AuditAuditofof

Bladder filling for pelvic Bladder filling for pelvic ultrasoundultrasound

byby

Kumbulani ZhouKumbulani Zhou

WhyWhy

continuation of audit cyclecontinuation of audit cycle

last audit October 2004last audit October 2004

commitment to quality scanningcommitment to quality scanning

problemproblem

workflow severely disrupted workflow severely disrupted

time is wasted; for patients & stafftime is wasted; for patients & staff

end up working under pressureend up working under pressure

cannot rule out suboptimal examinationscannot rule out suboptimal examinations

impactimpact

can range from staff inconvinience can range from staff inconvinience to compromised patient diagnosisto compromised patient diagnosis

aimaim

achieve 100% full bladders at achieve 100% full bladders at scanning timescanning time

obviate internal scans where possibleobviate internal scans where possible

increased patient throughputincreased patient throughput

Why full bladderWhy full bladder

•texture of the myometrium to be appreciated and any texture of the myometrium to be appreciated and any

abnormality, e.g. fibroid can be picked up.abnormality, e.g. fibroid can be picked up.

MethodMethod

Patients gently asked about Patients gently asked about instructions and bladder fillinginstructions and bladder filling

Excluded patients brought in scan Excluded patients brought in scan room room ±15min outside appointment ±15min outside appointment timetime

84 patients June-July 200684 patients June-July 2006

ResultsResults

48

36

71

7

0

10

20

30

40

50

60

70

80

full not full read R-advice

No

patie

nts

Series1

CommentsComments read parking instructions onlyread parking instructions only comes every year so she new what was expectedcomes every year so she new what was expected 2 expecting internal scan- Y3 UKCTOCS patient2 expecting internal scan- Y3 UKCTOCS patient thought she needed to starve –abd/pelvisthought she needed to starve –abd/pelvis

One could not get full at all – hot weatherOne could not get full at all – hot weather unable to tolerate very full bladderunable to tolerate very full bladder did not get appointment letterdid not get appointment letter bursting told no one, emptied – filling againbursting told no one, emptied – filling again one patient waited 2h, did not want internal scanone patient waited 2h, did not want internal scan 2 no obvious reason2 no obvious reason

Has bladder filling Has bladder filling improved?improved?

What happened to those who What happened to those who were were

not full?not full?

1

16

20

0 5 10 15 20 25

re-appt

internal

wait 20+

No. patients

Series1

Analysis of the internal Analysis of the internal scansscans

int.-clin.ind. 12

unfilled 4

not want 3

int.-clin.ind. unfilled not want

SuggestionsSuggestions

Fog Index:Fog Index: Score: 8.8 Recommended score:7/8Score: 8.8 Recommended score:7/8 The water must be finished 1h before The water must be finished 1h before

your appointment time.your appointment time. Make sure your bladder is full for the Make sure your bladder is full for the

scanscan You must finish 4 glasses of water at least You must finish 4 glasses of water at least

one hour prior to the procedure.one hour prior to the procedure. Do not empty your bladder.Do not empty your bladder.

SuggestionsSuggestions

Reception:Reception: ask degree of filling on arrivalask degree of filling on arrival

encourage bladder filling straight encourage bladder filling straight awayaway

ascertain extent of filling before pt is ascertain extent of filling before pt is brought into scan room (e.g.tick box)brought into scan room (e.g.tick box)

SuggestionsSuggestions

techniquetechnique:: ? internal only scans? internal only scans PCOs, endometriumPCOs, endometrium ∆ ∆ large pelvic tumours can be large pelvic tumours can be

missed if only internal scans carried missed if only internal scans carried outout

resolution of hfp only good up to 60-resolution of hfp only good up to 60-80mm (www.ebm-guidelines.com)80mm (www.ebm-guidelines.com)

EndEnd

When asked if they feel that their When asked if they feel that their bladder is full, such patients will bladder is full, such patients will show the practitioner the water show the practitioner the water bottle and typically say ‘I have drunk bottle and typically say ‘I have drunk all that’. Some will say ‘I hope so!’ all that’. Some will say ‘I hope so!’

Lerski (1988) and Zaidi (1996) both Lerski (1988) and Zaidi (1996) both agree that an insufficiently filled agree that an insufficiently filled bladder is the cause of a large bladder is the cause of a large number of mistakes in pelvic number of mistakes in pelvic ultrasoundultrasound

It is highly recommended to always It is highly recommended to always reinforce information that had reinforce information that had already been given. No assumption already been given. No assumption should be made that the patient has should be made that the patient has read it.read it.

provide information pertaining to provide information pertaining to importance of full bladderimportance of full bladder,,

correcting any inaccuracies correcting any inaccuracies

Practitioners should not suffer ‘burn Practitioners should not suffer ‘burn out’ from constantly juggling patients out’ from constantly juggling patients

Patients themselves should not suffer Patients themselves should not suffer long waiting times long waiting times