Indwelling urinary catheters are one of the most commonly used clinically invasive devices in the UK (Loveday et al, 2014; Feneley et al, 2015). There are at least 90,000 people living in community settings in England currently using longterm urinary catheters (Gage et al, 2016). It has long been recognised that the length of time a catheter is in place can increase the risk of developing an infection and a significant number of patients with long-term catheters develop sepsis, which can lead to death (Chenoweth and Saint, 2013; Loveday et al, 2014).

Feneley et al (2015) estimated that about 2,100 deaths a year are directly caused by the use of indwelling catheters. Given that the cost of treating catheter-related urinary tract infections (CAUTIs) is estimated to be about £2,000 an episode (Yates, 2016), and the total cost of using indwelling catheters in the NHS is estimated to be between £1–2.5 billion a year, appropriate management and early removal of these devices must be a priority.
 

'Ensuring that best practice guidelines are followed and that catheters which are no longer necessary are removed promptly may be a way of reducing infection rates and unnecessary deaths...'  



There are many clinical situations where an indwelling urinary catheter is indicated for bladder drainage (see pp. 28–34). Ensuring that best practice guidelines are followed and that catheters which are no longer necessary are removed promptly may be a way of reducing infection rates and unnecessary deaths (Magers, 2013; Chenoweth et al, 2014). This article will explore optimum timing for trial without catheter (TWOC) and current evidence advising on how to safely and effectively manage TWOC.

Hospital episodic data (HES, 2011–12 data) for one year alone recorded more than 280,000 episodes of urinary tract infection (UTI) in acute care in England and Wales (Health and Social Care Information Centre, 2013). It is probable that a fair proportion of these were linked to indwelling catheters when considered with the statistical data on how often these devices are used (Feneley et al, 2015). The impact of catheter complications is felt by the patient who suffers the often significant issues relating to infection and the need for antibiotics (Chapple et al, 2016). Nursing and care services both in the community and emergency departments experience an increased demand on their services, a reduction in capacity and ability to respond to the holistic needs of patients with indwelling catheters, which results in an increased economic burden on the NHS and social care sector (Tay et al, 2016; Ansell and Harari, 2017).

TWOCIndwelling catheterisation should only be considered when all other options have been discounted (Geng et al, 2012; Royal College of Nursing (RCN), 2012; National Institute for Health and Care Excellence (NICE), 2017). There should be evidence of a comprehensive and individualised patient assessment with a clear documented reason for using the catheter and a set date for review or removal (Geng et al, 2012; RCN, 2012; Loveday et al, 2014; Simpson, 2017).


Practice pointUse of catheter passports has encouraged the sharing of appropriate information among care professionals, prompting health and social care staff to challenge the presence of catheters and ensuring timely review is completed (Yarde, 2015; Simpson, 2017). The passports are also a valuable aid in patient education and empowerment, often providing the patient, carer or family with useful information on hygiene and catheter maintenance, which is crucial in helping to reduce the risk of infections (Loveday et al, 2014).

WHY, WHEN AND HOW TO USE TWOC

The purpose of a TWOC is to assess the patient’s bladder function and establish the patient’s ability to effectively and successfully empty the bladder unaided (Table 1). TWOC should always be planned in advance, considering:
  • Timing of catheter removal
  • The environment in which the TWOC is performed
  • Ongoing assessment of bladder function, including any urinary retention
  • A clear plan of action should the TWOC be considered a failure (Yarde, 2015; Bardsley, 2017).
It has been suggested a TWOC should take place within two weeks of catheterisation, although there has not been any robust clinical evidence to support this timescale. Some papers have reported that a TWOC should ideally be performed within two to three days after initial catheterisation (Kuppusamy and Gillatt, 2011), when the reason for the catheter has been acute urine retention. They report a 40% success rate for TWOCs in patients whose underlying cause of acute urinary retention, such as constipation, UTI and medication effects, has been resolved. TWOCs may also be more successful in early stages for those patients with a residual urine volume of less than one litre and no previous lower urinary tract (LUT) symptoms (Emberton and Fitzpatrick, 2008).

The timing of a TWOC in relation to catheter insertion should be decided using an individual assessment, which considers the reason for the initial catheterisation as well as the support planned for the TWOC procedure and any management strategies for possible failure of the trial.

Over the years there has been discussion about the optimum time to TWOC, with some stating early morning is best (Addison, 2001; Watering, 2001; Warrilow et al, 2004), and others preferring midnight (Kelleher, 2002). The author has not found any substantive clinical evidence to suggest a particular time of day improves the outcome or success of a TWOC. The author’s recommendation is to time the removal of a catheter based on individual assessment of need, environment and consideration of the availability for follow-up to ensure successful and effective bladder emptying is re-established.

Some areas have dedicated TWOC clinics in hospitals and healthcare environments, the aim being to formally manage the procedure and achieve the best outcomes for the patients with support from healthcare professionals. However, it is now commonplace to offer a TWOC at a patient’s own home, as long as a suitably experienced healthcare professional is available to monitor and support the patient to determine the success of the procedure, with a clear follow-up protocol in place (Gilbert, 2006).

DO CATHETER VALVES IMPROVE THE SUCCESS OF TWOC?


In some patients, bladder function can slow down over a period of weeks or months when a catheter is in situ, especially if the urine is on continuous drainage into a bag (Addison, 2001; Robinson, 2005). There has been some suggestion that using a catheter valve before a TWOC may improve the success and outcome of the procedure (Woodward, 2013; Yates, 2016), as this allows the bladder to fill and empty over several hours, preserving some sensation and detrusor function by mimicking a normal pattern of micturition. The author has not been able to find any clinical evidence suggesting a minimum amount of time to wear a valve before a TWOC to ensure its success. In practice, the recommended timescale to wear a valve system appears to range from 48 hours to two weeks before removing the catheter. The clinician should follow local policy and guidelines for use of catheter valves. It should be noted that some patients cannot safely use a catheter valve (see Table 3 on p.32), yet can still have a successful TWOC procedure.
Table 1 - Reason for TWOC
Table 2 - Potential issues during TWOC

POTENTIAL ISSUES DURING TWOC PROCEDURE

The removal of an indwelling catheter should be a simple and uncomplicated procedure, but there are some potential issues that staff need to be aware of, namely:
  • Being unable to deflate the balloon. This may be due to a faulty or damaged valve on the catheter
  • Wrinkling or cuffing of the balloon causing the catheter to stick to the urethral or suprapubic tract on removal
  • Pain or increased sensitivity when the catheter is removed.
Geng et al (2012) included a comprehensive troubleshooting guide in their best practice guidelines for the European Association of Urology Nurses (EAUN), with management strategies for dealing with these issues (Table 2).


MONITORING POST TWOC

Red FlagOnce a catheter has been removed, the patient’s urine output and fluid intake should be monitored over a period of time to ensure that the pattern of bladder emptying is consistent and effective. This should include the use of bladder scanning to check residual volumes (Burkhard et al, 2016). It should be noted that to achieve an accurate post void residual (PVR) measured on a bladder scanner, the scan must take place within 20 minutes of the spontaneous void (Newman, 2015, updated from 2007). It is important to understand the significance of the residual volume, the spontaneous void volume and the fluid intake of the patient to be able to accurately interpret the results and make a decision whether the TWOC has been a success, or if the patient needs re-catheterising. The general opinion of urologists worldwide when considering urine retention is that a PVR that is less than 100ml is not considered significant, while a PVR of more than 100ml should be investigated further to establish a pattern of retention (Gallien et al, 2005; Ghalayini et al, 2005).
 

OUTCOMES OF TWOC

A failed TWOC would be determined by a patient failing to void successfully and effectively resulting in a need to re-catheterise (Gilbert, 2006). However, other complications may need to be considered.

Incontinence after urological surgery and subsequent removal of a catheter or a recurrence of the incontinence symptoms that initially determined the need for a catheter will need assessment and an agreed treatment plan with the patient. This may involve replacing the catheter or teaching appropriate and effective pelvic floor muscle exercises to help improve the tone and tolerance of the supporting muscles and urinary sphincters (Kuppusamy and Gillatt, 2011).

Urgency and frequency of micturition after a TWOC are also reported by some patients. This may be the result of residual inflammation of the urethra caused by the catheter, or an infection. The patient with irritating symptoms should be tested for a UTI and treated according to clinical presentation and local policy. Overactivity of the detrusor should be eliminated as a cause of the frequency and urgency, as this can be successfully treated with anticholinergic medication in some patients.

Bladder capacity may have been reduced after long-term use of a catheter, particularly if the catheter has been on free drainage. Rectifying this will require a structured programme of bladder retraining after a TWOC. The retraining programme needs to be individualised and should take into account the patient’s dietary and fluid intake, as there are some well-known irritants such as caffeine, nicotine, carbonated drinks and artificial sweeteners that can adversely affect the bladder (Colley, 2015).

Timed voiding is a recognised method of retraining the bladder, based on the amount a normal healthy bladder should hold (400–600ml in adults) and how many times a day a normal healthy bladder empties (4–8 times in 24 hours). This can establish a ‘normal’ bladder function even in the absence of sensation with voiding set to times and prompted throughout the day.

Distraction techniques when the sensation to void is frequent and building up the intervals between voiding over a period of days can increase bladder capacity and help regain a more normal pattern of micturition.
Practice pointIncomplete emptying of the bladder should be determined through the use of frequency volume charts (Colley, 2015) and bladder scans post voiding at appropriate intervals after catheter removal. Clinicians should refer to local policy on how and when to perform a post void bladder scan after a TWOC.

It has been recognised that patients with any of the aforementioned complications in relation to TWOC and catheters would benefit from specialist nursing input to ensure the best management plan and options are considered and implemented (Mavin and Mills, 2015).

If a patient repeatedly fails TWOC or has repeated episodes of urinary retention, an opinion from a urology specialist would be beneficial and should be considered. The clinician should refer to local policy for guidance on the referral pathway.

THE HOUDINI PROTOCOL

The optimum time to perform a TWOC will be different for individual patients. The initial reason for catheterisation and availability of services to ensure that there is appropriate support and follow-up to determine the success of a TWOC can also differ. However, the use of evidence-based, nurseled daily checklists can reduce CAUTI rate significantly (Fuchs et al, 2011; Purvis et al, 2014; Yatim et al, 2016).

The HOUDINI protocol was developed by Adams et al (2012) and is a nurse-driven protocol offering staff a method of determining when to remove a catheter. The acronym stands for:
  • Haematuria of significant nature
  • Obstruction (urinary)
  • Urology surgery
  • Category 3 or 4 pressure ulcer or open sacral or perineal wound in a patient with incontinence
  • Input and output measurement for patient management or haemodynamic instability Nursing — end-of-life care
  • Immobility due to physical constraints.

Top tip:

Distraction techniques can be used by patients who are trying to regain a normal pattern of micturition.
 



The protocol recommends a daily challenge of asking whether patients meet any of the criteria reflected in the acronym. When a patient no longer meets the criteria, the catheter should be removed. The HOUDINI protocol provides a structure which enables nurses to make decisions and ensure safe and quality patient care.

CONCLUSION

Although indwelling urinary catheters are a high-risk intervention, they are unavoidable in some situations. The clinical evidence concludes that, where possible, the catheter should be removed at the earliest opportunity to reduce the risk of CAUTI. Planning and implementing a TWOC procedure should consider many factors that could affect the success of the TWOC. Patients with indwelling catheters should be reviewed daily, which includes assessing their need for catheterisation (Andreessen et al, 2012), and a structured system or protocol should be in place to manage the TWOC (Carter et al, 2014; Meddings et al, 2014; Purvis et al, 2014; Sanjay Saint et al, 2015).

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