Seizing Opportunities: Easing Discomfort of Intravesical Therapy for Bladder Cancer

Evidence-based nursing practice (EBP) is critical in the delivery of safe, competent, and quality patient care. EBP integrates the best clinical research findings with clinician expertise and patient preferences to reduce variation in care and improve patient outcomes.

Nurses are instrumental in the development of new EBP guidelines. These practice-changing recommendations often start with direct-care nurses identifying a clinical problem. I’d like to provide one example that highlights how nurses drive practice changes.

Jennifer is a urologic oncology ambulatory nurse at Fox Chase Cancer Center. She works with patients who are being treated for bladder cancer with chemotherapy. The treatment for bladder cancer is based on the extent, severity, and type of the disease and may include more than 1 treatment modality.

Patients may receive intravesical chemotherapy or immunotherapy treatment, with the medication instilled directly into the bladder through a catheter. The patient is required to retain the medication in their bladder for 90 minutes, referred to as dwell time. A second instillation may be given to the patient, with instructions to retain the medication in the bladder for 2 hours.

Jennifer identified that patients were having difficulty retaining the medication in their bladder for the required amount of time, which reduced dwell time, thus affecting overall treatment effectiveness. A review of literature attributed the discomfort experienced by patients during dwell time to the acidity of the medications. The current research indicates that interventions such as catheter management, use of bladder medications, and patient position changes have been mostly unsuccessful.

Jennifer hypothesized that pretreating patients with sodium bicarbonate tablets the night before and the morning of the treatment would neutralize urine acidity, reduce discomfort, and increase the tolerance of patients to the prescribed dwell times. In collaboration with physicians and oncology nurse colleagues, the clinical team piloted the initiative.

Patients participated in 1-on-1 education sessions with a clinical nurse prior to their therapy on the benefits of urine alkalization and optimization of intravesical drug dwell times. These sessions promoted active patient participation in their care, improving outcomes in the process. The pilot was successful and patients reported a reduction in discomfort and an increase in tolerance that allowed them to complete the full 90-minute dwell time. This nurse-initiated, collaborative, evidence-based improvement led to a successful practice change at Fox Chase Cancer Center.

This change in practice was one that warranted dissemination amongst other urologic oncology teams to ensure patients’ comfort. Jennifer has since presented her evidence-based improvement project on the benefits of treating patients with sodium bicarbonate tablets prior to receiving their treatment.

Ambulatory care nurses play a significant role in seeking innovative approaches to improve patient care. This is a critical facet of oncology nursing and one that is applied in our center every day through work like Jennifer’s.

Anna L. Rodriguez is chief nursing officer and vice president of Nursing and Patient Services at Fox Chase Cancer Center.