowledge ofverification anatomy and through closed circuit eriod observation to tract allowand the trainee topathologies become familiar with the tion ofofknowledge anatomy and physiology ofidentified thephysiology lower urinary of the tract lower and urinary identified tract pathologies and identified pathologies • ofis Handling the deflection and inflection controls ofof the endoscope in the logy the lower urinary Identification of bladder landmarks, verification knowledge ofwhile anatomy andbladder erforming a flexible and for the Supervisor to verify that the trainee entified pathologies To observe the handling of • cystoscopy Handling •deflection Handling and theinflection deflection controls and of the endoscope controls ofwhile in the bladder the endoscope while in the bladder To observethe technique of the withdrawal of theinflection cystoscope ng the deflection and inflection controls of the endoscope while in the bladder physiology of the lower urinary tract and identified pathologies equisite and knowledge. ols theskills endoscope while in the bladder To observe ofand the withdrawalcontrols the cystoscope •deflection Tocystoscope observe technique ofofthe withdrawal of the cystoscope listen and observe the post-examination explanations and advice to patients erveoftechnique of ••the withdrawal of the Handling thetechnique inflection of the endoscope while in the bladder he and cystoscope To observe listen and the post-examination explanations advice to patients •observe To listen andwithdrawal observe and advice to patients en observe the•• post-examination explanations and advicethe to patients To technique of the ofpost-examination the cystoscopeandexplanations explanations and advice to patients To listen to and observe the post-examination explanationsand andadvice advicetotopatients patients listen and of observe thecystoscopy post-examination explanations en to and observe•theTo explanation flexible to the patient and of informed consent To observe towelling and sterile precaution techniques erve the technique of inertion of the into the urethra erve the anatomy and endoscopic appearances of the lower urinary as seen h closed circuit television ication of bladder landmarks, verification of knowledge of anatomy and logy of the lower urinary tract and identified pathologies 9 9 9 9 9 in the bladder ng the deflection and inflection controls of the endoscope while 9 Learning Outcomes The trainee will be able to: 1. Describe the internal anatomy of the lower urinary tract. pathologies: 2. Recognise the following common Pathologies: Paphimosis I. Paraphimosis Paraphimosis Phimosis/Paraphimosis II. Urethral stricture III. Debris IV. Haematuria V. Diverticulae VI. Inflammatory changes VII. Stones VIII. Cystitis cystica IX. Squamous metaplasia X. Prostatic enlargement XI. Abnormalities that may be suggestive of cancer (papillary, solid or CIS) 3. Gain an understanding of the techniques used in the performance of flexible cystoscopy: I. II. Patient counselling and consent Positioning of the patient III. Handling the cystoscope including retroflexion of tip to perform J/U manoeuvre IV. Communication of results to patient and post procedure patient advice V. VI. VII. Documentation of procedure Formulation of follow up/management plan Communication of results to patients General Practitioner Observation of Cystoscopy Training Record 10 10 VII. Communication of results to patients General Practitioner Observation of Cystoscopy Training Record Observation No. 10 M F Date Anatomy identified Reason for cystoscopy Male Patient Female Patient Haematuria Dome of bladder Dome of bladder UTI Body of bladder Body of bladder LUT’s Irritative Right Ureteric orifice Right Ureteric orifice LUT’s Obstructive Left Ureteric orifice Left Ureteric orifice TCC Surveillance Trigone Trigone Bladder neck Bladder neck Prostatic urethra Urethra Verumontanum Membranous urethra Penile urethra Pathology Seen Outcome of Procedure NAD Calculi Discharge Cystitis cystica Inflamed bladder urothelium Further investigation Debris Papillary lesion Review in OPD Diverticula Solid lesion Biopsy GA Enlarged prostate Urethral stricture Biopsy LA Squamous metaplasia Cystodiathermy Trabeculation Litholopaxy Introduction, explanation and consent Rigid cystoscopy Patient results and post procedure information TURBT Communication to GP Urethrotomy Signature 11 11 Aims and Objectives Withdrawal of Flexible Cystoscope Minimum number to achieve 10 (5 male and 5 female) Aim For the trainee to gain experience in the handling of the cystoscope, in particular the use of the control lever to locate urethral landmarks and inspect the urethra. Learning Outcomes The trainee will be able to: 1. Understand the importance of keeping the lumen of the urethra in view all times. 2. Demonstrate the use of the control lever to facilitate keeping the lumen of the urethra in view at all times. 3. Comment on the anatomy and physiology of the lower urinary tract viewed through the cystoscope procedures, 4. At Atthe theend end of of10 theprocedures, 10 withdrawals, withdraw the flexible cystoscope withdraw the cystoscope smoothly and smoothly safely withand safely with minimal to discomfort to the patient. minimal discomfort the patient. 12 12 Withdrawal No. Withdrawal No. Withdrawal of Cystoscope Training Record M of CystoscopeFTraining Record Date Withdrawal M F Date Anatomy identified Reason for cystoscopy Male Patient Reason for cystoscopy Male Patient Anatomy identified Female Patient Female Patient Haematuria Dome of bladder Dome of bladder Haematuria UTI Dome of bladder Body of bladder Dome of bladder Body of bladder UTI LUT’s Irritative Body of bladder Right Ureteric orifice Body of bladder Right Ureteric orifice LUT’s Irritative LUT’s Obstructive Right Ureteric orifice Left Ureteric orifice Right Ureteric orifice Left Ureteric orifice LUT’s Obstructive TCC Surveillance Left Ureteric orifice Trigone Left Ureteric orifice Trigone TCC Surveillance Trigone Bladder neck Trigone Bladder neck Bladder neck Prostatic urethra Bladder neck Urethra Prostatic urethra Verumontanum Urethra Verumontanum Membranous urethra Membranous urethra Penile urethra Penile urethra Pathology Seen NAD Pathology Seen NAD Cystitis cystica Cystitis cystica Debris Outcome of Procedure Outcome of Procedure Discharge Calculi Calculi Inflamed bladder urothelium Inflamed bladder Discharge Further investigation urothelium Papillary lesion Further investigation Review in OPD Debris Diverticula Papillary lesion Solid lesion Review in OPD Biopsy GA Diverticula Enlarged prostate Solid lesion Urethral stricture Biopsy GA Biopsy LA Enlarged prostate Squamous metaplasia Urethral stricture Biopsy LA Cystodiathermy Squamous metaplasia Trabeculation Cystodiathermy Litholopaxy Trabeculation Introduction, explanation and consent Litholopaxy Rigid cystoscopy Introduction, explanation and consent Patient results and post procedure information Rigid cystoscopy TURBT Patient results and post procedure information Communication to GP TURBT Urethrotomy Communication to GP Urethrotomy Signature Signature 13 13 13 Aims Aims and and Objectives Objectives Examination Examination of of Bladder Bladder Urothelium Urothelium Using Using a Flexible a Flexible Cystoscope Cystoscope Minimum Minimum number number to to achieve achieve – 10 – 10 (Five (Five male male andand five five female) female) Aim Aim ForFor thethe trainee trainee to to gain gain further further experience experience in in thethe handling handling of of thethe cystoscope, cystoscope, in in particular particular thethe useuse of of thethe control control lever, lever, byby systematically systematically inspecting inspecting thethe bladder bladder urothelium urothelium andand locating locating bladder bladder landmarks. landmarks. . . Learning Learning Outcomes Outcomes 1. 1. Demonstrate Demonstrate thethe safe safe useuse of of thethe control control lever lever (including, (including, deflection deflection andand inflection inflection of of tiptip to to perform perform JJ/U manoeuvre) J manoeuvre) andand rotation rotation of of thethe cystoscope to to systematically examine cystoscope systematically examine manoeuvre bladder urothelium andand identify bladder landmarks with minimal discomfort to to thethe bladder urothelium identify bladder landmarks with minimal discomfort patient. patient. 2. 2. Comment onon thethe anatomy andand physiology of of thethe lower urinary tract viewed through Comment anatomy physiology lower urinary tract viewed through thethe cystoscope cystoscope 1414 14 Examination of Bladder Urothelium Training Record Examination No. M F Date Anatomy identified Reason for cystoscopy Male Patient Female Patient Haematuria Dome of bladder Dome of bladder UTI Body of bladder Body of bladder LUT’s Irritative Right Ureteric orifice Right Ureteric orifice LUT’s Obstructive Left Ureteric orifice Left Ureteric orifice TCC Surveillance Trigone Trigone Bladder neck Bladder neck Prostatic urethra Urethra Verumontanum Membranous urethra Penile urethra Pathology Seen Outcome of Procedure NAD Calculi Discharge Cystitis cystica Inflamed bladder urothelium Further investigation Debris Papillary lesion Review in OPD Diverticula Solid lesion Biopsy GA Enlarged prostate Urethral stricture Biopsy LA Squamous metaplasia Cystodiathermy Trabeculation Litholopaxy Introduction, explanation and consent Rigid cystoscopy Patient results and post procedure information TURBT Communication to GP Urethrotomy Signature 15 15 Aims and Objectives Insertion of Flexible Cystoscope Minimum number to achieve – 10 (Five male and five female) Aim For the trainee to gain further experience in the handling of the cystoscope, in particular the use of the control lever to safely insert the flexible cystoscope through the urethra into the bladder. Learning Outcomes 1. Safely prepare the aseptic field 2. Correctly clean the patient 3. Safely instil local anaesthetic lubricant into the urethra with minimal discomfort to the patient 4. Safely insert the cystoscope into the bladder, using aseptic technique with minimal discomfort to the patient, whilst observing the lumen of the urethra. 5. Demonstrate the use of the control lever to facilitate keeping the lumen of the urethra in view at all times 6. Comment on the anatomy and physiology of the lower urinary tract viewed through the cystoscope proceduresofdemonstrate insertion ofdemonstrate the cystoscope 7. At At the the end of the 10 insertions the flexible cystoscope insertion of the smoothly safely with minimal discomfort to the patient keeping lumenthe cystoscopeand smoothly and safely with minimal discomfort to the patientthe keeping of the urethra in viewinatview all times. lumen of the urethra at all times. 16 16 Insertion of Flexible Cystosope Training Record Insertion No. M F Date Anatomy identified Reason for cystoscopy Male Patient Female Patient Haematuria Dome of bladder Dome of bladder UTI Body of bladder Body of bladder LUT’s Irritative Right Ureteric orifice Right Ureteric orifice LUT’s Obstructive Left Ureteric orifice Left Ureteric orifice TCC Surveillance Trigone Trigone Bladder neck Bladder neck Prostatic urethra Urethra Verumontanum Membranous urethra Penile urethra Pathology Seen Outcome of Procedure NAD Calculi Discharge Cystitis cystica Inflamed bladder urothelium Further investigation Debris Papillary lesion Review in OPD Diverticula Solid lesion Biopsy GA Enlarged prostate Urethral stricture Biopsy LA Squamous metaplasia Cystodiathermy Trabeculation Litholopaxy Introduction, explanation and consent Rigid cystoscopy Patient results and post procedure information TURBT Communication to GP Urethrotomy Signature 17 17 Aims and Objectives Aims and Objectives Flexible Cystoscopy Full Procedure Minimum number to achieve: - 50 (25 male patients and 25 female patients) Flexible Cystoscopy Full Procedure Minimum number to achieve: - 50 (25 male patients and 25 female patients) Aim By Aimthe end of 50 flexible cystoscopies the trainee will be able to perform a flexible cystoscopy safely, identifycystoscopies any and develop aa flexible treatment follow up By the 50 thepathology traineethe willpresent be ablewill to perform safely, By the end end of of 50 procedures flexible trainee be able to performcystoscopy a and flexible identify any pathology present and develop a treatment and follow up plan. plan. cystoscopy safely, identify any pathology present and develop a treatment and follow up plan. Learning outcomes The traineeoutcomes will be able to: Learning The trainee will be able to: 1. Gain informed consent from the patient 2. 1. 3. 2. Correctly clean the patient Gain informed consent from the patient Safely instil local anaesthetic lubricant into the urethra with minimal discomfort to the Correctly clean the patient patient 3. Safely instil local anaesthetic lubricant into the urethra with minimal discomfort to the 4. Safely pass a flexible cystoscope using aseptic technique with minimal discomfort to the patient patient 4. Safely pass a flexible cystoscope using aseptic technique with minimal discomfort to the 5. Correctly identify bladder landmarks and make a complete examination of the bladder patient urothelium 5. Correctly identify bladder landmarks and make a complete examination of the bladder 6. Withdraw the flexible cystoscope smoothly and safely with minimal discomfort to the urothelium patient 6. Withdraw the flexible cystoscope smoothly and safely with minimal discomfort to the 7. Recognise situations, which require the trainee to stop and if necessary abandon the patient procedure 7. Recognise situations, which require the trainee to stop and if necessary abandon the 8. Provide a report of the procedure and the findings procedure 9. Explain the findings to the patient and provide an action plan for follow up 8. Provide a report of the procedure and the findings 10. Communicate the findings and action plan to the patients General Practitioner 9. Explain the findings to the patient and provide an action plan for follow up 10. Communicate the findings and action plan to the patients General Practitioner 18 18 18 Performance of Full Procedure Training Record Observation No. M F Date Anatomy identified Reason for cystoscopy Male Patient Female Patient Haematuria Dome of bladder Dome of bladder UTI Body of bladder Body of bladder LUT’s Irritative Right Ureteric orifice Right Ureteric orifice LUT’s Obstructive Left Ureteric orifice Left Ureteric orifice TCC Surveillance Trigone Trigone Bladder neck Bladder neck Prostatic urethra Urethra Verumontanum Membranous urethra Penile urethra Pathology Seen Outcome of Procedure NAD Calculi Discharge Cystitis cystica Inflamed bladder urothelium Further investigation Debris Papillary lesion Review in OPD Diverticula Solid lesion Biopsy GA Enlarged prostate Urethral stricture Biopsy LA Squamous metaplasia Cystodiathermy Trabeculation Litholopaxy Gains informed consent Rigid cystoscopy Gives Patient results and post procedure information TURBT Communicates results and management plan to GP Urethrotomy Signature 19 19 Summary of Training Record Observations of Flexible Cystoscopy Start Date Completion Date Number Achieved Comments: - ………………………………………………………………………………….. ………………………………………………………………………………………………. Withdrawal of Flexible Cystoscope Start Date Completion Date Number Achieved Comments: - ………………………………………………………………………………….. …………………………………………………………………………………………............ Insertion of Flexible Cystoscope Start Date Completion Date Number Achieved Comments: - ………………………………………………………………………………….. …………………………………………………………………………………………............ Examination of Bladder Urothelium Start Date Completion Date Number Achieved Comments: - ………………………………………………………………………………….. ………………………………………………………………………………………………… . Full Procedure of Flexible Cystoscopy Start Date Completion Date Number Achieved Male Female Surveillance Total Comments:…………………………………………………………………………………… ………………………………………………………………………………………………… 20 20 Record of Assessment of Flexible Cystoscopy Skills Date Name NMC Number Assessment Number Minimum Five Assessments Reason for Cystoscopy Difficulty of Procedure Easier than usual Patient Gender Average difficulty M F More difficult than usual Time to complete procedure mins Standard: The trainee should be judged against the standard expected of a competent urologist Not Performed accuratelyand andcorrect correctpatient patient Ensuresmedical medicalnotes notes are are checked checked accurately 1. Ensure identified for indentified forprocedure procedure 2. Takes informed consent, 3. Ensures equipment is in working order 4. Ensures that pre-procedure checks have been carried out e.g. urine sample checked for UTI and acts upon them accordingly Administers pre-procedure antibiotics in accordance with local policy Ensures safe positioning of patient on examination couch 5. 6. 7. 8. 9. Maintains good communication with patient and observes and responds to their needs throughout the procedure Prepares sterile field and maintains aseptic technique throughout procedure Cleans, identifies and examines the urethral orifice and surrounding area 21 21 Performed 1. 10. Instils local anaesthetic into urethra and allows time for it to work in accordance with manufacturers recommendations Not Performed Performed 11. Introduces Introducesscope scopeinto intothe theurethra urethraunder underdirect directvision vision using using thethe deflection and inflection of the tip, ensuring irrigation fluid is on deflection and inflection of the tip, ensures irrigation fluid is 12. Fills bladder to enable examination running with sufficiently minimum discomfort to the patientof bladder urothelium 13. Identifies Identifies anatomical anatomicallandmarks landmarks using a systematic of using a systemic system system of deflection deflection and and infection inflectionofofthe thetip tip(J/U (J/Umanoeuvre) manoeuvre) 14. Recognises Recognisesabnormalities abnormalitieswithin within anatomical structure thethe anatomical structure and and records as appropriate records as appropriate 15. Withdraws Withdrawsscope scope maintaining irrigation whilst observing urethral maintaining irrigation whilst observing urethral lumen lumen 16. Maintains Maintainsgood good communication assistant throughout the communication with with assistant throughout the procedure procedure 17. Recognises Recognises deals any complications and andand deals with with any complications and seeks helpseeks help when whenappropriate appropriate 18. Makes appropriate management/follow up plan 19. Communicates findings and management plan with patient and assistant and arranges appropriate follow up 20. Gives clear post procedure instructions to patient in a professional manner. 21. Disposes of rubbish as per local health and safety policy 22. Documents Documentsclearly clearlythe thefindings findingsand andfollow followupupplan plan ininthethe patients record record and communicates results to tothe patients General patients and communicates results the patients Practitioner General Practitioner 23. Ensure Ensure used used flexible flexiblecystoscope cystoscopeisisreprocessed reprocessedininaccordance accordancewith with Infection Control Services Ltd (2007) decontamination policy Services Ltd (2007) decontamination policy, Infection Control ControlServices Infection Ltd (2007) decontamination policy manufacturers andand safety at work manufacturers instructions instructions and andlocal localhealth health safety at work policies policiesand andprocedures procedures Signature of Trainee Signature of Assessor Adapted from Intercollegiate Surgical Programme Curriculum (ISCP) (2012) 22 22 Statement Statement of Competence of Competence to Perform to Perform FlexibleFlexible Cystoscopy Cystoscopy Name ofName Trainee of Trainee NMC Number NMC Number The aboveThe named above person named hasperson achieved has the achieved learning theoutcomes learning outcomes and assessed andas assessed competent as competent to to perform flexible performcystoscopy. flexible cystoscopy. Name ofName Assessor of Assessor GMC Number GMC Number Signature Signature of Assessor of Assessor 23 23 23 B CYST3 - Remove ureteric stent using a flexible cystoscope OVERVIEW This standard covers the use of a flexible cystoscope to visualise and remove ureteric stents. This standard covers ureteric stent removal using a flexible cystoscope for adults only. Paediatric services are excluded. Users of this standard will need to ensure that practice reflects up to date information and policies Version No 1 KNOWLEDGE AND UNDERSTANDING You will need to know and understand: 1. the types of ureteric stents, reasons for ureteric stent insertion, and when not to remove 2. the complications of undertaking ureteric stent removal using flexible cystoscopy and the appropriate remedial strategies 3. sensations associated with ureteric stent removal 4. the safe operation of grasping forceps 5. the limits of one’s own knowledge and experience and the importance of not operating beyond these ADDITIONAL INFORMATION This National Occupational Standard was developed by Skills for Health. This standard links with the following dimension within the NHS Knowledge and Skills Framework (October 2004): Dimension: HWB7 Interventions and treatments Reproduced with kind permission of Skills for Health 24 24 Performance Criteria for Undertaking Removal of Ureteric Stent Action Action Action Rationale Rationale Rationale Verify correct patient with correct notes for removal of stent that the correct patient has Verify correct patient with notes ofofureteric To ensure has the Verify correct patient withcorrect correct notesfor forremoval removal ureteric stent To Toensure ensurethat thatthe thecorrect correctpatient patient has the ureteric stent at correct time the correct procedure performed atatcorrect correct procedure performed correcttime time correct procedure performed To Toavoid avoidadverse adverseincident incidentby byremoving removingthe the To avoid adverse incident by removing wrong wrongureteric uretericstent stentififbilateral bilateralureteric ureteric the wrong ureteric stent if bilateral stents stentsare areininplace place ureteric stents are in place Confirm Confirmwhich whichureteric uretericstent stentisistotobe beremoved removed Confirm which ureteric stent is to be removed To Tocomply complywith withDH DH(2009) (2009) Explain Explainprocedure procedureincluding includingrisks risksand andbenefits benefitstotopatient patientand andobtains obtains To comply with DH (2009) recommendations on consent recommendations on consentand andtoto Explain procedure including risks and benefits to patient informed written consent informed written consent recommendations on consent and to ensure for ensurepatient patientisisprepared prepared forprocedure procedure and obtains informed written consent ensure patient is prepared for procedure To Toavoid avoidadverse adverseincident incidentduring during Select Selectgrasper grasperand andensure ensurethat thatititisisininworking workingorder order Select grasper and ensure that it is in working order To avoid adverse incident during procedure procedure procedure To Toavoid avoidadverse adverseincident incidentby byremoving removingthe the Locate Locatethe thecorrect correctureteric uretericstent stent Locate the correct ureteric stent Insert Insertthe thegrasper grasperthrough throughthe thecorrect correctchannel channelofofthe thecystoscope, cystoscope, ensuring ensuringthe thecystoscope cystoscopetip tipisismaintained maintainedininstraight straightposition. position. Insertthe thegrasping grasperforceps through correct channel of the Identify asasthe they enter bladder. Identify the grasping forceps they enterthe the bladder. cystoscope, ensuring the cystoscope tip is maintained in Position Positionthe thegrasping graspingforceps forcepsover overthe theureteric uretericstent stenttotobe beremoved, removed, straight position. Identify the grasping forceps as they enter ensuring ensuringthe thehinges hingesofofthe theforceps forcepsare arenot notwithin withinthe thechannel channelofofthe the the bladder. cystoscope. cystoscope. Position the grasping forceps over ureterichandles, stent toor be Open the ofofthe using the instrument Open theforceps forceps thegrasper grasper using thethe instrument handles, or instruct assistant totodo instruct assistant doso. so. hinges of the forceps are not within removed, ensuring the the channel of the cystoscope. Grasp Graspthe theureteric uretericstent stentfirmly firmlybetween betweenthe thejaws jawsofofthe theforceps forceps taking care tototake hold any urothelium. taking care not takeof hold anyofofthe thebladder bladder urothelium. Open thenot forceps theofof grasper using the instrument handles, or instruct assistant to do so. Keeping Keepinghold holdofofthe theureteric uretericstent stentwith withthe thetightly tightlyclosed closedforceps, forceps, withdraw the ureteric stent and together withdraw thecystoscope, cystoscope, ureteric stent andgraspers graspers together from Grasp the ureteric stent firmly between the jaws of thefrom the bladder and the urethra, maintaining direct vision throughout. the bladder and the urethra, maintaining direct vision throughout. forceps taking care not to take hold of any of the bladder urothelium. IfIfresistance resistanceisisencountered, encountered,abandon abandonthe theprocedure procedureand andseek seek appropriate appropriateadvice. advice. Keeping hold of the ureteric stent with the tightly closed forceps, withdraw the cystoscope, ureteric stent and Inspect the stent totoensure ititisiscomplete. Inspect theureteric ureteric stent ensure complete. graspers together from the bladder and the urethra, maintaining direct vision throughout. Recognise complications and takes appropriate action Recognises complications and appropriate action Recognises complications andtakes takes appropriate action If resistance is encountered, abandon the procedure and seek appropriate advice. Reminds Remindspatient patientofofexpected expectedurinary urinarydiscomfort/bleeding discomfort/bleedingrisk riskofof urinary urinarytract tractinfection infectionand andtotoensure ensuregood goodfluid fluidintake intakefollowing following procedure. patient isisaware aware ofofaction action totobe be taken ininthe the event procedure.Ensures Ensurespatient patientis awareof actionto betaken takenin theevent event procedure. Ensure ofofcomplications complicationsarising. arising. Document procedure in case notes and communicate communicatesresult resulttotothe the patients General Practitioner 25 25 To avoid adverse incident by removing wrong ureteric stent ififbilateral ureteric wrong ureteric stent bilateral ureteric stents ininplace stents place the wrong ureteric stent if bilateral ureteric stents in place To Toavoid avoiddamaging damagingcystoscope cystoscope To avoid damaging cystoscope To Toavoid avoiddamaging damagingcystoscope cystoscopeand and grasping graspingforceps forceps To avoid damaging cystoscope and grasping forceps To Toallow allowremoval removalofofthe theureteric uretericstent stent without withoutdamaging damagingbladder bladderurothelium urothelium To Toremove removethe theureteric uretericstent stentwith withminimal minimal discomfort to the patient discomfort to the patient To allow removal of the ureteric stent without damaging bladder urothelium To Toavoid avoidtraumatic traumaticremoval removalofofureteric ureteric stent stent To remove the ureteric stent with To Toensure ensureureteric uretericstent stentisiscompletely completely minimal removed removeddiscomfort to the patient To reduce the adverse Toavoid reduce therisk riskofofremoval adverseincident incident To traumatic of ureteric stent To Toavoid avoidunnecessary unnecessarypatient patientanxiety, anxiety, reduce reducethe therisk riskofofurinary urinarytract tractinfection infection and andtotoensure ensurepatient patientisisaware awareofofwhen when and andwho whototocontact contactininthe theevent eventofof complications complicationsarising. arising. To ensure everyone involved in the patient pathway is informed that the procedure has been performed and of the result to maintain continuity of care Assessment of Removal of Ureteric Stent Skills Using a Flexible Cystoscope Date Date Name Name NMC Number NMC Number Assessment Number Minimum five Assessments Minimum Five Assessments Assessment Number Reason for Removal of Ureteric stent Reason for Removal of Ureteric stent Difficulty of Procedure Difficulty Easier than usual of Procedure Easier than usual Side of Ureteric Stent L Average difficulty Average difficulty R More difficult than usual More difficult than usual Time to complete procedure mins Side of ureteric L to complete Standard: The assessment should beR judges againstTime the standard expectedprocedure of a competent urologist stent mins Standard: The assessment should be judged against the standard expected of Not a competent urologist Ensure medical Ensures medicalnotes notesare arechecked checked accurately accurately and and correct correct patient patient indentified 1 2 Performed Not 1 Performed Ensure medical notes are checked accurately and correct patient Describes indication for ureteric stent and reason removal indentified 3 2 Correctly Describes indication for ureteric reason removal verifies which ureteric stent is stent to be and removed 4 informedverifies consent,which after explaining procedure andremoved risks and 3 Takes Correctly ureteric stent is to be 5 6 7 8 9 10 4 5 benefits of removing the ureteric stent Takes informed consent, after explaining procedure and risks Selects for procedure andappropriate benefits ofequipment removingrequired the ureteric stent and checks that it is in working order Selects appropriate equipment required for procedure and checksaseptic that ittechnique is in working orderprocedure Maintains throughout bladder sufficiently to enable examination bladder wall 6 FillsMaintains aseptic technique throughoutofprocedure 7 Identifies correctly ureteric stent for removal Fills bladder sufficiently to enable examination of bladder wall Removes ureteric stent with minimal discomfort to the patient 8 Maintains Identifies ureteric stent for removal goodcorrectly communication with patient and observes and 9 responds to their needs throughout the procedure Removes ureteric stent with minimal discomfort to the patient 11 Recognises and deals with any complications and seeks help when Maintains good communication with patient and observes and 10appropriate 12 Correctly recognises abnormalities within the anatomical structure Recognises and deals with any complications and seeks help 11and records as appropriate 13 Maintains assistant throughout procedure Maintains good goodcommunication communicationwith assistant throughout thethe procedure responds to their needs throughout the procedure when appropriate 14 Correctly recognises abnormalities within the anatomical 12Documents ureteric stent removal and management plan in the structure and records as appropriate 16 Maintains good communication assistant throughout the 13Gives clear post procedure instructions to patient in a professional procedure 16 patients records and informs patients General Practitioner manner. Arranges appropriate follow up Signature of Trainee Signature of Assessor 27 26 Performed Performed Statement of Competence Remove Ureteric Stents Using a Flexible Cystoscope Name of Trainee Registration Number The above named person has achieved the learning outcomes and assessed as competent to remove ureteric stents using a flexible cystoscopy. Name of Assessor GMC Number Signature of Assessor 29 27 B CYST4 - Use cystodiathermy via flexible cystoscope OVERVIEW OVERVIEW This standard covers the use of a flexible cystoscope and diathermy equipment to control small bleeding points, to facilitate the detachment of tissue or to destroy small areas of tissue within the This standard covers the use a flexible cystoscope and diathermy equipment to bladder through the application of of heat. control small bleeding points, to facilitate the detachment of tissue or to destroy small This standard covers cystodiathermy procedures using a flexible cystoscope for adults only. areas of services tissue within the bladder through the application of heat. Paediatric are excluded. This standard covers cystodiathermy procedures using a flexible cystoscope for adults only. Paediatric services are excluded. Users of this standard will need to ensure that practice reflects up to date information and policies Version No 1 Users of this standard will need to ensure that practice reflects up to date information and policies Version No 1 KNOWLEDGE AND UNDERSTANDING You will need to know and understand: 1. the types and use of irrigation fluids 2. the indications and contra-indications for cystodiathermy 3. the complications of undertaking cystodiathermy using flexible cystoscopy and the appropriate remedial strategies KNOWLEDGE AND UNDERSTANDING You will need to know and understand: 4. the sensations resulting from use of heat cauterisation 1. the types and use of irrigation fluids 5. the theindications function, specifi and performance characteristics of diathermy equipment 2. and cation contra-indications for cystodiathermy 6. the thecomplications safe operationof of undertaking diathermy equipment in accordance national and localand policies 3. cystodiathermy usingwith flexible cystoscopy the and guidelines appropriate remedial strategies 7. the thesensations importanceresulting of timely equipment fault recognition and local procedures for dealing 4. from use of heat cauterisation with these 5. the function, specification and performance characteristics of diathermy equipment 8. equipment capabilities, limitations and routine maintenance 6. the safe operation of diathermy equipment in accordance with national and local 9. policies the manufacturer’s guidelines for preparation, checking and use of diathermy equipment and guidelines 10. the theimportance limits of one’s own knowledge andfault experience and the of not operating 7. of timely equipment recognition andimportance local procedures for beyond these dealing with these 8. equipment capabilities, limitations and routine maintenance 9. the manufacturer’s guidelines for preparation, checking and use of diathermy equipment INFORMATION ADDITIONAL 10.National the limits of one’s own knowledge and experience the importance of not This Occupational Standard was developed by Skillsand for Health. operating beyond these This standard links with the following dimension within the NHS Knowledge and Skills Framework (October 2004): Dimension: HWB7 Interventions and treatments 30 Reproduced with kind permission of Skills for Health 28 Performance Criteria for Undertaking Cystodiathermy using a Flexible Cystoscope Rationale Action Verify that patient does not have a cardiac pacemaker/defibrillator fitted To identify contraindications to undertaking cystodiathermy Check patient’s past medical history for metal prosthetic implants and ask patient to remove jewellery. (Apply non conductive tape to jewellery that can’t be removed) To perform procedure with care and safely Inform patient of risks and benefits of cystodiathermy using a flexible cystoscope and obtain informed consent To comply with DH (2009) recommendations on consent and to ensure patient is prepared for procedure Position patient on couch ensuring that they are not in contact with any metal surface To perform procedure safely Verify that cystoscope is diathermy compatible To avoid adverse incident during cystodiathermy Verify that irrigation fluid is diathermy compatible, i.e. sterile water or 1.5% Glycine To avoid adverse incident during cystodiathermy Ensure cystodiathermy generator is available, in working order and set at required power level To avoid adverse incident during cystodiathermy Identify abnormality or bleeding area within the bladder that is appropriate for cystodiathermy using a flexible cystoscope Ensure assistant correctly applies Patient Return Electrode (diathermy plate) to clean dry skin, preferably on patients thigh, avoiding bony prominences, scar tissue, tattoos, over an implanted metal prosthesis, or hairy surfaces (if necessary shave skin before applying). Ask assistant assistanttotoplace placefoot foot pedals foot controls Ask pedals/controls so they so arethey easily and comfortably accessible. accessible. are easily and comfortably Inspect the diathermy wire to ensure that the insulation coating is intact. Ask assistant to connect wire to diathermy lead Insert the diathermy wire through the correct channel of the cystoscope, ensuring the cystoscope tip is maintained in straight position. Identify the diathermy wire as it enters the bladder, advance the diathermy wire so that it is not touching the tip of the cystoscope Position tip of the diathermy wire so that it is gently touching the area to be diathermied To avoid causing burns to the patient To avoid adverse incident during cystodiathermy To avoid damaging cystoscope To confine diathermy current to the area to be diathermised 32 29 Action Rationale Maintain good communication with patient throughout the procedure, ensuring patient is aware when diathermy is about to take be taken place To keep patient informed of what is happening and to prepare them for when discomfort/pain may be felt Press foot pedals in short bursts until the abnormality is destroyed or bleeding stopped, whilst observing patient and responding to their needs throughout the procedure To achieve the desired effect whilst causing minimum discomfort to the patient Withdraw the diathermy wire and hand it over to assistant maintaining aseptic technique To allow checking of bladder urothelium for additional lesions or bleeding requiring further cystodiathermy Examine bladder urothelium to ensure treatment complete before fully withdrawing the cystoscope. To confirm successful procedure Check skin under diathermy plate for evidence of burns. Poor application of diathermy plate can cause burns to skin which will need documented and or treatment Ensure diathermy generator switched off and foot pedals and diathermy lead put away. Document procedure in case notes and communicate result to the patient’s General Practitioner To ensure everyone involved in the patient pathway is informed that the procedure has been performed and of the result to maintain continuity of care Remind patient of expected urinary discomfort/bleeding risk of urinary tract infection and to ensure good fluid Ensure patient intake following procedure. Ensures patientisisaware awareofof action to be taken in the event of complications arising. To avoid unnecessary patient anxiety, reduce the risk of urinary tract infection and to ensure patient is aware of when and who to contact in the event of complications arising. Inform patient of follow up arrangements and make appropriate arrangements To maintain continuity of care 33 30 Assessment of Cystodiathermy Skills Using a Flexible Cystoscope Date Name NMC Number Assessment Number Minimum Five Assessments Reason for Cystodiathermy Difficulty of Procedure Easier than usual Average difficulty More difficult than usual Time to complete procedure mins Standard: The assessment should be judged against the standard expected of a competent urologist Not Performed 1 2 3 4 5 6 7 8 Ensure medical notes are checked accurately and correct patient indentified Describes indication for undertaking a cystodiathermy Performs pre procedure checks to ensure there are no contraindications for cystodiathermy Takes informed consent, after explaining procedure and risks and benefits of performing cystodiathermy Ensures cystodiathermy equipment available and in working order Selects appropriate equipment required for procedure, ensuring that the cystoscope is diathermy compatible and checks that it is in working order Ensures irrigation fluid is diathermy compatible Maintains good communication with patient and observes and responds to their needs throughout the procedure 9 Fills bladder sufficiently with diathermy compatible irrigation fluid to enable examination of bladder urothelium 10 Identifies correctly abnormality suitable for cystodiathermy 11 Performs cystodiathermy with minimal discomfort to the patient 12 Maintains aseptic technique throughout procedure 13 Visually checks bladder and diathermy site for additional lesion or bleeding and performs further cystodiathermy if appropriate 34 31 Performed Not Performed 14 Recognises and deals with any complications and seeks help when appropriate 15 Maintains good communication with assistant throughout the procedure 16 Documents cystodiathermy performed and management plan in the patients records and informs patients General Practitioner 17 Gives clear post procedure instructions to patient in a professional manner. Performed 18 Arranges appropriate follow up Signature of Trainee Signature of Assessor Adapted from ISCP (2012) 35 32 Statement Statement of Competence of Competence to Perform to Perform Cystodiathermy Cystodiathermy Using Using a Flexible a Flexible Cystoscope Cystoscope Name Name of of Trainee Trainee NMC NMC Number Number TheThe above above named named person person hashas achieved achieved thethe learning learning outcomes outcomes andand assessed assessed as competent as competent to to perform perform cystodiathermy cystodiathermy using using a flexible a flexible cystoscope. cystoscope. Name Name of of Assessor Assessor GMC GMC Number Number Signature Signature of of Assessor Assessor 36 36 33 34 B CYST2 - Undertake biopsy using a flexible cystoscope OVERVIEW OVERVIEW This standard covers the use of a flexible cystoscope to take tissue samples from the inside of the bladder. It also covers the requests for ahistopathology investigations and the initialsamples handling of the This standard covers use of flexible cystoscope to take tissue tissue the samples. from inside of the bladder. It also covers requests for histopathology investigations andbiopsy the initial handling ofathe tissue samples. This standard covers procedures using flexible cystoscope for adults only. Paediatric services are excluded. This standard covers biopsy procedures using a flexible cystoscope for adults only. Paediatric services are excluded. Users of this competence will need to ensure that practice reflects up to date information and policies.of this competence will need to ensure that practice reflects up to date Users information Version No 1 and policies. Version No 1 KNOWLEDGE AND UNDERSTANDING You will need to know and understand: KNOWLEDGE AND UNDERSTANDING 1. The clinical conditions appropriate for bladder biopsy 2. The and contra-indications for bladder biopsy You will indications need to know and understand: Tissue specimen criteria for histopathology 1.3. The clinical conditions appropriate forexaminations bladder biopsy 2.4. The indications and contra-indications for bladder biopsy Emergency indications of use of cystodiathermy 3.5. Tissue specimenofcriteria for histopathology examinations The complications undertaking a biopsy using flexible cystoscopy and the appropriate remedial strategies 4. Emergency indications of use of cystodiathermy Sensations resulting from use of biopsyaforceps 5.6. The complications of undertaking biopsy using flexible cystoscopy and the appropriate remedial strategies 7. The safe operation of biopsy forceps 6.8. Sensations resulting use offault biopsy forceps The importance of timelyfrom equipment recognition and local procedures for dealing with these 7. The safe operation of biopsy forceps The importance limits of one’sof own knowledge and experience and the importance of not operating 8.9. The timely equipment fault recognition and local procedures beyond these for dealing with these 9. The limits of one’s own knowledge and experience and the importance of not operating beyond these ADDITIONAL INFORMATION This National Occupational Standard was developed by Skills for Health. This standard links with the following dimension within the NHS Knowledge and Skill Framework (October 2004): Dimension: HWB6 Assessment and treatment planning Reproduced with kind permission of Skills for Health 37 35 36 Performance Criteria Criteria for Via a Flexible Cystoscope Performance for Undertaking Undertaking Biopsies Biopsies Using a Flexible Cystoscope Action Rationale Verifythat thatpatient patient taking anticoagulant therapy Verify is is notnot taking anticoagulant therapy or or has a cardiac pacemaker/defibrilator fitted To identify contraindications to undertaking biopsies Verify that cystoscope is diathermy compatible To avoid adverse incident if cystodiathermy necessary Ensure cystodiathermy equipment available and in working order In case needed for prevention of bleeding following taking biopsies Inform patient of risks and benefits of cystodiathermy biopsy using a flexible cystoscope and obtain informed consent To comply with DH (2009) recommendations on consent and to ensure patient is prepared for procedure Identify abnormality within the bladder that is appropriate for biopsy using a flexible cystoscope Select biopsy forceps and ensure that they are in working order To avoid adverse incident during procedure Insert the biopsy forceps through the correct channel of the cystoscope, ensuring the cystoscope tip is maintained in straight position. Identify the jaws of the forceps as they enter the bladder. To avoid damaging the flexible cystoscope Position the biopsy forceps over the area to be biopsied, ensuring the hinges of the forceps are not within the channel of the cystoscope. To avoid damaging the flexible cystoscope and allow forceps to open fully Maintain good communication with patient throughout the procedure, ensuring patient is aware when biopsy is about to be taken To keep patient informed of what is happening and to prepare them for when discomfort/pain may be felt Open the biopsy forceps using the instrument handles, or instruct assistant to do so. Grasp the area to be biopsied firmly between the jaws of the forceps ensuring sufficient tissue for histopathological examination is within the forceps. Keeping the jaws of the forceps closed, pull sharply but carefully away from the bladder urothelium 39 37 To allow removal of the tissue to be biopsied with minimum discomfort to the patient Performance Criteria for Undertaking Biopsies using a Flexible Cystoscope Action Rationale Keeping hold of the biopsy with the tightly closed forceps, withdraw the biopsy forceps from the cystoscope channel, or instruct assistant to do so To ensure biopsy is not lost during removal from the bladder Drop specimen into fixative or instruct assistant to do so ensuring all tissue is removed from biopsy forceps. Inspect biopsy, before repeating procedure if necessary To ensure that sufficient tissue is taken and is suitable for histopathological examination Observe for bleeding and perform cystodiathermy if necessary To reduce the risk of haemorrhage and clot retention of urine Complete histopathology request form in accordance with national and local policies and guidance. To ensure specimen labelled with correct patient identification details and facilitate histopathological examination Ensure biopsy is packaged within a leak proof container in accordance with local and national policies and guidelines for transport to pathology To comply with Health and Safety at work regulations Document procedure in case notes and communicate result to the patients General Practitioner To ensure everyone involved in the patient pathway is informed that the procedure has been performed and of the result to maintain continuity of care Remind patient of expected urinary discomfort/bleeding risk of urinary tract infection and to ensure good fluid Ensure patient intake following procedure. Ensures patient is aware of action to be taken in the event of complications arising. To avoid unnecessary patient anxiety, reduce the risk of urinary tract infection and to ensure patient is aware of when and who to contact in the event of complications arising. Inform patient of follow up to receive biopsy results and arrange appropriate arrangements To maintain continuity of care 40 38 Assessment of Biopsy Skills Using a Flexible Cystoscope Date Name NMC Number Assessment Number Minimum Five Assessments Reason for Biopsy Difficulty of Procedure Easier than usual Average difficulty More difficult than usual Time to complete procedure mins Standard: The assessment should be judged against the standard expected of a competent urologist Not Performed 1 2 3 4 5 6 7 8 9 Ensures medical notes are checked accurately and correct patient indentified Describes indication for undertaking a biopsy Performs pre procedure checks to ensure there are no contraindications for bladder biopsy Takes informed consent, after explaining procedure and risks and benefits of performing a bladder biopsy Ensures cystodiathermy equipment available and in working order Selects appropriate equipment required for procedure, ensuring that the cystoscope is diathermy compatible and checks that it is in working order Maintains good communication with patient and observes and responds to their needs throughout the procedure Fills bladder sufficiently with diathermy compatible irrigation fluid to enable examination of bladder urothelium Identifies correctly abnormality suitable for biopsy 10 Takes biopsy with minimal discomfort to the patient 11 Visually checks biopsy is sufficient for histopathological examination and repeats biopsy if necessary 12 Maintains aseptic technique throughout procedure 13 Visually checks biopsy site for obvious bleeding and performs cystodiathermy if appropriate 41 39 Performed Not Performed 14 Performed Recognises and deals with any complications and seeks help when appropriate 15 Ensures biopsy sample container correctly labelled. 16 Ensures histopathology request card completed in accordance with national and local policies and guidance 17 Maintains good communication assistant throughout the procedure 18 Documents biopsy taken and management plan in the patients records and informs patients General Practitioner 19 Gives clear post procedure instructions to patient in a professional manner. 20 Arranges appropriate follow up Signature of Trainee Signature of Assessor Adapted from ISCP (2012) 42 40 Statement of Competence to Undertake Biopsies Using a Flexible Cystoscope Name of Trainee Registration Number The above named person has achieved the learning outcomes and assessed as competent to undertake biopsies using a flexible cystoscopy. Name of Assessor GMC Number Signature of Assessor 43 41 Background Reading and References Department of Health (2004) The NHS Knowledge and Skills Framework (NHS KSF) and the Development Review Process. London. Department of Health Publications. Department of Health (2009) Reference Guide to Consent for Examination or Treatment. 2nd Edition. [Online] Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_1 03653.pdf (Accessed 10th October 2010). Hinchcliff S & Rogers R (Eds.) Competencies for Advanced Nursing Practice. London. Edward Anurseold Publications Ltd. Infection Control Services Ltd (2007) Cystoscopes [Online] Available at: http://www.infectioncontrolservices.co.uk/endoscopes_cystoscopes.htm (Accessed April 29th 2011). Intercollegiate Surgical Curriculum Programme (2012) Direct Observation of Procedural Skills (Surgical DOPS). Johns C. (2006) Guided Reflection Advancing Practice. Aylesbury Blackwell Publishing. Skills for Health (2010a) CYST1 Undertake diagnostic and surveillance cystoscopy using a flexible cystoscope. Version 1. [Online] Available at: https://tools.skillsforhealth.org.uk/competence/show/html/id/2005/ (Accessed 20th March 2011) Skills for Health (2010b) CYST2 Undertake biopsy using a flexible cystoscope. Version 1. [Online] Available at: https://tools.skillsforhealth.org.uk/competence/show/html/id/2005/ (Accessed 20th March 2011) Skills for Health (2010c) CYST3 Remove ureteric stent using a flexible cystoscope Version 1. [Online] Available at: https://tools.skillsforhealth.org.uk/competence/show/html/id/2005/ (Accessed 20th March 2011) Skills for Health (2010d) CYST4 Use cystodiathermy via flexible cystoscope. Version 1. [Online] Available at: https://tools.skillsforhealth.org.uk/competence_search/?search=&advanced=1&suite[]=43 (Accessed 20th March 2011) 44 42 Assessment of Biopsy Skills Using a Flexible Cystoscope Date Name NMC Number Assessment Number Minimum Five Assessments Reason for Biopsy Difficulty of Procedure Easier than usual Average difficulty More difficult than usual Time to complete procedure mins Standard: The assessment should be judged against the standard expected of a competent urologist Not Performed 1 2 3 4 5 6 7 8 9 Ensures medical notes are checked accurately and correct patient indentified Describes indication for undertaking a biopsy Performs pre procedure checks to ensure there are no contraindications for bladder biopsy Takes informed consent, after explaining procedure and risks and benefits of performing a bladder biopsy Ensures cystodiathermy equipment available and in working order Selects appropriate equipment required for procedure, ensuring that the cystoscope is diathermy compatible and checks that it is in working order Maintains good communication with patient and observes and responds to their needs throughout the procedure Fills bladder sufficiently with diathermy compatible irrigation fluid to enable examination of bladder urothelium Identifies correctly abnormality suitable for biopsy 10 Takes biopsy with minimal discomfort to the patient 11 Visually checks biopsy is sufficient for histopathological examination and repeats biopsy if necessary 12 Maintains aseptic technique throughout procedure 13 Visually checks biopsy site for obvious bleeding and performs cystodiathermy if appropriate 41 39 Performed Not Performed 14 Performed Recognises and deals with any complications and seeks help when appropriate 15 Ensures biopsy sample container correctly labelled. 16 Ensures histopathology request card completed in accordance with national and local policies and guidance 17 Maintains good communication assistant throughout the procedure 18 Documents biopsy taken and management plan in the patients records and informs patients General Practitioner 19 Gives clear post procedure instructions to patient in a professional manner. 20 Arranges appropriate follow up Signature of Trainee Signature of Assessor Adapted from ISCP (2012) 42 40 Statement of Competence to Undertake Biopsies Using a Flexible Cystoscope Name of Trainee Registration Number The above named person has achieved the learning outcomes and assessed as competent to undertake biopsies using a flexible cystoscopy. Name of Assessor GMC Number Signature of Assessor 43 41 Background Reading and References Department of Health (2004) The NHS Knowledge and Skills Framework (NHS KSF) and the Development Review Process. London. Department of Health Publications. Department of Health (2009) Reference Guide to Consent for Examination or Treatment. 2nd Edition. [Online] Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_1 03653.pdf (Accessed 10th October 2010). Hinchcliff S & Rogers R (Eds.) Competencies for Advanced Nursing Practice. London. Edward Anurseold Publications Ltd. Infection Control Services Ltd (2007) Cystoscopes [Online] Available at: http://www.infectioncontrolservices.co.uk/endoscopes_cystoscopes.htm (Accessed April 29th 2011). Intercollegiate Surgical Curriculum Programme (2012) Direct Observation of Procedural Skills (Surgical DOPS). Johns C. (2006) Guided Reflection Advancing Practice. Aylesbury Blackwell Publishing. Skills for Health (2010a) CYST1 Undertake diagnostic and surveillance cystoscopy using a flexible cystoscope. Version 1. [Online] Available at: https://tools.skillsforhealth.org.uk/competence/show/html/id/2005/ (Accessed 20th March 2011) Skills for Health (2010b) CYST2 Undertake biopsy using a flexible cystoscope. Version 1. [Online] Available at: https://tools.skillsforhealth.org.uk/competence/show/html/id/2005/ (Accessed 20th March 2011) Skills for Health (2010c) CYST3 Remove ureteric stent using a flexible cystoscope Version 1. [Online] Available at: https://tools.skillsforhealth.org.uk/competence/show/html/id/2005/ (Accessed 20th March 2011) Skills for Health (2010d) CYST4 Use cystodiathermy via flexible cystoscope. Version 1. [Online] Available at: https://tools.skillsforhealth.org.uk/competence_search/?search=&advanced=1&suite[]=43 (Accessed 20th March 2011) 44 42
