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Urology Referral Pathways

Referral

The first point of contact for urology advice and referral is the general surgical SHO. This is the on-call surgical SHO carrying the on-call bleep. Some of the on call general surgical SHO have a urology background.

If a time critical emergency such as torsion is presenting, then the first point of contact should be the urology registrar.

In the case of Urological/Surgical emergency

  1. Refer directly to Middle Grade on-call
  2. If Middle Grade unavailable/uncontactable – Contact speciality consultant on-call
  3. If NO senior available – inform ED senior
    • Admit directly (admission rights) to SAU/Ward 4 HRI
    • Attempt to contact surgical SHO (to inform)

(agreed with both surgical and urological leads)

 

Under 3’s go to Leeds

Urologist are happy to operate on patients over the age of 3 years old. Under the age of 3 if this on a urological emergency such as a torsion then this patient should be referred to Leeds paediatric urology services.

Streaming

Any patent with a post op complication for up to 7 days form urological procedure – should be streamed directly to the urology team via the surgical SHO. If the patient is unwell and needs resuscitation and immediate management for example sepsis, then ED team needs to be involved in resuscitation measures and the urological registrar needs to be involved as well

Pyelonephritis

Currently ALL Pyelonephritis should be admitted under the urology team. There is a conversation between urology and medical teams happening currently to see if that requires further rationalisation. However currently the position is all pyelonephritis patients who need admitting are done so under the urology team.

  • Uncomplicated pyelonephritis – does not require CT scanning or ultrasound scanning from the emergency department.
  • Suspicion of an obstructive uropathy –  CT KUB needs to be arranged from the ED

Investigations including:

  • FBC
  • U&E, CRP
  • Blood Cultures
  • Urine cultures

Appropriate Antibiotics should be prescribed using the current antibiotic guidelines.

Renal Colic

CTKUB are now available 24/7.

Patient presenting >50 years old  with a renal colic story, should have a ultrasound scan done at the bedside to ensure that there is no aortic aneurysm before being sent for a CT KUB.

Uncomplicated renal colic needs a non contrast CT scan. This should be organised by the ED

Uncomplicated renal colic patients can wait CT KUB for  results on SDEC. (The case must be to be discussed with the surgical SHO on-call and accepted by them before transfer of the patient. SDEC closes at 6 pm)

Haematuria

All frank hematuria needs investigation

  • Admit + 3-way catheter – those at risk of clot retention and shock 
    • Hb <100
    • Post void bladder scan>250 ml 
  • All those discharged: will need a OPD cystoscopy arranged as well as a USS (the request for flexible cystoscopy on EPR is Urol Cystoscopy  post Wd Dis)
Catheters

New catheters and catheter complications – follow current guidelines. Community nurses follow up for TWOC or other catheter care (HOUDINI team in Kirklees)

Massive Transfusion Pathway

In the case of patient with Massive Haemorrhage weather that be from Trauma, Surgical, O&G, UGIB, you can activate the MTP

Remember:

  • Do the Basics – don’t forget ABCD
  • Inform Transfusion and get someone to run a G&S sample down
  • FFP can take up to 45min and platelets come from Leeds
  • If you no longer need the MTP – inform transfusion and return products ASAP
major haemorrage

PDF:MTP

 

2. HAZMAT – Suspected Contamination Incident

So a patient comes to ED after white powder thrown is at them what do you do? Your initial response can help them and everyone in the department!

  1. Ask them to leave the department
    • Going to garage was useful
    • Inform Nurse in Charge and Consultant
  2. Dynamic risk assessment
    • Performed by nursing/medical staff while outside
  3. Decontaminate
  4. Return to ED

If you haven’t seen the Initial Operational Response (IOR) training video please watch it.

The patient can then be thoroughly assesses, to identify the substance involved (this may involve witnesses, police info and symptomatology), and treated appropriately.

Police should be informed of the incident for several reasons: 1. Public safety, 2. To collect the evidence and possible find out what it was for you. (if this is not a criminal act Public health England can advise on return/disposal of personal effects)

Inform Manager On-Call of incident as it may disrupt the functioning of ED and can provide support.

 

Patient symptom-free and substance unknown

In our recent case Public Health England advised

  • 4-6hr observation
  • Discharge with advice:
    • “if developing symptoms to return to the ED via ambulance but the patient must be aware that they must inform 999 of the original exposure.”

Resourses