Processes and planning in transferring patients with indwelling urinary catheters from secondary to primary care
Coral Seymour, BSc, RGN, is urology clinical nurse specialist, Royal Gwent Hospital, Gwent Healthcare NHS Trust, Wales.
abstract Seymour, C. (2007) Transferring patients with a urinary catheter. Nursing Times; 103: 42, 52–54.
Transferring patients with indwelling urinary catheters from secondary to primary care can be problematic and the process requires careful planning. Both the patient and the healthcare professional taking over the plan of care need details on the reason for catheterisation and plans for ongoing care. Failure to plan transfers, including the provision of appropriate equipment for use at home, can lead to inappropriate care and, on occasion, results in referral back to hospital. Coral Seymour outlines new guidelines to assist nurses in making a discharge plan for these patients.
The nursing care of patients with bladder-related disorders is rarely, if ever, static. Those with an indwelling urinary catheter may be discharged from hospital into the community, or they may be transferred from one hospital to another or from ward to ward within the same hospital.
The transfer of care for these patients and the responsibility for that care can be problematic – especially if the nursing staff involved have not received the appropriate education and training. Patients also require clear and concise information about the equipment they will need and the procedures that should be followed.
To help reduce the potential risk to patients during the transfer of care, an independent group of healthcare professionals (see p54) compiled a new set of guidelines. These have been designed to encourage the implementation of consistent policies for the safe transition of catheterised patients, and are based on current evidence of
Problems with hospital discharge
Research literature on hospital discharge goes back at least 30 years and there is remarkable consistency in the published studies. They continue to report on breakdowns in routine discharge arrangements.
In recent years, a number of initiatives have been introduced with the aim of creating a better, more coherent transfer of care service. These include:
- The £300m Cash for Change initiative launched by the Department of Health in 2001, which aimed to reduce the number of delayed discharges;
- The 2002 creation of the Health and Social Care Change Agent Team;
- The publication of the Hospital Discharge Workbook (DH, 1994);
- The introduction of the Community Care (Delayed Discharges) Act (2003).
Despite these initiatives, both research and anecdotal evidence suggests that hospital discharge continues to be a problematic area of practice (Glasby, 2004).
Tierney et al (1999) concluded that the interface between hospital and community care remains poor. There are particular issues about who should ensure that patients are adequately informed about their care and management at home after they are discharged from hospital.
This study demonstrated that patients often solved problems by using commonsense solutions or seeking lay advice, and that they also need guidance about where (and from whom) to seek professional advice should it be needed. The study also found that a need for primary and secondary services to develop joint, local policies that ensure continuity in the provision of information and clarity about the roles of staff based in hospital and the community.
As responsibility shifts from healthcare professionals based in hospital to those working in primary care and patients are discharged earlier into the community, it is important to ensure that patients and carers receive adequate information about how to manage their condition. In conclusion, this study identified the need for better and quicker transfer of discharge information across the secondary-primary
care interface, particularly between hospital doctors and GPs.
Transfer of care guidelines
It is estimated that 4% of patients on district nursing caseloads have urinary catheters (Pomfret, 2000). There is anecdotal evidence that district nursing time is wasted because patients have been discharged from hospital with insufficient equipment and little or no information having been passed on to the district nurse about what these patients require.
The new guidelines discussed here have been based on a discussion between an independent group of healthcare professionals who met to address the issue of transferring patients with indwelling urinary catheters. Issues included:
- Lack of knowledge about good catheter practice and the discharge requirements of patients with urinary catheters;
- Problems with discharge of patients with catheters from general wards, where nurses are expected to grasp a wide range of policies and protocols;
- Lack of continuous training in order to reiterate the essential discharge policy messages;
- The need for discharge planning to begin the moment the patient is admitted to a ward;
- The inadequacy of communication about catheterisation details between acute and primary care, with little information being forwarded to the district nursing service;
- The fact that, ideally, patients should be discharged with a long-term indwelling urinary catheter, although some hospitals have a policy not to stock these and district nurses do not have the resources to keep a stock, which means a prescription is needed for a new catheter;
- The issue of cost when discharging patients with catheter-related equipment (many hospitals rely on manufacturers to provide starter packs);
- The dilemma of whether or not to discharge a patient with a spare catheter to cover the period before their prescription can be activated – this may be important in the event of the indwelling catheter becoming blocked during the first few nights at home;
- The fact that failure to contact the patient’s GP at least 24 hours before discharge can slow down the prescription process.
The group compiling the new guidelines has drawn inspiration from a number of schemes already running in the UK (see case study, Box 1). Thirty NHS trusts were asked for copies of their discharge policies related to catheterisation. Only three replies were received. One of the most comprehensive approaches to discharge planning has been devised by York Hospitals NHS Trust in conjunction with York PCT. It includes:
- A nurse-to-nurse catheter discharge letter;
- A good practice standard for catheterisation and urinary catheter drainage;
- A troubleshooting guide dealing with potential catheter-related problems;
- A flow-chart and protocol for patients who encounter catheter problems in the community, to prevent unnecessary requests for admission or readmission.
- Among other useful discharge initiatives, Ashford and St Peter’s Hospital NHS Trust has a patient ‘tick box’ checklist that accompanies patients’ notes.
The guidelines have been designed to help nurses and the NHS trusts that employ them to fulfil the strict legal requirements and standards associated with an appropriate transfer of care (Box 2).
In addition, the guidelines identify that for a transfer of care policy to be successful and implemented to the total satisfaction of both patients and nursing personnel, effective training, audit and communication are essential.
The process for discharge or transfer of a patient with an indwelling urinary catheter should begin at least 24 hours before it is scheduled to happen. Healthcare professionals working in hospitals should insist that all patients are referred to the relevant district nursing service – and that the district nurse who will be responsible for the patient’s ongoing care knows exactly why the patient’s catheter has been inserted.
Electronic and computer-based systems (for example, fax, email) should be used to facilitate contact between acute and primary care nursing personnel – in particular, to link the nurse who is discharging the patient from hospital to the district nurse taking on the care of that patient once they are in the community.
Box 1: How one trust has improved discharge care
Gwent Healthcare NHS Trust’s continence advisory team comprises a consultant nurse and seven urology/continence specialist nurses (one senior manager, four working in the community and two in the acute sector). The service covers a population of 600,000.
Nurses in Gwent identified a number of problems related to transfer between acute and primary care, including:
- There was a lack of awareness of a discharge policy among nurses;
- Not all patients were referred to the district nursing service;
- Patients were often being discharged with insufficient or inappropriate equipment.
Some of these issues were highlighted in completed ‘inappropriate discharge’ forms; others via complaints from patients and members of the multidisciplinary team (MDT).
Every hospital ward has a documented operational discharge policy (ODP), which states that on discharge, each patient should have seven days’ supply of appropriate equipment. The trust’s current supplier of catheters offers free starter packs, bed stands and patient information leaflets, and also supports the provision of training and education for all nurses within the trust.
To improve discharge planning, a laminated poster with information on catheter bags, stands, how to order supplies and contact telephone numbers was distributed to all the wards throughout the district general hospital. Initial indications show that this approach to discharge care is making a significant and positive difference to patient welfare.
Box 2: The guidelines
- Before transfer, ensure the patient has the appropriate type and size of catheter.
- Be satisfied that the patient and carer have the necessary understanding of basic catheter care requirements.
- Ensure the patient knows the proposed date of transfer; ideally 24 hours in advance.
- Make certain that all legally required documentation has been completed.
- Discuss how the patient wants to receive post-discharge products (for example, by home delivery service, community pharmacist or by a dispensing GP).
- When the patient has been given the ‘all clear’ to be discharged into the community, contact the district nurse, giving all relevant information about the patient.
- Ensure the discharged patient is given the completed Catheterisation Transfer of Care (CTC) form to pass on to the district nurse, or other nominated healthcare professional and (if possible) keep a copy of the completed form for inclusion in the patient’s records.
- Ensure the patient has a sufficient supply of appropriate products to last for a minimum of seven days.
- This supply should include one spare leg bag and seven single-use bed bags (provision should be made for further supply of products within seven days).
- Be aware that it is a legal requirement that all patients being discharged with catheters are given a patient information leaflet.
- Double-check that the patient is satisfied with the chosen method of supplying products (see Step 1).
- Ensure everything is in place to ensure a seamless transfer of care.
- Take appropriate action in the event of problems.
- When necessary, inappropriate discharge forms should be completed by the district nurse and returned as soon as possible to the relevant healthcare professional (for example, the continence adviser, urology nurse or discharge nurse).