Leading change

The Urogynaecology Nurse Consultant in the Department of Women’s Services at the Royal Victoria Infirmary led on the implementation of a new Trial Without Catheter (TWOC) at home service within the Trust. The new service has contributed to improved outcomes, experiences and use of resources locally.

Where to look

The Royal Victoria Infirmary (RVI) has been providing healthcare to communities in Newcastle and the North East for over 250 years with the maternity department helping bring over 5,700 babies into the world each year. The evidence base suggests that between 0.05% and 37% of these women will experience problems urinating postpartum (Lim, 2010). There is a paucity of evidence within the UK regarding the management of post-partum bladder management. The department of Women’s Services at the RVI have developed their own guidelines to follow. These reflect the recommendations in the NICE guidance document for intrapartum care for healthy women and their babies, where clinicians should leave the woman no longer than 6 hours before acting.

At the Royal Victoria Infirmary, the midwifery ward managers highlighted unwarranted variation with the practice of catheter removals and TWOCs to the Nurse Consultant, which led to the development of new approaches in postpartum TWOCs to improve outcomes for the women using the services and their families.

What to change

The Nurse Consultant identified through discussions with midwifery ward managers that the existing pathway meant women were re-attending the post-natal ward for removal of their indwelling urinary catheter, several days after giving birth. In practical terms this frequently meant women had to be on the ward for the day, along with their new baby, and women reported this interfered with their new routine and was both a difficult and uncomfortable experience.

Staff on the ward reported difficulties with managing simultaneous inpatient and outpatient services on the ward. Staff also needed to ensure they had the skills and confidence to teach the women intermittent self–catheterisation if the trial without catheter was unsuccessful. The evidence base suggests people prefer to be taught self-catheterisation at home and are more relaxed and manage better with this skill (Robinson, 2007). Therefore the Nurse Consultant, with the support of the senior nursing and midwifery team and the independent sector, set out to reduce the unwarranted variation seen in practice, through the redesigning clinical pathways, services and educational programmes; thus ensuring the continued provision of high quality care.

How to change

Existing hospital based pathways were reviewed by the Nurse Consultant and midwifery team to explore where improvements could be made and where alterations to clinical pathways could be made safely. Notably, clinical pathways were adapted to include the use of a catheter valve. A supportive call from the community nurse specialist team once the woman was discharged home supported the use of this. By fitting and using this device it ensures the women undergoing TWOC have a full bladder before the catheter is removed.  This has significantly sped up the time frame of the TWOC without compromising safety as the bladder should be full as soon as the catheter is removed. The women’s care is closely managed by the community Nurse Specialist within their own home until they are emptying their bladder fully without difficulty, or can manage intermittent catheterisation independently.

An audit of the women using the service identified that whilst most women could safely have their catheter removed, a small number of women required intermittent self-catheterisation (ISC) due to urinary retention. The Nurse Specialist can implement this immediately, whereas not all midwives had the opportunity to demonstrate this skill due to the small numbers of women requiring ISC.

Prior to the change, women attended the ward for TWOC on the Monday following discharge regardless of the day the catheter was inserted. This ensured a staff member competent in ISC was available should this required. This however wasn’t seen as a holistic personalised approach to caring for postpartum women so it was agreed with senior midwifery leads that a change of environment for the TWOC clinic would be beneficial for staff resources as well as service user experience. In agreement with the head of midwifery and Directorate Manager, community team support was gained to provide the service in the women’s’ own home.

In collaboration with the community Nurse Specialists, the Nurse Consultant developed a new referral pathway and audit tool for this new TWOC@Home service and parameters, metrics and standard operating procedures were agreed.

Adding value

Better outcomes – At the end of a 6-month trial period, the service was evaluated and demonstrated improved outcomes for women who used the service, where of the 31 women referred, 24 had successful TWOC without the need to self-catheterise. All women were contacted by the team within 48 hours and seen within the expected 7-10 days with the average wait being only 3.4 days. The new catheter valve has helped the women to maintain bladder tone and normal function, which has meant a significant number of women have been able to pass urine as soon as the catheter is removed.

Better experience – Women who use the service have reported they are extremely happy with the new service and feedback has included:

“Excellent service, I was pleased to be able to come home and spend time with my family instead of having extra 2-3 days in Hospital.  Thank you so much”

“The fact I was in a situation to need to TWOC I found this very hard to deal with and was very anxious re how this would affect me long term.  Being able to be in the comfort of my own home took a little bit of this angst away as I would have struggled to get back and forth to the hospital and was much more relaxed in my own environment”

“I had an emergency section and was sent home with a catheter in place. To have had to go to hospital and wait around with a new born baby would have been extremely painful”

“Was great to stay at home due to reduced mobility”

Staff have also reported the new service and clinical pathways have been an improvement on the previous arrangement and that this has increased their confidence in dealing with women with urinary catheters.

Better use of resources – The new service has released resources to provide care for women on the ward. The use of the new catheter valve has been seen to speed up the process of TWOC for both the patient and the nurse as the nurse is able to check residual urine volume on the same visit. On average, using a catheter valve has saved approximately 3 hours per visit meaning staff can provide other elements of care during this time and women are not inconvenienced by long delays. All postnatal women who have a second urethral catheter placed are referred to the TWOC@Home service. Over six-months, this has amounted to saving the ward 31 day-case procedures, as well as allowing the women to be cared for within their own home.

Challenges and lessons learnt for implementation

Implementing change in a clinical area where there are rotational staff has been a challenge and this can make communication complex.

Intermittent catheterisation (IC) education continues for all midwives as the guidelines recommend trying IC where possible prior to insertion of a second indwelling catheter.

In addition, a centralised mailbox has been created for all referrals to be picked up by both the Nurse Consultant and the Community Specialist nurse.

A new look at an existing way of working can bring fresh ideas and a simple idea can make a huge difference to supporting both staff and patients.

For more information contact

Tracy Ord – Urogynaecology Nurse Consultant
The Royal Victoria Infirmary
tracy.ord@nuth.nhs.uk