Improving interdepartmental communication to avoid forgotten ureteric stents

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David Maudgil

There are some very serious risks associated with forgotten ureteric JJ stents. David Maudgil, a consultant interventional radiologist at Wexham Park Hospital, Frimley Health Foundation Trust (Slough, UK), outlines why and when these devices are used, explains the risks a forgotten stent might pose and provides some guidance on how to mitigate such risks.

Interventional radiologists routinely place large numbers of ureteric JJ stents, for a number of different indications including ureteric blockage or ureteric injury. This is often when retrograde attempts have failed or when there is no available retrograde route from the bladder. The patients who require this come from a wide range of non-urological or nephrological specialties, particularly general surgery, gynaecology and medicine, but will usually require follow up and change of the stent by urologists within three to six months.

Ureteric JJ stent

If the stent is not removed or changed in a timely fashion, there is a high risk of encrustation of stone material around the stent which may not only block the stent but also make it extremely difficult to remove without damaging the kidney, ureter and bladder. There is also a small risk of the stent fracturing within the ureter, causing acute blockage with probable added infection. For these reasons, a forgotten ureteric stent constitutes a “never” event and a serious untoward incident (SUI).

Although guidelines and procedures exist for routine monitoring and change of stents placed retrogradely (by urologists), we did not have a robust system for handing these patients promptly to urology for follow up of their stent (see Box 1 for Healthcare Safety Investigation Branch [HSIB] guidelines).

Box 1 – The UK HSIB published its report: Unplanned delayed removal of ureteric stents in October 2020. They made the following safety recommendations:

Safety recommendation R/2020/091:

 

Relevant specialties to develop national standards which support electronic and paper-based systems for stent logging/ tracking. These standards should include guidance on monitoring and human oversight.

 

Safety recommendation R/2020/092:

 

Review stent patient information leaflets. This should include accessibility and clinical considerations, especially with regards to side effects and complications, and advice on the action to take should concerns arise.

 

Safety recommendation R/2020/093:

 

Provide guidance for staff working within the stone care pathway to promote consistent advice to patients as part of discharge planning.

 

Safety recommendation R/2020/094:

 

Include information in discharge letters and other communication sent to GPs and patients regarding patients’ stent status, potential complications and the possibility of a retained stent.

 

We performed an audit showing that of 50 patients in 2019 who had antegrade stents inserted (67% as emergency admissions), 40% subsequently had stents replaced retrogradely, 45% removed, and 15% had extra-anatomical stenting or died before readmission. The mean time from stent insertion to planning removal was 13 days, which appeared unacceptably long and increased the risk of the patient being lost to urological follow up.

These findings were discussed at a joint interdepartmental meeting and we agreed that a logbook should be kept where all antegrade stents would be recorded. Moreover, a standing item at the weekly uroradiological meeting was discussion of every antegrade stent insertion and formulation of an agreed plan for urology to follow up the patient.

Subsequent re-audit three months later showed that all patients had been discussed in a timely manner with mean interval from stent insertion to planning removal reduced to 3.3 days. It was clear that interdepartmental communication regarding these patients was much improved, and that a safe system of working had been developed. This audit, with subsequent significant improvement after discussion, was presented at the the BSIR Annual Scientific Meeting 2021 (8–10 December, Glasgow, UK).

David Maudgil is a consultant interventional radiologist at Wexham Park Hospital, Frimley Health Foundation Trust (Slough, UK).

Relevant disclosures:
None

References:
https://www.hsib.org.uk/investigations-and-reports


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