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Sam Chang: Hi everyone, my name is Sam Chang. I'm a urologist in Nashville, Tennessee and I have the great honor of actually sharing a informational video series discussion with Tara Cumming and Meredith Donahue. Tara and Meredith are both nurse practitioners that focus on urologic oncology and they were the ones responsible for establishing actually a much more efficient system and patient friendly system at Vanderbilt for those patients receiving instillation therapy for bladder cancer. And I thought it was very important to include some of our advanced practice providers because they're the ones who established the entire system, who have made it run, and have made it run quite efficiently.

So Tara is currently working in San Antonio with the Texas Urology Group and Meredith is currently working at Vanderbilt in the urology group there. Tara was the recipient of the traveling award that's given to Beacon. It's a very selective award for certain actually advanced practice providers every year. So she was just recognized just a couple years ago. So we have two real experts and two people that I've depended on actually much in the past. So I think we have a few slides to share. Is that right, Meredith?

Meredith Donahue: Yep. So I will start sharing and then Tara's going to get us started.

Tara Cumming: Great. So starting out here, just talking in general about what we endearingly call the BCG Clinic at Vanderbilt. So it was one day of the week, which is a pretty unique model for I'd say most urology clinics after talking to some other APPs at different meetings. This isn't really the way it's done at a lot of groups. So everybody at Vanderbilt comes in a Friday afternoon for their treatment, and we'll talk about benefits of this model later on in the talk, but it's really nice to just have them all together on that afternoon and cluster everything, and that's from clinic staff standpoint as well as a pharmacy too.

But our flow on that afternoon is patients come in, they'll get vital signs, they'll leave a urinalysis. When we're ready with medicine, then they will come back to the room. They'll be catheterized by a nurse or an LPN and then the NP will come in and instill the medication, catheter is removed, and then patients given instructions on how to hold the medication and then they will go home. So that is the rundown for our clinic, but Meredith has a good video that she came up with recently to help with patient education, so I'll let her go onto that.

Meredith Donahue: We're just going to show the portion of the video that explains how our clinic works, how it flows. But the whole video, A, explains the diagnosis and why they're getting intravesical therapy as well as side effects to expect and how to manage those side effects. So I will jump to, like I said, where we talk about our actual clinic.

Sam Chang: Well, looking forward to this video, Meredith. Let's take a look.

Meredith Donahue: Talk with you about what to expect when you come here for your first bladder cancer treatment and things to expect down the line as you continue to get your treatments. Initially what we're going to start with is talking about the process. So you'll come into our clinic, we'll have you leave a urine sample, you'll go back to the waiting room. We need to check your urine to make sure you don't have any signs of infection. Once we see that you don't have a urinary tract infection, then we'll mix your treatment. Once the treatment is mixed, we'll get you back to your room and we'll have you undress from the waist down. Once you're settled in the room, the nurse will come in and she will place the catheter into your bladder. We'll drain your bladder completely so you won't have any urine in your bladder, and then I'll come in and I will put the treatment into your bladder. Then the catheter comes out and we're all done.

After your first treatment, we have you get cleaned up and have you sit for about 10 or 15 minutes just to make sure we don't have any reactions that we're not expecting. For the rest of your treatments, it'll be the same process, but you won't have to wait for those 15 minutes. Some things to tell us...

All right. So as I explained in the video, just the process, and as Tara explained the process, there are a lot of logistics in organizing and planning a clinic like this. First one is working with our pharmacy. Fortunately at Vanderbilt, we have some pharmacists that we can work really closely with to make this happen. For our BCG, that comes to us pre-mixed and we mix that in the clinic right before the BCG Clinic starts. For all other intravesical therapies, those come to our clinic already mixed and ready to instill.

Other logistics that we've had to figure out, and some trial and error to figure out, is staffing. At Vanderbilt, we're seeing about anywhere from 30 to 40 patients receiving intravesical therapies each week. So obviously that requires a lot of staff and a lot of support help. Of course, our front check-in folks, they're getting the patients checked in, getting them to the bathroom to leave their urine sample. And then of course our nursing staff, because we require about five to eight nurses depending on our numbers to work up the patients, bring the patients back, get them catheterized, and all the steps in between.

Some benefits from this model. I think this is a really powerful way to give intravesical therapies for both the patients and the providers. So this is, as we mentioned, a nurse practitioner run clinic. I think a lot of facilities will do RNs giving the treatment, but here, nurse practitioners give the treatment.

Benefits of this is, multiple. I think there are multiple benefits. A big one is side effect management. I think just about every patient experiences some sort of side effect. A new process that I've developed in this is before the patients even start their treatment, everyone has a prescription waiting for them at their pharmacy for oxybutynin and pyridium, because two of the most common side effects are frequency, urgency, and burning. And that way before they even come in for their first treatment, they can get started on the oxybutynin to help calm the bladder down. Always will have a difficult foley catheterization that a nurse can't get, needs help with, and having an NP there to help navigate.

Also with having a NP run BCG Clinic, we're always sending cultures and someone has to follow up on those cultures. We may need to check a BMP, CBC, whatever it may be, whatever our doctors need, and the nurse practitioner can follow up on all those. I put here patient and provider satisfaction. I think the patients really appreciate having a point person to go to in regards to their treatment, and someone that they're getting to see every week and build a relationship with. And likewise, provider satisfaction. I think it's helps to take a load off of our doctors not having to receive all of the urines or urine cultures or all the messages about their having frequency, urgency, they feel like they can't empty their bladder. The nurse practitioner can manage that and take that load off of our physician colleagues.

Tara Cumming: Just to add in there, just some other models that I've seen where patients come in maybe just in the middle of an NP schedule or in the middle of an RN's day, and that can just logistically really mess up their schedule. But also before the BCG shortage, we would be wasting BCG essentially. So if a patient only required a half dose of treatment or a third dose, then the rest of that would be wasted. So here when we batch all the patients together, we're able to split the doses more efficiently.

The other models that I've seen, particularly here in Texas, is that they do their BCG in a nurse infusion center. And that's great because you have these nurses who are really familiar with giving chemo and the precautions associated with chemo. But like Meredith talked about, side effect management specifically to urology is something that NPs in urology are a little more familiar with. So oxybutynin is a great way to manage your symptoms, but if you have a gentleman who has a really big prostate, oxybutynin could send someone into retention. So those kind of things I think help with when it's run by a urology NP.

Sam Chang: Great. So I just want to chime in by saying this has been, I think, a huge advantage for our patients as they get care. So to me, some of the key takeaway points are the educational video, which again was the idea of the nurse practitioners and the providers in terms of putting that together. And that's available either by a link or by our QR code, which I think is fantastic for every patient who has never had an instillation before, or even those who have had instillations but never been to Vanderbilt to understand the process. I think that's great. In terms of the efficiency, being able to utilize those rooms and not interrupting the workflow, I think, are fantastic. Tara, how many patients do you think within an hour in one room can you all do an intravesical instillation?

Tara Cumming: In a three hour period we could do anywhere, when I was there, 25 to 30 patients. I think Meredith has really ramped that up, and that's just a matter of getting our staff familiar with the whole process. And when you have staff that are well trained and really familiar, then everything runs a lot smoother.

Sam Chang: Right. And how many rooms do you then dedicate for those instillations?

Tara Cumming: Historically it was five or six.

Sam Chang: Five or six, okay. All right. And then during that time period, though, just in a few hours, you're able to basically complete therapy for 25, 30, 30 plus patients. Is that right?

Tara Cumming: Correct.

Sam Chang: And then with that, I also noticed this sense of relationship that patients have with other patients. As they wait in the waiting room, there's conversations, they become friendly, but they also exchange, "I'm having this side effect on this. This might help." Et cetera. Have you all noticed that as well? They've at least mentioned that to me.

Meredith Donahue: Definitely. And it always makes me smile to see them make friends and get to share. They're all sharing this experience of having a really scary diagnosis and getting to connect and share. Somebody might have had a lot of frequency, urgency and I put them on oxybutynin and the next person might be scared to say something, but their new friend in the waiting room can encourage them to speak up and talk about these things.

Sam Chang: So I'm going to ask you guys just the one or two key takeaway points of advice as other clinics consider doing a model like this. So Meredith, what were some of the one or two key points of making this successful? Because this started not from the get go day one smooth machine. It took some time. So how about some key points?

Meredith Donahue: Definitely. Training your staff is definitely a big one on to keep the flow moving. And whether that be your intake, who's doing the intake... Because it starts with them in keeping things moving, but also training staff on appropriate catheterization and how to be efficient in that. Probably staff training is the big one, I would say. And start small.

Sam Chang: And start small. Tara, how about you? Any thoughts?

Tara Cumming: Yeah, I agree with Meredith as far as staff training, but also having a good relationship with your pharmacy. Because at the end of the day, they're going to be the ones that need to deliver medication in a timely manner, so making sure they understand also the size of the role they play in the process for it all too.

Sam Chang: Well, I want to thank both you all very, very much in terms of the initiative that you all took as you started seeing the need for this and the disruption of having patients come at different times. That Friday day, I think, is also a good day of in terms of, "Okay, patients understand." I tell patients upfront, "Your treatments are going to be Fridays." And it just makes things run more smoothly. And then the awareness and the experience that you all have and that you've developed. In terms of symptom management, side effect management, you all understand better of times to delay treatment and when not to and get us involved when we need to. I think it's really a model that I think may prove helpful to others. And I'm sure others may want to reach out to you all and have any questions. And if so, we'll make sure to pass on your contact information.

All right. So Tara and Meredith, thank you so much for sharing some time with us and sharing your experience with us regarding your initiatives in having an instillation clinic that's done weekly and really done actually quite efficiently. So thanks to you both.

Tara Cumming: Thank you.

Meredith Donahue: Thank you.