Unplanned delayed removal of ureteric stents

We agree with the HSIB recommendation that the insertion of a JJ stent should be a clear part of the operation note and discharge summary. In addition, we agree that some form of localised stent tracking is mandatory, but in the absence of a centralised NHS digital solution for tracking temporary implantable devices (such as stents and catheters), it is difficult for BAUS and partner organisations to develop consistent national standards. We recognise that trusts across the country employ a range of mechanisms to track ureteric stents currently, and that these vary in terms of the human oversight required as well as in their integration with existing electronic patient care records. As a minimum standard, we suggest that: Reasons for, and details of the ureteric stent insertion are clearly recorded in the operative record, or on a specific proforma which is to be attached to the patient’s notes. All urology departments have a system in place to track ureteric stent insertion, change and removal, although we recognise that at present, the format of such tracking systems will vary. Human oversight of the stent database is essential at present as there is no standardised IT solution which will alert the clinician to an overdue stent exchange or removal. Clinicians and administrative staff working within urology should be allocated time in their job plan to allow oversight of such a database, which represents a considerable amount of work. Urologists should liaise with other colleagues who insert/manage patients with ureteric stents (principally radiologists, oncologists, transplant surgeons and gynaecologists) to ensure all patients with stents are monitored appropriately regardless of the clinical setting. Response received on 12 December 2022.

This point has been addressed by the new BAUS patient information leaflet (PIL) (“Living with a stent”) published in 2021. The PIL has been updated with all the relevant information regarding stent symptoms, and now includes a section at the back of the leaflet which is to be filled in and given to the patient upon their discharge. This will provide patients with individualised information regarding their intended stent dwell time as well as with contact information for the relevant clinical team members. We hope that this improved PIL containing bespoke information will empower patients to take a role in shared-care of their stent as highlighted in the HSIB report. We would be very pleased to send the stent-related PILs to the Patient Information Forum for their comments and feedback. Response received on 12 December 2022.

In addition to the standardised information about stents in the newly updated BAUS PILs as detailed above, we have incorporated stent information as part of the BAUS Endourology/NHS GIRFT acute stone pathway, which was published last year. This GIRFT pathway emphasises the importance of primary treatment of obstructing stones unlikely to pass spontaneously (ideally within 48 hours) by means of extracorporeal shockwave lithotripsy (SWL) or ureteroscopy (URS). The pathway contains exemplars of best practice to demonstrate how this aspirational target can be achieved, including utilisation of urology area networks (UANs) to ensure patients have rapid access to necessary treatment. By encouraging the primary treatment of ureteric calculi, it is hoped that fewer “temporising stents” will be inserted in such patients over time. Information regarding the GIRFT acute stone pathway has been disseminated widely at both the Section of Endourology annual meeting in October 2021 as well as at the main BAUS congress in 2022. We would encourage all urology units to continue to develop their localised pathways using the GIRFT best practice examples to guide them. Response received on 12 December 2022.

We agree with this recommendation, and we would encourage that information regarding stent insertion and follow up is detailed clearly in the operative record. We have concerns that discharge information may already be long and complex, and information regarding stents is only one aspect that may need to be communicated to the GP. Due to variance in hospital IT systems, it is impossible to implement a digital “flag” which will be applied uniformly the NHS. As a minimum standard, we feel that GPs should be made aware of the following information on discharge letters/summaries: the reason for the insertion of the J-J stent the intended stent dwell time and whether it is intended that it will be removed or changed. We would suggest that all discharge information should be copied to patients and/or their carers. An example of a standardised discharge pro-forma that could be sent to GPs. Time will be needed for busy GPs to ensure that this information is read and understood, and education programmes will be needed to help GP practices appreciate the similarities in symptoms of UTI and those that might be more directly attributable to a JJ stent. Urinalysis (ideally formal microbiological culture rather than dipstick analysis) should be encouraged before patients are started on empirical antibiotics, unless they are febrile or otherwise systemically unwell. Response received on 12 December 2022.