The Getting It right First Time (GIRFT) programme in urology; rationale and methodology.

The Getting It Right First Time (GIRFT) programme is a quality improvement initiative covering the National Health Service in England. The programme aims to standardise clinical practices and improve patient and system level outcomes by utilising data-driven insights and clinically-led recommendations. There are GIRFT workstreams for every medical and surgical specialty, including urology. Defining features of the GIRFT methodology are that it is clinically led by experienced clinicians, data-driven, and specialty specific. Each specialty workstream conducts deep-dive visits to every hospital, analysing performance data and engaging with clinicians and management to identify and share improvement priorities. For urology, GIRFT has completed deep-dive visits and published reports outlining priority areas for development. Reports include recommendations pertaining to streamlining care pathways, reducing the acuity of care environments, enhancing emergency services, optimising utilisation of outpatient services, and workforce training and utilisation. The GIRFT academy provides guides for implementing best practices specific to priority areas of care. These include important disease pathways, and GIRFT-advocated innovations such as urology investigation units and urology area networks. GIRFT offers clinical transformation, cost reduction, equity in access to care, and leaner models of care that are often more environmentally sustainable. Evaluation efforts of the programme have focussed on assessing the adoption of GIRFT recommendations, understanding barriers to change, and modelling the climate impact of advocated practices.

Trends in day-case bladder outflow obstruction surgery: a study using Hospital Episode Statistics.

OBJECTIVES: To describe the contemporary evolution of day-case bladder outflow obstruction (BOO) surgery in England and to profile day-case BOO surgery practices across England in terms of the types of operation performed and their safety profiles. MATERIALS AND METHODS: This was a retrospective observational analysis of Hospital Episode Statistics and UK Office for National Statistics data. All 111 043 recorded operations across 117 hospital trusts over 66 months, from 1 January 2017 to 30 June 2022, were obtained. Operations were identified as one of: transurethral resection of prostate (TURP); laser ablation or enucleation; vapour therapy; prostatic urethral lift (PUL); or bladder neck incision. Monthly day-case rate trends were plotted across the study period. Descriptive data, day-case rates and 30-day hospital readmissions were analysed for each operation type. Multilevel regression modelling with mixed effects was performed to determine whether day-case surgery was associated with higher 30-day hospital readmissions. RESULTS: Day-case patients were younger, with fewer comorbidities. Time series analysis showed a linear day-case rate increase from 8.3% (January 2017) to 21.0% (June 2022). Day-case rates improved for 92/117 trusts in 2021/2022 compared with 2017. Three of the six trusts with the highest day-case rates performed predominantly day-case TURP, and the other three laser surgery. Nationally, PUL and vapour surgery had the highest day-case rates (80.9% and 38.1%). Most inpatient operations were TURP. Multilevel regression modelling found reduced odds of 30-day readmission after day-case BOO surgery (all operations pooled), no difference for day-case vs inpatient TURP, and reduced odds following day-case LASER operations. CONCLUSIONS: The day-case rates for BOO surgery have linearly increased. Minimally invasive surgical technologies are commonly performed as day cases, whereas high day-case rates for TURP and for laser ablation operations are seen in a minority of hospitals. Day-case pathways to treat BOO can be safely developed irrespective of operative modality.

Potential Carbon Savings with Day-case Compared to Inpatient Transurethral Resection of Bladder Tumour Surgery in England: A Retrospective Observational Study Using Administrative Data.

Background: The National Health Service (NHS) in England has set a net-zero target for carbon emissions by 2040. Increasing use of day-case surgery pathways may help in meeting this target. Objective: To investigate the estimated difference in carbon footprint between day-case and inpatient transurethral resection of bladder tumour (TURBT) surgery in England. Design setting and participants: This was a retrospective analysis of administrative data extracted from the Hospital Episode Statistics database for all TURBT procedures conducted in England from April 1, 2013 to March 31, 2022. Outcome measurements and statistical analysis: Day-case and inpatient TURBT procedures were identified and the carbon footprint for key elements of the surgical pathway was estimated using data from Greener NHS and the Sustainable Healthcare Coalition. Results and limitations: Of 209 269 TURBT procedures identified, 41 583 (20%) were classified as day-case surgery. The day-case rate increased from 13% in 2013-2014 to 31% in 2021-2022. The move from inpatient stays to day-case surgery between 2013-2014 and 2021-2022 demonstrates a trend toward a lower-carbon pathway, with an estimated saving of 2.9 million kg CO2 equivalents (equivalent to powering 2716 homes for 1 yr) in comparison to no change in practice. We calculated that potential carbon savings for the financial year 2021-2022 would be 217 599 kg CO2 equivalents (equivalent to powering 198 homes for 1 yr) if all hospitals in England not already in the upper quartile were able to achieve the current upper-quartile day-case rate. Our study is limited in that estimates are based on carbon factors for generic surgical pathways. Conclusions: Our study highlights potential NHS carbon savings that could be achieved by moving from inpatient stays to day-case surgery. Reducing variation in care across the NHS and encouraging all hospitals to adopt day-case surgeries, where clinically appropriate, would lead to further carbon savings. Patient summary: In this study we estimated the potential for carbon savings if patient undergoing bladder tumour surgery were admitted and discharged on the same day. We estimate that increasing use of day-case surgery between 2013-2014 and 2021-2022 has saved 2.9 million kg CO2 equivalents. If all hospitals were to achieve day case-rates comparable to those in the highest quarter of hospitals in England in 2021-2022, then the carbon equivalent to powering 198 homes for 1 year could have been saved.

Building capacities for universal health care in the Philippines: Development and implementation of a leadership training program for public health nurses

@#Achievement of Universal Health Care (UHC) in the Philippines requires capable health workers who can navigate changes and lead in the local implementation of health system reforms. Public health nurses are in a strategic position to lead in UHC implementation as they constitute the largest cadre of health workers in the public health setting, and core concepts of UHC intersect with principles of public health nursing practice. This paper aims to describe the development and implementation of a leadership training program for public health nurses in the Philippines, in response to UHC. Document reviews of training reports and evaluations, including course site data analytics, and evaluation of the training program were done for the four cohorts of the course. The University of the Philippines Manila College of Nursing, with support from the Department of Health, responded to the increased demand of the Philippine health system for public health nurses with strong foundations and advanced skills by designing and offering a leadership development course specific to PHNs. From November 2019 to March 2022, a total of 183 participants from 17 regions completed the training. With the COVID-19 pandemic and dynamic changes in governance, the experiences of the project highlighted the need for flexibility in delivering the training program, updating module contents according to the latest developments, and improving course duration and evaluation. Barriers to course engagement and completion must be addressed for PHNs, their workplaces, clients, and the health system to benefit the most from the training.

Percutaneous microwave ablation of renal masses in a UK cohort.

OBJECTIVES: To report a tertiary referral centre's experience of microwave ablation (MWA) for suspected renal cell carcinoma (RCC), describing complications and oncological outcomes. PATIENTS AND METHODS: Consecutive MWA procedures (n = 113) for renal masses (October 2016 to September 2019) were maintained on a prospective database. Data describing patient, disease, procedure, complications, and oncological outcomes were analysed. RESULTS: The median (range) age was 68 (33-85) years, 73% were male, and the median Charlson Comorbidity Index was 0. The median (interquartile range [IQR]) tumour diameter was 25 (20-32) mm. In all, 95% had renal mass biopsy, with histologically confirmed cancer in 75%. The median (IQR) R.E.N.A.L. (Radius, Exophytic/Endophytic, Nearness, Anterior/Posterior, Location) nephrometry score was 7 (6-8). The median ablation time was 6 min and length of stay was 1 day for 95% of the patients. Clavien-Dindo complication Grades I, II, IIIb and IV occurred in 18%, 1.8%, 0.9% and 0.9%, respectively. The median follow-up was 12 months and the median (IQR) renal function change was -4 (-18 to 0)%. One patient (0.9%) had local recurrence, treated with re-ablation; two developed metastatic progression; and two (1.8%) had indeterminate findings on follow-up (one lung nodule and one possible local recurrence), managed with ongoing protocolised computed tomography surveillance. Post-procedure complications were associated with total ablation time (odds ratio [OR] 1.152/min, 95% confidence interval [CI] 1.040-1.277) and total ablation energy (OR 1.017/kJ, 95% CI 1.001-1.033). CONCLUSIONS: We describe the largest UK series of MWA treatment for T1a/small T1b renal masses to date. MWA was well tolerated, with 95% discharged the following day and low complication/re-admission rates. Current follow-up demonstrates favourable disease control. MWA appears to be safe and effective and should be considered in future prospective comparisons of treatments for T1a/small T1b renal masses.

Evaluating enhanced recovery after surgery: time to cover new ground and discover the missing patient voice.

Multicomponent peri-operative interventions offer to accelerate patient recovery and improve cost-effectiveness. The recent National Institute of Health Research-commissioned evidence synthesis review by Nunns et al. considers the effectiveness and cost-effectiveness of all types of multicomponent interventions for older adults undergoing elective inpatient surgery. Enhanced recovery programmes (ERPs) were the most commonly evaluated intervention. An association between ERPs and decreased length of stay was observed, whilst complication rates and time to recovery were static or sometimes reduced. Important areas which lack research in the context of ERPs are patient-reported outcome measures, patients with complex needs and assessment of factors pertaining to successful ERP implementation. The next generation of ERP studies should seek to develop our understanding in these key areas.

Non-visible haematuria: would discontinuing urgent investigation have a visible impact?

National guidance in the UK continues to recommend urgent referral of selected patients with non-visible haematuria for urological assessment. The positive predictive value of non-visible haematuria for urological cancer is low, so it is uncertain whether this is an effective and equitable use of healthcare resources. This article considers rationales for and against continuing this practice, and outlines alternative investigative strategies for patients presenting with non-visible haematuria based on current knowledge and modern technology.

Time to make enhanced recovery after surgery the standard.

Multimodality perioperative interventions could accelerate patient recovery and improve cost-effectiveness. An evidence review found an association between enhanced recovery after surgery and decreased length of stay, while complications and recovery time were unchanged or reduced. More specialties should develop and implement enhanced recovery after surgery pathways.