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Implementation Project

Implementation project

contacts avaliablehave implemented the new seldinger suprapubic catheter kit into their clinical practice with the aim of improving the quality of care for urology patients.

On this page, you can access the learning gathered from the urologists, nurses and managers who have worked on this project. There are contacts avaliable so you can email or phone and hear from them directly about what really happened and the challenges they encountered. In addition there are support tools and resources for you to download, adapt and use.

To explore this section and view information relevant and useful to you and your organisation please click on the headings below:

Summary of Lessons Learnt

Suprapubic catheterisation can be carried out safely in the day case / outpatient setting for the majority of patients.
The indications for SPC insertion can be increased as more clinical staff become familiar and competent in the technique.
Suprapubic catheterisation can be safely inserted under local anaesthetic out of hours by suitably trained junior doctors.
Nurse practitioners can be trained to safely undertake procedures in the outpatient setting.
The number of Seldinger Suprapubic Catheter procedures undertaken under general anaesthetic with an inpatient stay can be reduced following implementation of this technique.
Waiting times for this procedure can be reduced if this procedure is transferred to the outpatient setting.

Service Improvement

Since it was first implemented in June 2008, the new technology has significantly improved direct access to day case / outpatient services, resulting in a safe and simple suprapubic catheter procedure for the majority of patients.

Initially funded from grants provided by NTAC to support its implementation, the permanent adoption of the modified suprapubic catheter procedure, as the intervention of choice for appropriate patients, was determined by successful business/governance case submission to ensure that the sustainability of the implementation is satisfied on clinical, operational and financial grounds.

Summary of change

The new technique can facilitate the development of a new protocol driven outpatient service for management of patients in urinary retention requiring suprapubic catheterisation.

New pathway for management of patients referred for suprapubic catheter assessment.
New protocol for the insertion of suprapubic catheter predominantly in the outpatient setting.
Provision of fast track direct access where appropriate to a nurse practitioner for primary care referring clinicians.
Reduction in number of inpatient suprapubic catheter procedures undertaken under GA.

Change rationale

There were 3 main objectives for this project:

To improve the quality and consistency of care provided for patients by the application of the new technique.
To reduce the number of general anaesthetics administered to an elderly patient group who frequently have complex medical conditions.
To reduce waiting times and improve access for patients.

The project was addressing perceived problems in the management of suprapubic catheterisation:

Patients were frequently undergoing general anaesthetic for suprapubic catheter insertion.
Patients were being admitted and utilising bed days for a procedure that could be carried out in the day case / outpatient setting.
Patients presenting in A+E with acute retention, who might be considered for suprapubic catherisation, were receiving indwelling urethral catheters.

The experience from the implementation sites indicates that outpatient suprapubic catheter insertion with Seldinger technique is not only a safe and simple procedure, but it helps avoid potential hazards associated with traditional blind techniques, especially in patients with a small bladder capacity or previous abdominal surgery. The new technique has facilitated the development of a dedicated outpatient service, freeing up theatre slots and so improving patient access to other surgical procedures.

Impact of Change

Patient Pathway

Patients requiring suprapubic catheter insertion present in three ways:

By a referral to the urology outpatient department for those patients with less acute symptoms.
By presenting themselves to A&E (Being sent to A&E by their GP following a referral to the on-call consultant urologist).
Internal hospital referral.

New Process

Referral direct to dedicated outpatient clinic for assessment and suprapubic catheter insertion.
A+E presenting patient reviewed by on-call urologist, assessment undertaken and SPC procedure undertaken under local anaesthetic, if indicated in A+E or acute surgical admissions unit.
Internal hospital referral with suprapubic catheter insertion on the wards under local anaesthetic.

Workforce

The successful implementation of the project required no directly related workforce changes.

Impact on patients

The number of patients requiring general anaesthetic and an inpatient stay within this elderly at risk patient group was reduced following introduction of the new Seldinger Suprapubic Catheter Kit technique.

Patients were asked to complete a simple questionnaire rating their satisfaction with the new procedure across five domains and reported low levels of discomfort and high levels of satisfaction with the new technique.

Impact on services

A recent published audit of regional practice of inserting suprapubic catheters in the SW region determined that in 2006 over half (52%) of patients underwent this procedure under general anaesthetic as an elective inpatient.

During the implementation period at our three hospital sites 79% of SPC procedures using the new technique were performed under local anesthetic with 65% of these procedures performed in the day case / outpatient setting.

Impact on staff

Overall, the impact on staff has been very positive. Staff were asked to complete a simple questionnaire rating their satisfaction with the new procedure across six domains. Overall staff using the device expressed confidence in both application and safety of the new technique.

Impact on service delivery

Patients requiring suprapubic catheter insertion are predominantly elderly with complex medical conditions. Following introduction of the new technique less patients required a general anaesthetic and an inpatient stay (traditionally an average of 2 -3 days) relieving pressure on both theatre capacity and inpatient services.

Impact on costs

Successful implementation of this technique reduces the number of procedures requiring a general anaesthetic and inpatient stay freeing up additional theatre capacity and bed days to undertake other surgical procedures that will attract additional income and reduce waiting times.

Click here to calculate potential costs savings / additional income using our Cost and Activity Model

Achieving change

The change was implemented with greatest benefits for patients and the service when:

The concept had been clearly presented to the team.
Consultant and management leads from urology had ownership of the project and were motivated to make the change.
Successful implementation was possible where capacity was available in day case / outpatient clinics.
A specialist urology nurse motivated to enhance their role, undertook training to carry out suprapubic catheterisation procedures in the outpatient setting.
The new service was communicated to general practitioners.
There was directorate leadership and management of the project, where the general manager was engaged, this resulted in support for change.
Training and core competency assessment was undertaken for all core trainees
The service change was evaluated and results shared with the multidisciplinary team.

Communication

Communicating the new service to primary care

The new service was communicated to referring GP's about the availability of a direct access outpatient clinic.

Communicating the new protocol to junior medical staff

The urology on-call team includes general surgery core trainees who work on rotation. The turnover of this team, and registrars in both urology and A&E, meant it proved challenging to ensure all junior staff understood and received training in the new protocol.

Measurements of success

Audit of Patient and Staff satisfaction with new procedure and service.
Complication rates.
Proportion of patients requiring general anaesthetic and inpatient stay.
Proportion of patients undergoing procedures in the day case / outpatient setting.
Proportion of core trainees competent in new technique.
Reduction in hospital stay.
Baselining - a comparison with the previous year to determine the change in the number of procedures undertaken, where they were performed, and whether it was still under general anaesthetic.

Click here for the the Medical Audit Sheets. Copies can also be downloaded from the resources on the left-hand side of this page.

Benefits vs. Barriers

Our Benefits vs. Barriers Guide gives a summary of the project - enabling you to take the next step in delivering positive change.

Systemic Adoption Issues

The introduction of the new technology within the three implementation sites demonstrated the need for only limited service redesign.

Key systemic adoption blockers

Implementation has proven that the new technology can deliver clear benefits. However, it has also highlighted several key barriers to adoption to be addressed. These include the increased cost of consumables, the current limited clinical evidence base for the technology, and the relatively small number of patients that will benefit from implementation.

Key systemic changes

The new procedure enables a greater number of procedures to be undertaken in the outpatient setting under local anesthetic, reducing demand for inpatient theatre and bed capacity.

What's more, there is an opportunity for referrals to be managed and assessed by a junior doctor or suitably trained nurse practitioner and for suprapubic catheter insertion to be undertaken by suitably trained urology nurse specialists. As a result, the majority of suprapubic catheter procedures can be performed safely under local anaesthetic in the day case / outpatient setting.

It is clear that developing a seldinger suprapubic catheter service within a nurse led outpatient clinic to maximise the benefits to patients and the service. With junior medical staff trained in the clinic, they can then provide suprapubic catheter insertion out of hours for patients presenting with acute bladder outflow obstruction when urethral catheterisation is contraindicated or undesirable.