A urology day unit: flow-through and bottle changing

Twenty-two patients before noon, one sluice, and a list that runs cystoscopies back to back at fifteen-minute intervals. Every patient arrives with a full bladder because the procedure needs one, and every patient leaves having voided between 300 and 500 ml, sometimes more, sometimes with blood in it. The bottles stack up faster than anyone can gel them.

Day-unit flow is a different problem from ward flow. Nothing stays put long enough to be dealt with later, and the space between patients is measured in minutes.

The bottle that fills before it is emptied

A two-litre specimen bottle with a 28 mm neck is designed for transport, not for gelling. Powder goes in, floats, skins over, and the gel forms a plug somewhere below the shoulder. The next patient’s sample then cannot go in without breaking the plug, and breaking the plug releases free liquid into a bottle that is already three-quarters full.

The result, in more units than you would expect, is a shelf of half-gelled bottles with the lids loose, waiting for someone to deal with them at the end of the list. That is the point where the smell starts and where the porter starts refusing the trolley.

Dose small, dose often

The instinct on a busy list is to let bottles accumulate and gel them in a batch at the end. That is exactly backwards. A 300 ml sample gelled at the point of collection takes 8 g and sets in under a minute. The same sample left for two hours needs more powder, more stirring and a longer wait, because the urea has already started doing what urea does.

Put the sachets on the sluice bench, not in a cupboard. If the powder is more than three steps from the sink, it will not get used during a list.

One day unit we visited had solved this by putting a small wall rack beside the sink with four sachets and a laminated strip showing three volumes. The nurse gelled each bottle as she passed, before the next patient was called, and the end-of-list backlog disappeared within a week. Total cost: about eleven pounds for the rack.

Changing bottles mid-stream

Some patients produce more than a single bottle holds, particularly after a hydrodistension or with a post-obstructive diuresis. The question is whether to swap bottles mid-flow or fit a larger container. Swapping is usually right, but only if the second bottle is already labelled and within reach, because nobody wants to be holding two containers and a torch.

Label both bottles with the same patient identifier and the sequence number, then gel each one separately. Do not pour the first into the second to consolidate. A gelled bottle cannot be poured, and an ungelled one that has been decanted loses the volume mark you were relying on for the dose.

Blood changes the calculation

Visible haematuria is common on a day unit and it does affect the set. Blood adds protein and cells that the polymer does not absorb, and a heavily bloodstained sample will produce a gel with a darker, wetter texture at the same dose. It still sets, but it sets more slowly and holds less.

The workable rule is to add a third more powder when the sample is visibly pink or darker, and to give it an extra thirty seconds before the lid goes on. Do not double the dose; a bottle of over-dosed gel with blood in it becomes a rubbery plug that is difficult to empty and looks alarming to whoever handles it next.

The bench itself needs five things. A marked jug for estimating volume, four sachets in reach, a stirrer that is not a thermometer, a lidded transport bin, and a laminated card with three numbers. Four items and no extras. The application guide has the volume table if you want to print your own card rather than write one from scratch.

If your list runs more than fifteen patients a session, time one bottle from collection to lid. If it is over four minutes, the bench is in the wrong place, and moving the sachets closer will do more than any change of product.

Try it on the next list and count the bottles left at the end. That number is your baseline.