The Journey to Office Cystoscopy Privileging

Christy B. Krieg, MSN, FNP, CUNP

Urol Nurs. 2020;40(2):99-103.

Abstract and Introduction

Introduction

I had been a urologic nurse practitioner for 9 years before I finally had the opportunity to take the cystoscopy course in the autumn of 2016, during the Society of Urologic Nurses and Associates (SUNA) Annual Conference. While I was the first adult nurse practitioner (NP) in our urology group when I was hired in 2007, historically, I have been a late bloomer. Late to lose my first tooth, late to marry, late to adopt the newest medications into my practice.

Frankly, I was intimidated and anxious about cystoscopy. I had a worry that I would cause harm by missing something important. Yet I knew satisfaction and continuity of care suffered when my new patients with hematuria (122 of them in 2016) were referred to a physician colleague for a 2-minute future cystoscopy appointment, then back to me for follow up.

This was problematic. Sometimes I was not copied on the cystoscopy reports. Sometimes the CT scan was ordered under the physician's name, and I did not see it until the 6-month follow up. Patients described their dissatisfaction directly to me. And I really abhor when patients are dissatisfied. I wanted to fix this problem.

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Appendix A.

Author's Letter to the Credentials Committee

To whom it may concern: I regret that I cannot attend in person the IUH credentialing meeting on 12/12/18. Please allow me to submit the following general background on cystoscopy performed by an NP and my personal history. You will find attached a number of supporting documents. Background I am a Family Nurse Practitioner (FNP) with 19 years of experience in Urology, with the last 11 in my role as an FNP. Please find my CV attached. In more recent years, I realized that the continuity of care for my patients presenting for hematuria workup, bladder pain, and chronic UTIs was poor. I would see them for an initial visit, counsel them in the condition and standard workup, then send them to a physician whom they had never met for a 2-minute office procedure. I would typically see them back for follow up many months later. While the care was competent, it lacked continuity. Several patients described to me their dissatisfaction. I had observed many cystoscopies and had the occasional opportunity to operate the scope during cystoscopy when the surgeon was finished, but was not trained at that point for independent practice. My physician colleagues for years had encouraged me learn to perform cystoscopy. To give a sense of volume, in 2016, I had 122 E&M unique patients with hematuria diagnosis. Literature Review Attached you will find four articles from American academic journals: Urology, Urologic Nursing, and Journal of Doctoral Nursing Practice. The Shields article and others reference the program established by the British equivalents to the American Urological Association and the Society of Urologic Nurses and Associates. I have attached a portion of the BAUN document as a point of interest; there is currently no U.S. equivalent to this document. Training In late 2016, I was able to complete a didactic and practical training course in flexible cystoscopy, hosted by the nationally accredited Society of Urologic Nurses and Associated (SUNA). The course description and my certificate of completion are attached. I returned to my department, and with the support of my physician staff, proceeded to engage in formal training. Two physicians in my group were immediately available and willing to assist with my training, Dr. Michael Koch and Dr. Amy Krambeck. Together, we arrived at a minimum competency number of fifty (50) procedures under their direct observation, of which I kept a procedure log. (As a point of comparison, the IU Urology residency competency requirement is four (4) flexible cystoscopies under direct observation.) During these 50 direct observations over 5 months, they concluded I was competent to perform the procedure independently. Please see their letters of attestation, attached. Value I heartily believe that my performing cystoscopy is good for my patients – sometimes we can accomplish the complete initial workup in a single visit, which is efficient and satisfying to patients. This reduces wait times in our practice, which are notoriously long. Further, when I perform cystoscopy, the valuable time of my physician colleagues is freed for more clinically complex work. Utilization of APPs to improve access to care is, of course, not unique to the field of Urology. The reference list for the 2017 Langston article I've attached includes similar discussions of APP roles in interventional radiology, diagnostic gastroenterology, trauma centers, colposcopies, and more. To my knowledge, we have had no reimbursement challenges in this matter. I am happy to answer any questions about my credentialing request upon my return to work on or after December 17, 2018. Christy B. Krieg, MSN, FNP, CUNP Family Nurse Practitioner Urology
Note: Documents mentioned as attachments in this letter are not reprinted here. Source: Reprinted with permission of Christy Krieg.

To whom it may concern:
   I regret that I cannot attend in person the IUH credentialing meeting on 12/12/18. Please allow me to submit the following general background on cystoscopy performed by an NP and my personal history. You will find attached a number of supporting documents.
Background
   I am a Family Nurse Practitioner (FNP) with 19 years of experience in Urology, with the last 11 in my role as an FNP. Please find my CV attached.
   In more recent years, I realized that the continuity of care for my patients presenting for hematuria workup, bladder pain, and chronic UTIs was poor. I would see them for an initial visit, counsel them in the condition and standard workup, then send them to a physician whom they had never met for a 2-minute office procedure. I would typically see them back for follow up many months later. While the care was competent, it lacked continuity. Several patients described to me their dissatisfaction.
   I had observed many cystoscopies and had the occasional opportunity to operate the scope during cystoscopy when the surgeon was finished, but was not trained at that point for independent practice. My physician colleagues for years had encouraged me learn to perform cystoscopy. To give a sense of volume, in 2016, I had 122 E&M unique patients with hematuria diagnosis.
Literature Review
   Attached you will find four articles from American academic journals: Urology, Urologic Nursing, and Journal of Doctoral Nursing Practice. The Shields article and others reference the program established by the British equivalents to the American Urological Association and the Society of Urologic Nurses and Associates. I have attached a portion of the BAUN document as a point of interest; there is currently no U.S. equivalent to this document.
Training
   In late 2016, I was able to complete a didactic and practical training course in flexible cystoscopy, hosted by the nationally accredited Society of Urologic Nurses and Associated (SUNA). The course description and my certificate of completion are attached.
   I returned to my department, and with the support of my physician staff, proceeded to engage in formal training. Two physicians in my group were immediately available and willing to assist with my training, Dr. Michael Koch and Dr. Amy Krambeck. Together, we arrived at a minimum competency number of fifty (50) procedures under their direct observation, of which I kept a procedure log. (As a point of comparison, the IU Urology residency competency requirement is four (4) flexible cystoscopies under direct observation.) During these 50 direct observations over 5 months, they concluded I was competent to perform the procedure independently. Please see their letters of attestation, attached.
Value
   I heartily believe that my performing cystoscopy is good for my patients – sometimes we can accomplish the complete initial workup in a single visit, which is efficient and satisfying to patients. This reduces wait times in our practice, which are notoriously long.
   Further, when I perform cystoscopy, the valuable time of my physician colleagues is freed for more clinically complex work.
   Utilization of APPs to improve access to care is, of course, not unique to the field of Urology. The reference list for the 2017 Langston article I've attached includes similar discussions of APP roles in interventional radiology, diagnostic gastroenterology, trauma centers, colposcopies, and more.
   To my knowledge, we have had no reimbursement challenges in this matter.
   I am happy to answer any questions about my credentialing request upon my return to work on or after December 17, 2018.
Christy B. Krieg, MSN, FNP, CUNP
Family Nurse Practitioner
Urology

Note: Documents mentioned as attachments in this letter are not reprinted here.
Source: Reprinted with permission of Christy Krieg.