Once identified, these concerns were escalated to urology management as the delay in removing the urinary catheters posed unnecessary risk to patients from CAUTI and other complications, such as catheter non-draining, recurrent blockage or urethral erosion. This excessive wait was first identified from catheter-related clinical incidents and root cause analysis (RCA) review by the authors. High demand for TWOC combined with limited capacity in urology and compounded by lack of information on discharge meant that patients waited 8–12 weeks or more for a TWOC appointment. The urology department who processed the referral required a urologist to triage it and pass on to the urology nurses, and then on to clerical staff to send the outpatient appointment. ![]() The referrals for a TWOC were either faxed or posted to urology by the ward doctor, but some were lost in the system, resulting in patients failing to receive an appointment. ![]() It is not clear why more TWOCs are not routinely attempted before discharge, possibly due to the pressure for hospital beds and the need to expedite discharge. Then, in 2000, the Covid-19 pandemic further affected access for patients when the local urology-based TWOC clinic was temporarily suspended.Ī deep dive review highlighted that the TWOC appointment requests came from all wards and directorates within the organisation and were sent by a ward doctor directly to the urology department requesting a hospital TWOC appointment. The authors of this paper identified through catheter-related clinical incident reporting that there were significant delays with hospital TWOC appointments. According to Warrilow et al (2004), when patients were given options, they chose a TWOC at home. The pressure to void in a strange and clinical environment can exacerbate anxiety, whereas a TWOC at home is less pressurised and thus more conducive to a successful outcome (Warrilow et al, 2004). Where a TWOC is carried out may have a bearing on the success of the outcome (Holroyd, 2020). In the authors’ organisation, TWOCs have been carried out in hospital outpatient departments, involving the patient staying all day and often having to travel over 45 minutes in hospital transport to reach the department. HOSPITAL OUTPATIENT TWOC - RATIONALE FOR CHANGE HOUDINI principles require a daily review of ward-based patients to reassess the need for the catheter and to determine when it can be removed. The catheter should be removed if it does not follow the indications illustrated in Figure 1.Ĭatheter care bundles should be implemented to help reduce the incidence of CAUTI, underpinned by HOUDINI principles, a protocol for management of catheterised patients, use of which is now widespread (Adams et al, 2012). The acronym HOUDINI (as in make it disappear) was developed to enable staff to recognise indications for continued catheter use. Indeed, the length of time a catheter is left in situ has direct implications on the increased risk of developing an infection (Holroyd, 2020). Urinary catheterisation is an invasive procedure that should be avoided, but if it cannot be, then it should be removed as soon as possible to prevent the unwanted complications described above. However, urinary catheters are indicated for other reasons, which are outlined in the HOUDINI box in Figure 1. Indwelling urinary urethral or suprapubic catheterisation is regularly employed post operatively on urology and urogynaecology wards to manage urinary retention. ![]() Over a prolonged period the catheter can cause pressure necrosis of the penile urethral tissues (Reid et al, 2021) and, in the authors’ experience, this complication can go unrecognised and unreported. Catheters can also recurrently block and cause damage to the delicate tissues in the bladder and urethra (Nazarko, 2020), and in men, a urethral erosion can occur.
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