- Email: [email protected]
Parental home removal of urethral catheters after urological surgery—a prospective benchmarking study
Journal of Pediatric Urology (2019) 15, 252.e1e252.e4
Parental home removal of urethral catheters after urological surgeryda prospective benchmarking study Department of Paediatric Surgery and Urology, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK * Corresponding author. Oxford Road, M13 9WL Manchester, UK. sarah.braungart@doctors. org.uk (S. Braungart) Keywords Pediatrics; Urinary catheter; Balloon catheter; Patient care; Health-care cost Received 8 December 2018 Accepted 21 March 2019 Available online 29 March 2019
S. Braungart *, A. Goyal Summary Introduction Many urological operations require placement of a urethral Foley catheter. The catheter often needs to remain in situ for a period of time after discharge; and patients subsequently require either a further hospital admission or community nurse review for catheter removal. Parents can easily remove the catheter at home by cutting the balloon port. This disrupts the valve and hence deflates the retaining balloon, thereby facilitating spontaneous passage of the catheter. The authors introduced this practice to their institution.
Aim The aim was to assess safety and success of parental home catheter removal.
Methods A prospective data study was performed in a large pediatric urology center over a 12-month time period. Patients <16 years after single-stage hypospadias repair or other penile surgery were included on a voluntary basis. Parents of eligible patients were instructed verbally and with an information leaflet, including date for removal. Telephone follow-up after removal was undertaken to assess the outcome.
Results Thirty-eight patients were included over a 12-month time period. Patient age ranged from 9 months to 12 years
(median age 2.5 years). The majority (82%) of patients had required a catheter after hypospadias repair. Home catheter removal was successful in 92% cases. Three children required professional support for catheter removal. Median time until catheter passage was 3 h (range 0e24 h). Considering that cost for day case admission for catheter removal averages at 130£ per patient, home catheter removal saved the NHS 4550£ in the time period.
Discussion This is the first study to report the safety and feasibility of parental home catheter removal by cutting the balloon port valve in the pediatric population. It offers a number of distinct advantages compared with traditional methods for removal. These include, namely, (i) positive patient experience: catheter removal in a familiar environment by a relative minimizes stressful experiences for the family; (ii) minimal trauma to healing tissues through spontaneous catheter passage; and (iii) health careerelated cost savings. This was an initial benchmarking study, so patient numbers were relatively small. Nevertheless, it shows that the method is safe and received positive parental feedback.
Conclusion Parental home removal of a urethral catheter is a feasible and safe alternative to catheter removal by a health-care professional. It minimizes parental anxiety and inconvenience related to the catheter removal appointment and allows for significant cost savings.
Summary Fig. Information leaflet provided to parents with instructions on how to remove their child’s urinary catheter at home. https://doi.org/10.1016/j.jpurol.2019.03.018 1477-5131/ª 2019 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Parental home removal of urethral catheters
252.e2
Introduction Many urological operations require placement of a urethral Foley catheter. This often needs to remain in situ for several days after surgery; hence, the children are discharged home with the urethral catheter. For the subsequent catheter removal, patients have traditionally required a further hospital admission or a visit by the community nurses. Foley catheters have an inflatable balloon which anchors the catheter in the bladder. The catheter has two channelsdone for urinary drainage and one for inflation of the balloon. To remove the catheter, the balloon must be deflated [1]. Most commonly, this is carried out using a syringe to aspirate the water from the balloon. However, this method carries the risk of incomplete emptying of the balloon [8]. If a subsequent catheter removal is attempted, it may cause pain and injury to the urethra. Therefore, this method is not suitable for home catheter removal without professional oversight. Alternatively, the anchoring balloon can be deflated by cutting the balloon port of the catheter, thereby disrupting the balloon valve. This automatically allows the retaining balloon to deflate and facilitates subsequent spontaneous passage of the catheter due to bladder contractions, hence minimizing the risk of injury to the urethra [2]. The authors hypothesized that this alternative technique constitutes a safe and easy method for parents to remove the catheter at home. The aim of this study was to assess safety and success of parental home removal of Foley catheters in children by cutting the balloon port of the catheter.
Methods A prospective data study was conducted at one of the major paediatric urology centers in the UK. The study was approved by the institutional audit board (audit number #8019). Children <16 years of age who underwent urological day-case surgery between July 01, 2016, and June 30, 2017, and required placement of a Foley catheter were included based on the following inclusion criteria: Parental consent to participate. Surgery requiring urinary catheter postoperatively and procedure suitable for Foley catheter insertion Only hypospadias repairs not requiring dressing. In the center, the authors perform an anatomical hypospadias repair, in which the tissues are approximated in layers and the skin is closed with absorbable monofilament sutures. The only dressing that is applied is a topical skin adhesive (Dermabond) or a strip of Micropore tape over the ventral aspect of the penis. More extensive dressings are only used in cases of 1st stage hypospadias repair with graft (such cases were not included in this study). Parents of eligible patients were instructed verbally and with an information leaflet (Fig. 1) including a date for catheter removal. The majority of eligible children were not toilet trained yet. Therefore, postoperatively, these children were managed with the catheter draining into double
Fig. 1 Information leaflet provided to parents for instruction on how to remove their child’s catheter at home.
nappies. In the evening of the day of removal, parents were advised to open the outer nappy and cut the balloon port of the catheter. They were informed to expect spontaneous migration of the catheter into the nappy overnight. Parents were asked to ensure adequate hydration and analgesia of their child, to prevent dysuria associated with first void after catheter removal. It was advised to attend the pediatric surgical emergency department in case of uncertainties or problems. On the day after removal, a member of the pediatric urology team contacted the parents over the telephone to assess the outcome.
Results Thirty-eight patients were included during the time period. Age range was 9 monthse12 years (median age 2.5 years). Thirty-one (82%) of these patients had required a urinary catheter after hypospadias repair, and 7 children had required a catheter for a different urological procedure. The aforementioned home catheter removal was successful in 92% (35) of cases. Median time to catheter passage was 3 h (range 0e24 h). Three children required professional support for catheter removal. In two cases, difficulties resulted from pain through bladder spasms and were not actually related to the catheter removal technique. One patient’s catheter required a little tug for removal but was removed by the doctor on duty without any problems. There were no cases in which the balloon failed to deflate. Two out of the 31 patients that underwent a single-stage hypospadias repair developed a fistula, which equals a fistula rate of 6%. One patient developed a minor wound infection that healed with topical antibiotic ointment. A comprehensive summary of parental feedback can be found in Table 1 and indicates the overall positive experience (Table 1).
Discussion This is the first study to report the safety and feasibility of parental home catheter removal by cutting the
252.e3 Table 1
S. Braungart, A. Goyal Parents’ feedback on their experience with the home catheter removal.
Parent
Feedback regarding experience with the catheter removal
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
“Best catheter removal ever” “No problem, pleased with the process” “Nervous initially but feels really good now, would recommend for every patient” “Easy, good method, felt comfortable” “No problem at all” “Happy e found catheter in the nappy the following day.” “No concerns e found catheter in the nappy 30min after removal.” “I found the catheter removal stressful, and would not want to have to do it again.” “Found it a bit scary, but preferred it to coming back to the hospital for removal.” “No problems. Found catheter in the nappy the next morning.” “Catheter came out spontaneously within the hour.” “Catheter fell out within 10 min” “No problems at all. Very positive experience.” “Catheter passed without any problems.” “Removed catheter accidentally but did not cause problems” “Catheter was removed by A&E staff, because it was bypassing” “Came out within 2 h, no problems” “Catheter came out spontaneously at day 7” “Catheter came out straight away because I pulled it upon cutting the port.” “No problems” “Catheter was removed one day early by A&E staff because of hematuria.” “Found in nappy the morning after.” “No problems” “Did cause some discomfort, but overall no problems” “No problems with removal” “Felt very nervous about the procedure. Had to give the catheter a little tug for it to come out” “Slight discomfort, but overall no concerns” “No problems e found in nappy”
Four parents did not wish to leave a comment, and six parents simply stated they had no concerns.
balloon port valve in the pediatric population. This method of catheter removal is more frequently used in adult urology practice [3,4]. It offers a number of distinct advantages compared with traditional methods for catheter removal.
Positive patient experience Removal of a urethral Foley catheter should be a simple and uncomplicated procedure. Especially in children with anatomical urological problems, it should be as uneventful as possible to avoid any traumatic memories. These children frequently require further urological interventions, and research shows that invasive treatmentsdspecifically urogenital surgerydcan have significant psychological effects on children [5,6]. Therefore, removal of the catheter in a familiar environment by a close relative (such as a parent) seems ideal for the children from a psychological point of view. In addition, home removal can be performed at a time convenient for the parents and hence minimizes stress and inconvenience for the family related to the health-care appointment. This is an important factor to consider, because it has been shown that a child’s distress resulting from a medical procedure is increased, if the parents
themselves experience a high level of distress [7]. The multiple positive comments in the feedback speak for themselves.
Minimizing trauma to healing tissues From a surgical perspective, a spontaneous passage of the catheterdrather than manual removaldis least disruptive to the healing tissues. Catheter removal by syringefacilitated balloon aspiration always carries the risk of incomplete emptying of the balloon. Attempting removal of a catheter with an incompletely deflated balloon can cause significant injury to the urethra and can easily disrupt a recent hypospadias wound repair [8]. This method of catheter removal minimizes this risk, because only a catheter with a completely deflated balloon will migrate spontaneously from the bladder. In this study, the balloon deflated spontaneously in all cases.
Reduction of health careerelated costs The method of home catheter removal described can help reduce health careerelated costs as described in the following sample calculation: cost for a day-case admission to the unit for catheter removal averages at 130 £ per
Parental home removal of urethral catheters patient. Home catheter removal for the children in the audit resulted in a total saving of 4550 £ for the National Health Service [9]. This calculation does not include further additional cost savings through saving the health professional’s time through avoiding a removal appointment and the financial implications for parents caused by absence from the workplace and travel to the hospital. This study is limited by a relatively small sample size, and results, therefore, must be interpreted with caution. Nevertheless, removal using this novel method was successful in more than 90% of cases in this study. Further studies using larger patient cohorts would be desirable to further evaluate this method.
Conclusion This is the first study of parental home catheter removal by cutting the balloon port valve in the pediatric population. The study demonstrates that this method is a safe and successful alternative to catheter removal by a health-care professional. Distinct advantages include improved patient and parent experience and reduction in health careeassociated costs.
Author statements Acknowledgments This study was presented at the Annual Conference of the European Association of Pediatric Surgeons in Paris 2018 and won the Trainee Prize of the Annual Congress of the British Association of Paediatric Urologists 2018.
Ethical approval The study was approved by the institutional audit board (audit number #8019).
252.e4
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-forprofit sectors.
Competing interests None declared.
References [1] Feneley RCL, Hopley IB, Wells PNT. Urinary catheters: history, current status, adverse events and research agenda. J Med Eng Technol 2015;39(8):459e70. [2] Dougherty L, Lister S. The royal marsden hospital manual of clinical nursing procedures. Oxford: Wiley-Blackwell; 2015. [3] WakeMed Physician Practices: Catheter removal instructions. https://www.wakemed.org/urology-catheter-removalinstructions [accessed 01 December 2018]. [4] Hollingsworth M, Quiroz F, Guralnick ML. The management of retained Foley catheters. Can J Urol 2004;11(1). 21632136. [5] Ha ¨gglo ¨f B. Psychological reaction by children of various ages to hospital care and invasive procedures. Acta Paediatr Suppl 1999;88(431):72e8. [6] Peterson L. Coping by children undergoing stressful medical procedures: some conceptual, methodological, and therapeutic issues. J Consult Clin Psychol 1989;57(3):380e7. [7] Jay SM, Ozolins M, Elliott CH, Caldwell S. Assessment of children’s distress during painful medical procedures. Health Psychol 1983;2(2):133e47. [8] Parkin J, Scanlan J, Woolley M, Grover D, Evans A, Feneley RC. Urinary catheter ‘‘deflation cuff’’ formation: clinical audit and in vitro analysis. BJU Int 2002;90:666e71. [9] NHS Improvement reference costs 2017/2018: reference cost data. https://improvement.nhs.uk/resources/reference-costs/ [accessed 01 December 2018].
Parental home removal of urethral catheters after urological surgeryda prospective benchmarking study Department of Paediatric Surgery and Urology, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK * Corresponding author. Oxford Road, M13 9WL Manchester, UK. sarah.braungart@doctors. org.uk (S. Braungart) Keywords Pediatrics; Urinary catheter; Balloon catheter; Patient care; Health-care cost Received 8 December 2018 Accepted 21 March 2019 Available online 29 March 2019
S. Braungart *, A. Goyal Summary Introduction Many urological operations require placement of a urethral Foley catheter. The catheter often needs to remain in situ for a period of time after discharge; and patients subsequently require either a further hospital admission or community nurse review for catheter removal. Parents can easily remove the catheter at home by cutting the balloon port. This disrupts the valve and hence deflates the retaining balloon, thereby facilitating spontaneous passage of the catheter. The authors introduced this practice to their institution.
Aim The aim was to assess safety and success of parental home catheter removal.
Methods A prospective data study was performed in a large pediatric urology center over a 12-month time period. Patients <16 years after single-stage hypospadias repair or other penile surgery were included on a voluntary basis. Parents of eligible patients were instructed verbally and with an information leaflet, including date for removal. Telephone follow-up after removal was undertaken to assess the outcome.
Results Thirty-eight patients were included over a 12-month time period. Patient age ranged from 9 months to 12 years
(median age 2.5 years). The majority (82%) of patients had required a catheter after hypospadias repair. Home catheter removal was successful in 92% cases. Three children required professional support for catheter removal. Median time until catheter passage was 3 h (range 0e24 h). Considering that cost for day case admission for catheter removal averages at 130£ per patient, home catheter removal saved the NHS 4550£ in the time period.
Discussion This is the first study to report the safety and feasibility of parental home catheter removal by cutting the balloon port valve in the pediatric population. It offers a number of distinct advantages compared with traditional methods for removal. These include, namely, (i) positive patient experience: catheter removal in a familiar environment by a relative minimizes stressful experiences for the family; (ii) minimal trauma to healing tissues through spontaneous catheter passage; and (iii) health careerelated cost savings. This was an initial benchmarking study, so patient numbers were relatively small. Nevertheless, it shows that the method is safe and received positive parental feedback.
Conclusion Parental home removal of a urethral catheter is a feasible and safe alternative to catheter removal by a health-care professional. It minimizes parental anxiety and inconvenience related to the catheter removal appointment and allows for significant cost savings.
Summary Fig. Information leaflet provided to parents with instructions on how to remove their child’s urinary catheter at home. https://doi.org/10.1016/j.jpurol.2019.03.018 1477-5131/ª 2019 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Parental home removal of urethral catheters
252.e2
Introduction Many urological operations require placement of a urethral Foley catheter. This often needs to remain in situ for several days after surgery; hence, the children are discharged home with the urethral catheter. For the subsequent catheter removal, patients have traditionally required a further hospital admission or a visit by the community nurses. Foley catheters have an inflatable balloon which anchors the catheter in the bladder. The catheter has two channelsdone for urinary drainage and one for inflation of the balloon. To remove the catheter, the balloon must be deflated [1]. Most commonly, this is carried out using a syringe to aspirate the water from the balloon. However, this method carries the risk of incomplete emptying of the balloon [8]. If a subsequent catheter removal is attempted, it may cause pain and injury to the urethra. Therefore, this method is not suitable for home catheter removal without professional oversight. Alternatively, the anchoring balloon can be deflated by cutting the balloon port of the catheter, thereby disrupting the balloon valve. This automatically allows the retaining balloon to deflate and facilitates subsequent spontaneous passage of the catheter due to bladder contractions, hence minimizing the risk of injury to the urethra [2]. The authors hypothesized that this alternative technique constitutes a safe and easy method for parents to remove the catheter at home. The aim of this study was to assess safety and success of parental home removal of Foley catheters in children by cutting the balloon port of the catheter.
Methods A prospective data study was conducted at one of the major paediatric urology centers in the UK. The study was approved by the institutional audit board (audit number #8019). Children <16 years of age who underwent urological day-case surgery between July 01, 2016, and June 30, 2017, and required placement of a Foley catheter were included based on the following inclusion criteria: Parental consent to participate. Surgery requiring urinary catheter postoperatively and procedure suitable for Foley catheter insertion Only hypospadias repairs not requiring dressing. In the center, the authors perform an anatomical hypospadias repair, in which the tissues are approximated in layers and the skin is closed with absorbable monofilament sutures. The only dressing that is applied is a topical skin adhesive (Dermabond) or a strip of Micropore tape over the ventral aspect of the penis. More extensive dressings are only used in cases of 1st stage hypospadias repair with graft (such cases were not included in this study). Parents of eligible patients were instructed verbally and with an information leaflet (Fig. 1) including a date for catheter removal. The majority of eligible children were not toilet trained yet. Therefore, postoperatively, these children were managed with the catheter draining into double
Fig. 1 Information leaflet provided to parents for instruction on how to remove their child’s catheter at home.
nappies. In the evening of the day of removal, parents were advised to open the outer nappy and cut the balloon port of the catheter. They were informed to expect spontaneous migration of the catheter into the nappy overnight. Parents were asked to ensure adequate hydration and analgesia of their child, to prevent dysuria associated with first void after catheter removal. It was advised to attend the pediatric surgical emergency department in case of uncertainties or problems. On the day after removal, a member of the pediatric urology team contacted the parents over the telephone to assess the outcome.
Results Thirty-eight patients were included during the time period. Age range was 9 monthse12 years (median age 2.5 years). Thirty-one (82%) of these patients had required a urinary catheter after hypospadias repair, and 7 children had required a catheter for a different urological procedure. The aforementioned home catheter removal was successful in 92% (35) of cases. Median time to catheter passage was 3 h (range 0e24 h). Three children required professional support for catheter removal. In two cases, difficulties resulted from pain through bladder spasms and were not actually related to the catheter removal technique. One patient’s catheter required a little tug for removal but was removed by the doctor on duty without any problems. There were no cases in which the balloon failed to deflate. Two out of the 31 patients that underwent a single-stage hypospadias repair developed a fistula, which equals a fistula rate of 6%. One patient developed a minor wound infection that healed with topical antibiotic ointment. A comprehensive summary of parental feedback can be found in Table 1 and indicates the overall positive experience (Table 1).
Discussion This is the first study to report the safety and feasibility of parental home catheter removal by cutting the
252.e3 Table 1
S. Braungart, A. Goyal Parents’ feedback on their experience with the home catheter removal.
Parent
Feedback regarding experience with the catheter removal
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
“Best catheter removal ever” “No problem, pleased with the process” “Nervous initially but feels really good now, would recommend for every patient” “Easy, good method, felt comfortable” “No problem at all” “Happy e found catheter in the nappy the following day.” “No concerns e found catheter in the nappy 30min after removal.” “I found the catheter removal stressful, and would not want to have to do it again.” “Found it a bit scary, but preferred it to coming back to the hospital for removal.” “No problems. Found catheter in the nappy the next morning.” “Catheter came out spontaneously within the hour.” “Catheter fell out within 10 min” “No problems at all. Very positive experience.” “Catheter passed without any problems.” “Removed catheter accidentally but did not cause problems” “Catheter was removed by A&E staff, because it was bypassing” “Came out within 2 h, no problems” “Catheter came out spontaneously at day 7” “Catheter came out straight away because I pulled it upon cutting the port.” “No problems” “Catheter was removed one day early by A&E staff because of hematuria.” “Found in nappy the morning after.” “No problems” “Did cause some discomfort, but overall no problems” “No problems with removal” “Felt very nervous about the procedure. Had to give the catheter a little tug for it to come out” “Slight discomfort, but overall no concerns” “No problems e found in nappy”
Four parents did not wish to leave a comment, and six parents simply stated they had no concerns.
balloon port valve in the pediatric population. This method of catheter removal is more frequently used in adult urology practice [3,4]. It offers a number of distinct advantages compared with traditional methods for catheter removal.
Positive patient experience Removal of a urethral Foley catheter should be a simple and uncomplicated procedure. Especially in children with anatomical urological problems, it should be as uneventful as possible to avoid any traumatic memories. These children frequently require further urological interventions, and research shows that invasive treatmentsdspecifically urogenital surgerydcan have significant psychological effects on children [5,6]. Therefore, removal of the catheter in a familiar environment by a close relative (such as a parent) seems ideal for the children from a psychological point of view. In addition, home removal can be performed at a time convenient for the parents and hence minimizes stress and inconvenience for the family related to the health-care appointment. This is an important factor to consider, because it has been shown that a child’s distress resulting from a medical procedure is increased, if the parents
themselves experience a high level of distress [7]. The multiple positive comments in the feedback speak for themselves.
Minimizing trauma to healing tissues From a surgical perspective, a spontaneous passage of the catheterdrather than manual removaldis least disruptive to the healing tissues. Catheter removal by syringefacilitated balloon aspiration always carries the risk of incomplete emptying of the balloon. Attempting removal of a catheter with an incompletely deflated balloon can cause significant injury to the urethra and can easily disrupt a recent hypospadias wound repair [8]. This method of catheter removal minimizes this risk, because only a catheter with a completely deflated balloon will migrate spontaneously from the bladder. In this study, the balloon deflated spontaneously in all cases.
Reduction of health careerelated costs The method of home catheter removal described can help reduce health careerelated costs as described in the following sample calculation: cost for a day-case admission to the unit for catheter removal averages at 130 £ per
Parental home removal of urethral catheters patient. Home catheter removal for the children in the audit resulted in a total saving of 4550 £ for the National Health Service [9]. This calculation does not include further additional cost savings through saving the health professional’s time through avoiding a removal appointment and the financial implications for parents caused by absence from the workplace and travel to the hospital. This study is limited by a relatively small sample size, and results, therefore, must be interpreted with caution. Nevertheless, removal using this novel method was successful in more than 90% of cases in this study. Further studies using larger patient cohorts would be desirable to further evaluate this method.
Conclusion This is the first study of parental home catheter removal by cutting the balloon port valve in the pediatric population. The study demonstrates that this method is a safe and successful alternative to catheter removal by a health-care professional. Distinct advantages include improved patient and parent experience and reduction in health careeassociated costs.
Author statements Acknowledgments This study was presented at the Annual Conference of the European Association of Pediatric Surgeons in Paris 2018 and won the Trainee Prize of the Annual Congress of the British Association of Paediatric Urologists 2018.
Ethical approval The study was approved by the institutional audit board (audit number #8019).
252.e4
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-forprofit sectors.
Competing interests None declared.
References [1] Feneley RCL, Hopley IB, Wells PNT. Urinary catheters: history, current status, adverse events and research agenda. J Med Eng Technol 2015;39(8):459e70. [2] Dougherty L, Lister S. The royal marsden hospital manual of clinical nursing procedures. Oxford: Wiley-Blackwell; 2015. [3] WakeMed Physician Practices: Catheter removal instructions. https://www.wakemed.org/urology-catheter-removalinstructions [accessed 01 December 2018]. [4] Hollingsworth M, Quiroz F, Guralnick ML. The management of retained Foley catheters. Can J Urol 2004;11(1). 21632136. [5] Ha ¨gglo ¨f B. Psychological reaction by children of various ages to hospital care and invasive procedures. Acta Paediatr Suppl 1999;88(431):72e8. [6] Peterson L. Coping by children undergoing stressful medical procedures: some conceptual, methodological, and therapeutic issues. J Consult Clin Psychol 1989;57(3):380e7. [7] Jay SM, Ozolins M, Elliott CH, Caldwell S. Assessment of children’s distress during painful medical procedures. Health Psychol 1983;2(2):133e47. [8] Parkin J, Scanlan J, Woolley M, Grover D, Evans A, Feneley RC. Urinary catheter ‘‘deflation cuff’’ formation: clinical audit and in vitro analysis. BJU Int 2002;90:666e71. [9] NHS Improvement reference costs 2017/2018: reference cost data. https://improvement.nhs.uk/resources/reference-costs/ [accessed 01 December 2018].