Improved access to ultrasound and one stop testicular clinic

Background

Since half the population of East Suffolk is actually within a four mile radius of the Ipswich Hospital, our clinic was proposed to provide dedicated ultrasound and sonographer services within the hospital shared by primary (direct access) and secondary care. The aim was to provide GPs with a means of speedy access to diagnosis for patients with testicular conditions through the provision of a one stop clinic.

The joint sonographer and nurse specialist service aimed to offer the following benefits:

• The patient would have a consultation, ultrasound scan, be reviewed with results and where necessary, an agreed management plan on a same day visit;

• The patient could be educated on testicular/scrotal conditions, self-examination and be given information/sent literature where appropriate;

• Reduction in the demands placed on outpatient clinics and Diagnostic Imaging Department;

• Reduction in the number of patient visits to the outpatient department, Diagnostic Imaging Department and GP surgeries;

• Financial savings to the Hospital Trust by reducing transport costs for clinic visits;

• Patient has convenience of one stop service; and

• Reduction in clerical and administrative time.

GPs were to be made aware of the service and asked to make referrals for patients requiring investigation into testicular/scrotal conditions to the appointed clinic on the appropriate referral form.

What is the problem you are trying to solve?

Previously, GPs in East Suffolk were able to refer a patient directly to the Ipswich Hospital Trust Diagnostic Imaging Department for a testicular ultrasound scan but there was often a considerable delay before the scan was performed. GPs were informed of the result by fax or mail and the patient might be required to return to the surgery for the result. Any secondary care opinion/involvement then needed to be arranged, resulting in further delay for the patient. Patients with testicular/scrotal conditions who were initially referred directly to a senior urologist and seen in the outpatient clinics might be sent to the Diagnostic Imaging Department for an ultrasound scan and return to the clinic for results and discussion of future management. This process involved the patient attending two different departments on three occasions, in addition to their initial GP visit. This secondary care process might be undertaken on the same day if there was a high indication or suspicion of malignancy. Alternatively, patients might be informed of the result by letter, thus causing the whole process from referral to diagnosis to be a lengthy one.

These systems were neither providing a good quality service for the patient nor utilising health resources efficiently. We therefore set out to redesign the pathway for this patient group in order to achieve a more rapid and simpler route to diagnosis and possible treatment.

Our aim was to establish a new dedicated protocol based service for patients with testicular/scrotal conditions who require an ultrasound scan. The service was designed to provide:

• Examination of suitable patients with testicular/scrotal conditions and provide feedback to the referring clinician;
• Advice on symptomatic problems;
• Access route for further required interventions; and
• Referral to and liaison with other multidisciplinary team members regarding social, physical and psychological issues.

What local organisations are involved?

The service is run in secondary care but is set up as a direct access primary care “owned” service. The project was an element of the East Suffolk Action on Urology Project.

How many people are running this project and who are they?

The service is run by Sue Scurrell, urology nurse specialist, and a sonographer.

What local population are you targeting?

Any adult male referred from East Suffolk primary care services.

How many people are you targeting?

Initially around 50 patients per month

Interventions

What interventions are you using to address the problem?

A new nurse specialist was appointed and trained in testicular examination, and protocols were developed with the urologist and sonographers. In liaison with the radiology department, a sonosgraher was recruited to work with the nurse specialist within the urology department. The new process was initiated with one clinic per week with the view to expand the service to three clinics per week. At the moment we are running two.

Men who are referred by their GP for investigation for a testicular/scrotal condition are now reviewed in a joint sonographer and urology nurse specialist clinic. This is a rapid access clinic with the service provided entirely within the Urology Department. The service runs concurrently with established urology outpatient clinics where a consultant urologist is in attendance and is available to offer immediate clinical review.

Is the project design based on evidence? If so, please state reference.

Prompt access to ultrasound is agreed as being the greatest benefit in providing patients with a diagnosis for their urology condition in both primary and secondary care ^{1 2 3} .

Outcome

What outcomes or planned outcomes are you measuring?

The number of patients accessing service and waiting times

Do you have any outcomes or results yet? If so, what are they?

• Waiting times at December 2004 were below five weeks.

• Within urology, it has enabled ultrasound scans to be undertaken as needed in clinics when a sonographer is present, rather than booking patients a separate appointment for the scan;

• Testicular patients are seen rapidly;

• One visit now replaces three;

• Consultants can access ultrasound within their general clinics resulting in rapid diagnosis for other patients;

• Capacity within general ultrasound is now available for other patients;

• Ease of referral for GPs;

• Faster diagnosis for patients presenting with testicular conditions.

Is your project relevant to a government target or guideline?

The two week cancer outpatient waiting time standard ⁴ , and the 18 week referral to treatment target ⁵ .

Feedback

What obstacles did you have to overcome to set up this project?

It was extremely difficult to recruit a sonographer due to a shortage of qualified staff. This delayed implementation by nine months. Although we persevered with the recruitment of a sonographer this would not be practical on a general basis for other hospitals until there are sufficient sonography skills available to deliver this type of service. We are currently investigating the development of other professional groups in the provision of testicular sonography.

There has been a huge increase in demand since we have introduced the service, requiring greater resources than originally planned. We have had to run extra sessions to maintain a reasonable waiting time. The reasons for the increase in demand are unclear although it may partly be due to increased awareness and ease of referral for GPs.

What have you learned about the project so far?

For patients categorised as low risk but who are found to have cancer, this faster diagnosis potentially improves prognosis. Treating patients more quickly also reduces the risk of clinical complications.

What would you do differently?

Nothing

References:

1. Resnick MI, Sanders RC. Ultrasound in Urology. Williams and Wilkins: Baltimore/ London. 1984.
2. Polák V, Horňák M. Department of Urology, Komensky University Medical School, Bratislava, Czechoslovakia. Received: 23 August 1989.
3. Arger PH, Mulhern CB, Coleman BG, Pollack HM, Wein A, Koss J, Arenson R, Banner M. Prospective analysis of the value of scrotal ultrasound. Radiology. 1981; 141: 763-766.
4. Department of Health. The NHS Cancer plan: a plan for investment, a plan for reform. 2000. www.dh.gov.uk (search for 22293, accessed 26 April 2007).
5. Department of Health. Tackling hospital waiting: the 18 week patient pathway – an implementation framework and delivery resource pack. 2006. www.dh.gov.uk (Search for 6468, accessed 26 April 2007).