How long does a stent remain in place?
“In most centres across the world, it would be probably around six weeks time, which is what people would be considering ideal. We have recently done a meta-analysis of the worldwide literature on this. It appears to be safe enough to remove at three weeks time, which we have now incorporated into our policy and which we will be starting with from next week onwards.”
What was your previous patient pathway for stent removal?
“Ureteral stent removals are usually organised by the nephrologists who see them in the transplant clinic afterwards with the aim of taking it out around six weeks time, but it requires an active participation and planning from the nephrology side which means that sometimes if there are logistical issues for performing the procedure, there is a delay. Maybe one or two weeks extra, or longer.
The actual procedure would be performed under local anaesthetic, in most situations in theatres using regular diagnostic cystoscopes and a biopsy forceps. Quite often, it is as part of a whole day’s operating list. Patients would come in usually in the morning about 7.30am and may get operated sometimes during that day. Sometimes they are added onto the end of the lists and might wait for most of the day to have the procedure done. On rare occasions, if there happens to have been an overwhelming emergency, we have to cancel our elective operating list obviously and they would have to go home and come back for the procedure on another day. That obviously will have an impact on when they have their stent removed.”
What difference has Isiris α made to your service?
“Since its implementation now in day-to-day practice, Isiris α has completely transformed the way we deliver the service. It is not an operating data based procedure anymore, it is effectively a clinic based procedure which runs completely outside the theatre services. It is organised with specific time slots for patients which means that patients are not in the day unit or usually for more than an hour at a time. The turnaround makes it easier for us to organise more patients in a day so with a typical stent removal list, we would go through eight/ten or twelve patients on the morning list without any difficulty, which means we are all able to keep on top of our waiting list and we are not having people waiting excessively simply because of difficulties with logistics.”
What made you consider Isiris α?
“The first part of the rationale for using Isiris α was to obviously move away from the elective theatre setting, which had difficulties with logistics and also issues with equipment, because it would be practically impossible for us to remove eight stents on an afternoon list which means we would need to have sufficient number of scopes available on just one day. This was a big change because we now are able to remove as many stents as we need. The second part of it was that we are now using it on a more compressed fashion, we needed someone who was able to help run the service reliably along with the clinicians and be responsive enough to all to respond to an emergency removal and so on. This was a part of the whole package of enabling the nursing teams to step up and play different roles and, in fact, one of the people who actually taught me how to remove stents as a trainee was a nurse specialist who was already performing this in an outpatient clinic.”
Do you feel Isiris α improves the patient’s experience?
“Now that we have Isiris α based in our stent removal service, our quality of care has improved enormously. We have much shorter waiting times. It is much more of a friendlier environment rather than an operating theatre which patients find quite stressful. The fact that they are all removed on time means that they do not have to worry about additional risks of having a stent left in place for longer.”
What do you think about the performance of the Isiris α stent removal solution?
“The disposable Isiris α stent removal device works very well. It does have a different kind of learning curve especially for people who are used to traditional cystoscopes and biopsy forceps.”
What impact has adopting Isiris α had on your service/trust?
“Using a single use device like Isiris α makes a whole host of problems go away. Mainly we are not having to have a wall full of cystoscope stacks which need to be cleaned and returned at the right time to run a half a day list. On average, we perform between 10 to 12 removals on a morning’s list, which requires a rapid turnaround of at least half a dozen scopes which we would need for performing these procedures, and quite often, we end up using single-use biopsy forceps anyway. So there was some part of it which still worked out more expensive and time consuming, but now we are not hampered by any of this at all.
Even if there is a sick patient who comes in with urosepsis and it is irritated to the extent that it needs to be taken out, we just drag our trolley to the patient’s bedside and take it out. We do not actually have to worry about taking the patient into an operating theatre and organising it among the other emergency services in the hospital and so on. It gives you such a lot of flexibility and independence.”
Why is a stent placed into a patient at the end of a kidney transplant operation?
“In a kidney transplant, the majority of the stents are placed at the time of the transplant to protect the join from the transplant ureter to either the recipient’s urinary bladder or the recipient’s ureter to allow a safe urinary drainage. There is plenty of data suggesting that this reduces the chance of a urine leakage and it is an almost universally accepted part of a kidney transplant procedure.”
What is the impact of Nurse-led DJ removal procedures in your unit?
“As part of the current development of the nurse-led service which is now nearly complete, we have a much better patient experience because patients are more able to relate to having a nurse to talk to them and also having someone available without other specific commitments. Like a clinician who might have emergency commitments it gives them that little bit more extra to be able to have a quick and easy procedure.”
Would you recommend Isiris α to other healthcare professionals?
“Certainly, using a single-use device like Isiris for transplant patients, in particular, makes it a lot simpler to run a long list of stent removals compared to a reusable cystoscope system where you have to have a stock of fairly expensive scopes which need to be turned around and sterilised to allow the list to complete.”
What impact does Isiris α have on infection control?
“We do not have to worry about infection full stop, because they are all sterilised and single use. So we can proceed with removals whenever and wherever needed, which is handy. When you have patients who come in admitted as an emergency with urosepsis for instance, you do not have to worry about putting them onto an emergency list and taking them to operating theatres. You just go to the patient’s bedside and perform the procedure on the ward.”
What would you say to someone considering Isiris α?
“For anyone who is thinking about moving to Isiris α, the reasons are obvious from what we have learned over the last three years. It makes it simpler, the pathway becomes much more easy and flexible which means much less burden on the services so your theatre services are not hampered as much. You do not have to have a number of personnel involved in organising this which means that it is more streamlined. And if you are able to train a nurse to deliver this as a specialist, that makes them an integral part of a team which you did not have before. Patients will love it because it is much more easy for them to go to a side room in a day unit rather than to go into a very alien looking foreign operating theatre awake and have a procedure done with about half a dozen people or more sometimes looking at them.”
What are the main advantages of Isiris α?
“Introducing Isiris stent removal has completely changed the way we deliver the stent removal service in the kidney transplant programme. It has made a major impact on the timing and the duration of patient’s stay in hospital. Because it is so much more controlled with very little possibility of cancellations and so on, it has made it more acceptable for patients, who have certainly enjoyed it a lot more than before. From the organisational perspective, it has made it easier because there are obviously some economical advantages in moving away from the operating theatre, which also frees up valuable operating data time.”
How did you learn about the Isiris α stent removal device?
“We were approached by the team from Isiris α. We were quite excited by the technology, so we first wanted to look at the clinical feasibility of it. We arranged for a day for the stents to be removed using Isiris α, with the regular cystoscopes available on standby if there was any difficulty, and Isiris α just flew through it without any problems.
The next step was to develop a business case, which we submitted to the department, and we had help from the procurement business strategy as well as from our management team, which helped to put the case together, which was then approved by the department and we started prospectively collecting data on stent removals using Isiris α. This was audited and then submitted back to the department to satisfy the quality and safety committee that this was a very safe procedure, after which it was approved for clinical use”.
