Dr. Krupski on the development of a tele-cystoscopy program


“The 1 tweak that's different for our model is that the trained urologist is watching the cysto at the same time as the nurse practitioner is doing it,” says Tracey L. Krupski, MD.

In this interview, Tracey L. Krupski, MD, discusses the development and implementation of a model for tele-cystoscopy at the University of Virginia (UVA). Krupski is a professor of urology and the division chief at UVA in Charlottesville.

Video Transcript:

What was the rationale behind developing this program at your institution?

As a rural academic medical center, we have patients who come from 5, 6, 7 hours away. I was in clinic and 1 of these patients was coming from rural Appalachia, just for a cystoscopy. This was actually pre-COVID. I thought to myself, "This seems weird. You can do FaceTime; you can do WhatsApp; you have all these video applications. Why couldn't we do cysto closer to where they live and see if there [is] some way to operationalize that?" So, that was the impetus, that people were driving a long way for, essentially, a 5- or 10-minute exam. We ended up getting pilot funding from our population health center here for what we termed tele-cystoscopy. This ultimately created pilot data that we [used to] obtain an American Cancer Society research investigator grant. That's what allowed us to pursue this work. We ended up finding, through patients of mine, 2 sites in Saltville and Wise, Virginia, which are about 3.5 and 5 hours away from Charlottesville respectively.

How did you and your team implement this model?

Cystoscopy by nursing is not new. This has been done in Australia, it's been done in Britain, and the British Association of Urologic Nursing, or BAUN, had done a ton of work in this, assessing competency and creating a whole diagnostic manual. That was our foundation. We used that to do our own training program for 3 nurse practitioners here at UVA. Then ultimately, the vision was to train the nurse practitioners who live and work in these areas to do the cystoscopy. Now, that's what was funded in the grant. And I'll circle back, but that's a little bit of a hurdle. We realized that you could train [them,] just like in Australia and Britain and the other institutions. You can train them to do it, but the physical aspects of it are much more trainable than the interpretation aspects. This has been shown in different abstracts, when you look at that, or papers from Britain, that knowing what you're looking at, that experience component of being a trained urologist who has looked in thousands of bladders, is what's missing. The 1 tweak that's different for our model is that the trained urologist is watching the cysto at the same time as the nurse practitioner is doing it. While the nurse practitioner can of course make their own assessment, the urologist is watching it in real time.

This is both good and bad in terms of efficiency. The reason why it's good is that it doesn't require me to carve out additional time from my busy schedule to watch a bunch of videos done by a nurse or nurse practitioner later at night or sometime outside of my own clinical environment. That's an increased efficiency to it. But in the little micro schedule, you have to look at it and somebody has to grab you and drag you over to the computer and say, “they're about to do the cysto 6 hours away.” There's a little bit of a disconnect there. But generally, it's more efficient than trying to review somebody else's cystos later or just trusting that they knew what they saw and that you would have done the same action as them. So, our first pillar of this was to train the nurse practitioners, which we did. We used a gynecologic competency that was an objective measure. We took that, a validated instrument from the literature, and then we successfully trained them. We had a really cool paper that came out where we use Amazon Mechanical Turk workers, as well as experts to review who was doing the study and what apparatus we were using. They matched up very nicely, so we had a good confirmation that we were doing a decent cystoscopy with our nurse practitioners and that the video quality was adequate. I'm not going to say it's great or better, but it was reasonable.

This transcription has been edited for clarity.

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