A Care Bundle to Improve Perioperative Mitomycin Use in Non-Muscle-Invasive Bladder Cancer – Beyond the Abstract

There is good quality evidence that instillation of a chemotherapeutic agent such as mitomycin into the bladder within twenty-four hours of an initial transurethral bladder tumour resection reduces the rate of recurrences and prolongs recurrence-free intervals in patients with non-muscle invasive bladder cancer. Most guideline panels recommend this practice. However, despite this evidence and recommendations, there is considerable disparity in the actual use of intravesical chemotherapy amongst urologists. The reasons are manifold and include lack of awareness of the benefits, non-availability of the drug, delay in procurement from pharmacies, fear of side effects and complications, reimbursement issues and wariness of deep resections leading to extravasation.

In our hospitals, we use mitomycin for intravesical chemotherapy after initial resection of bladder tumours. We found a similar lacuna in the frequency of use of intravesical mitomycin in our hospitals.

The Institute for Healthcare Improvement (Cambridge, MA, USA) has demonstrated the utility of care bundles in a variety of healthcare settings when bundle guidelines are meticulously followed. Therefore, to improve compliance with the use of intravesical chemotherapy, we devised a care bundle to help urologists become complaint with intravesical mitomycin. We initially carried out a root-cause analysis to identify causes of non-compliance. Based on this knowledge, we trained stakeholders in improved prescription practices as well as on-table mitomycin instillation. Our pathway consisted of key steps to address gaps in our practice and comprised of a stepwise approach to prevent oversight. Towards this, we incorporated the various tasks into the patient’s electronic medical records (EMR) and trained theatre personnel to use a check-list approach to help drive compliance. Personnel were trained by certified chemotherapy nurses in the safe delivery of intravesical mitomycin instillations both by ex vivo instruction and supervised practice on patients. Finally, the discharging clinicians were instructed to reinforce this information on the EMR to make this information available to the patient’s primary care provider. Additionally, the care bundle steps were frequently reinforced during team clinical governance meetings and compliance with the bundle audited at random periods annually.

Subsequent audits showed much-improved compliance with the use of intravesical mitomycin by following the care-bundle. We make a case that a care bundle approach helps teams achieve compliance with intravesical mitomycin use where it is indicated.

Written by: Deepak Batura, Department of Urology, London North West University Healthcare NHS Trust, Harrow, London, UK

Read the Abstract