Hypothesis / aims of study
It is recognised that catheters and related infections are a significant challenge. It was estimated that catheter-related complications cost the NHS up to £99 million per year (1). Trial With Out Catheter (TWOC) interventions often fail, leading emergency call outs or Emergency Department attendances.
There is limited evidence on optimal processes for maximising TWOC success, especially in community, or on expected success rates.
The aim was to assess each TWOC referral to understand what had led to the catheterisation, identify whether the problem was resolved, establish if it was safe and appropriate to TWOC and put a plan in place to maximise the chances of success. We had support of an organisation to perform carbon foot printing and look at sustainability.
Study design, materials and methods
The project included reviewing every TWOC referral, contacting the patient/carers as appropriate. A decision was made around TWOC suitability and preparation needed, such as medication, resolving constipation or using a catheter valve. Once plans were carried out, removal took place in clinic or at home with District Nurses (for housebound patients). An appropriate review was also planned.
Results
The project has been successful. We are seeing a small reduction in Emergency Department attendances for catheter-related issues but it is too early to be sure of why that is.
We identified several patients with catheters that have been left in long-term but with no clinical rational, and have successfully removed five so far.
The last six months of the TWOC project has had the following results:
16 successful TWOCs
12 unsuccessful TWOCs
Two refused as inappropriate
Data collection, comparing three months before the project and three months after, showed:
Ambulance call outs for catheter issues reduced by 12 (47 to 35)
Emergency Department attendance for catheter issues reduced by 3 (102 to 99)
Hospital admissions for catheter issues reduced by 4 (32 to 28)
District Nurse call-outs for catheter issues reduced by 3 (87 to 84)
Carbon foot printing by a specialist indicated there was an estimated overall reduction in terms of CO2 production, that may be connected with the reduction in use of catheters and related materials, as well as hospital attendances and admissions. The analysis showed a monthly reduction of 475kg of CO2 with a cost saving of £16,650.
Interpretation of results
There is limited data on TWOC success rates and therefore we are keeping detailed data to track results and see how much we can improve. Prior to the project, we had two clinical incidents in four weeks, where TWOCs had been unsuccessful and led to Emergency Department admission and significant complications. We have had no adverse incidents since the project started, and all repeat catheterisations have been done in a controlled and safe manner.
Data collected is on a very small scale and it is therefore not possible to generalise results at this stage but there are positive indications that this is a project supporting a safe and effective TWOC process with benefits in sustainability, cost, workload, clinical effectiveness and patient experience.