Patients with a spinal cord injury (SCI) require investigatory cystoscopy because the increase incidence of recurrent urinary tract infections, stone formation or haematuria. They are offered intradetrusor botulinum toxin A injections to manage neurogenic detrusor over activity (NDO). Historically, these procedures would require an admission under a urology consultant into hospital to be performed in a theatre setting with a general anaesthetic using a rigid cystoscope. (BAUS, 2020). 

The rationale for developing an outpatient service was influenced by service factors; reduced medical cover, increased patient population, theatre access, and significant waiting lists. 

Patients had a significant wait for cystoscopy and Botox requiring them to return to bladder medications for prolonged periods which has intolerable side effects. The opportunity for a clinical nurse specialist with competency and skills to provide this service to patients in line with BAUN/BAUS performance criteria guidelines was undertaken (BAUN, 2017).

Aim: To share the results of the service evaluation, patient feedback and the cost-effectiveness of the flexi-cystoscopy outpatient clinic.

150 patient attended the flexi-cystoscopy outpatient clinic for diagnostic cystoscopy or intradetrusor botulinum toxin injections. Post procedure they were given the opportunity to complete a patient satisfaction survey. This was performed via a QR code scanned on a smart device that linked to GoogleDocs. 
Data was collected on income generation from attending an outpatient procedure instead of main theatre
Validation of the current waiting list and moving suitable patients from inpatient procedure to outpatient procedure to demonstrate reduction in waiting times for patients and to evaluate effectiveness of this new service

100% of patients found their overall experience as an outpatient very good/good. 98% of patients preferred to have the procedure as an outpatient than be done in a theatre setting. The 2% of patients that preferred to have this done in theatre was because 1 patient had a prolonged autonomic dysreflexia (AD) episode and the other found the procedure very painful.  However, over 90% patients scored their pain < 5 out of 10. 100% of the patients found the staff friendly and helpful. 

Typically income to the trust for a typical flexi-cystoscopy/Botox procedure £984.65. Estimated 150 patients seen since Jan 2023. This means the income estimated generated for the trust is £147,697.50. This figure is an estimate as before the QI project was set up, our waiting list was approx. 400 patients in 2021.

Between Jan 2023 and Oct 2023 150 patients had been seen and there is currently no waiting list planned repeat intradetrusor BOTOX injections. This has allowed the Urology medical list to accommodate new  patient intradetrusor Botox and diagnostic cystoscopy in a timely manner.

Performing this procedure has clear implications for delivering a cost effective service to meet current financial demands, reduce waiting times in line with Trust and national guidelines (RTT) .

 It supports the patients experience and enhances continuity, efficiency and better patient outcomes.  It has further allowed the service to free up medical time to focus on complex/major theatre cases and dedicated complex clinics.

Clinical Nurse Specialists competent and skilled in flexible cystoscopy have value to patients and their organisation in delivering expert care for neuropathic patients requiring Botox. 
There are limited services within the UK that have a dedicated service for spinal cord injury and the management of neuro-urological care. This service is delivered by a highly skilled nursing team with significant spinal cord injury experience and competency which not only enhances continuity of care but also achieves better reported patient outcomes.

BAUN (2017) Flexible cystoscopy guidelines & assessment. The British Association of Urological Surgeons Limited. Available at: https://www.baus.org.uk/professionals/baus_business/publications/15/flexible_cystoscopy_guidelines_assessment/ (Accessed: 26 February 2024).
BAUS (2020) Botulinum Toxin-A Injections into the Bladder Wall. The British Association of Urological Surgeons Limited. Available  at: https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Botox.pdf. (Accessed: 26 February 2024)