Safer insertion of suprapubic catheters: summary of a safety report from the National Patient Safety Agency
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d924 (Published 24 February 2011) Cite this as: BMJ 2011;342:d924
- Tara Lamont, special adviser 1,
- Simon Harrison, consultant urologist 2,
- Sukhmeet Panesar, clinical adviser1,
- Michael Surkitt-Parr, joint head of patient safety (response) 1
- Correspondence to: T Lamont tara.lamont{at}npsa.nhs.uk
Suprapubic catheters are used when urethral catheterisation is not possible or desirable because of, for example, urethral stricture, prostatic enlargement, or urethral trauma.1 In some cases the procedure may be carried out as an emergency on the ward. Elective indications include postoperative drainage after lower urinary tract or bowel surgery and the management of the neuropathic bladder. Many patients with conditions such as multiple sclerosis and spinal cord injury use long term suprapubic catheter drainage, to simplify catheter management and minimise risks of urethral damage.
Anecdotal evidence suggests that a typical hospital will carry out more than 100 suprapubic catheterisations each year. The doctors who undertake suprapubic catheterisation may lack experience: unless they are urologists, they may rarely perform the procedure. Suprapubic catheterisation is often delegated to junior medical staff.
The procedure involves passing a urinary catheter directly into the bladder through the lower abdominal wall, sometimes guided by ultrasound. Most are done safely, but important risks associated with catheter insertion include haemorrhage and infection of the urine or catheter track, and serious complication from intestinal injury. Bowel damage can lead to fatal peritonitis and is a particular risk in patients with contracted bladders that fail to distend sufficiently for safe catheter passage and in those with adhesions from previous lower abdominal surgery tethering bowel loops to the lower abdominal wall.
From September 2005 to June 2009, staff in England and Wales reported three deaths and seven cases of severe harm relating to insertion of suprapubic catheters. A further 249 incidents related to problems in suprapubic catheter use. Complications are likely to be under-reported, given 30 day mortality rates, in relatively small studies, ranging from 0.82 to 1.8.3
A typical incident report reads: “Patient underwent insertion of suprapubic catheter on [date] and was discharged back to nursing home the following day. Advised by coroner officer that patient had subsequently died. Coroner postmortem has shown cause of death to be peritonitis and instrumental perforation of the small bowel.”
Problems identified by the National Patient Safety Agency
Procedures were being performed out of hours without adequate supervision.
Some reports described a lack of confidence in doing the procedure or unfamiliarity with the equipment.
Staff had problems in accessing ultrasound machines on the wards or finding other staff who were able to use the equipment.
The patient safety incident reports seemed to show that the procedure is done in a range of settings and by different staff. Overall, staff seemed to perceive suprapubic catheterisation as a low risk procedure and were not always aware of potential complications.
The National Patient Safety Agency issued a safety report (known as a rapid response report or RRR) on minimising risks of suprapubic catheter insertion (for adults) in July 2009 (NPSA/2009/RRR005).4 The report recommended some immediate actions to ensure safer systems, and a good practice briefing sheet for clinicians. The agency also discussed risks with the British Association of Urological Surgeons, which published more detailed clinical guidelines for practitioners in November 2010.1 This summary is based on key points from both publications.
What can we do?
The rapid response report recommended system changes to reduce errors. These include identifying a named lead for training in each trust, reviewing guidelines or policies in line with best practice, and ensuring access to ultrasound equipment and to staff trained in its use.
For individual clinicians
Different techniques are used, but be aware that all closed (abdominal puncture) techniques run the risk of injury to internal organs.
Ask yourself: “Does this need to be done? Does this need to be done now? Would it be safer to use temporising measures (such as urethral catheterisation or bladder aspiration using a fine needle of up to 21 gauge)?”
Be aware of potential contraindications such as previous lower abdominal surgery (given the risk of bowel adherence); carcinoma of the bladder; anticoagulation and antiplatelet treatment; abdominal wall sepsis; or the presence of a subcutaneous vascular graft in the suprapubic region.
Ask yourself: “Am I competent to do this?” You should be trained in the procedure, know who the training lead is in your organisation, and be familiar with local equipment and guidelines. Until competent, junior staff should insert catheters only under the direct supervision of senior staff. If you do not feel comfortable undertaking this procedure, ask for help.
Talk to patients about the risks of the procedure at the time of taking consent, and give written information, including telephone contact details in case post-procedure problems arise.
If you cannot palpate the bladder, use ultrasonography to visualise the bladder and check that it is distended. Make sure that you are trained in the use of the ultrasound equipment. You may also want to use ultrasound to guide insertion of the catheter and check for interposing bowel loops along the planned catheter track. But this is an approach that is not supported by a strong evidence base and should be used only by trained individuals after discussion with a senior radiologist.
Use open surgery (or a closed procedure with expert ultrasound guidance) for patients whose bladder cannot be adequately distended or who have a history of previous lower abdominal surgery.
Monitor patients carefully after the catheterisation and keep in mind the possibility of bowel perforation, looking for lower abdominal pain (persistent or worsening, or pain spreading away from the site of the catheter insertion), signs of localised peritonitis, or general signs of sepsis.
Further details, including evidence for these actions, are given in the British Association of Urological Surgeons’ guideline,1 which also includes an algorithm (figure⇓) to guide decisions.
Guide for decision making on suprapubic catheterisation. Adapted from Harrison et al1
What else do we need to know?
Some stakeholders commenting on the draft guidance from the National Patient Safety Agency asked for suprapubic catheterisation to be restricted to urologists or others skilled in this task (such as urogynaecologists or general surgeons). However, this would pose problems for smaller hospitals without on-call urology services, especially as these procedures may sometimes need to be done as an emergency. More guidance may be needed from professional bodies on how competence in suprapubic catheterisation can be determined (such as a minimum number of procedures under supervision).
Different suprapubic catheterisation techniques are in use; commercial kits typically use a trocar system (with or without a Seldinger guidewire) and can be used either blind or with ultrasound guidance; open surgical placement is the standard approach for complex cases.1 Some methods may offer advantages of greater service efficiencies5 and improved outcome,6 but we do not know enough yet about the relative safety or effectiveness of different approaches.
We also need formal evaluation of the role of ultrasonography in reducing complications. For example, in patients with previous abdominal scars, can it reliably identify a safe route, avoiding bowel loops for the catheter track, and thus be used instead of open procedures?1 We also need clarity on the level of training and competence required for general physicians to use ultrasonography in this way.
How will we know when practice has become safer?
All NHS organisations were given until April 2010 to complete these actions. By the end of November 2010, 34/269 (13%) eligible organisations had still not completed actions. The British Association of Urological Surgeons is currently conducting a national audit of suprapubic catheter insertion, and data on the complications of the procedure should be available by the end of 2011. To measure improvement, local organisations could check access to ultrasound equipment on wards and survey junior staff to check they know the name of their training lead and contact number (for any time of day or night) in case patients show signs of complications after catheterisation. More detailed follow-up could be achieved by local retrospective audits of around 20 consecutive procedures against best practice set out in the British Association of Urological Surgeons’ guidance.
Notes
Cite this as: BMJ 2011;342:d924
Footnotes
Following a Department of Health review in July 2010, the National Patient Safety Agency will be abolished and some of its functions transferred to a patient safety subcommittee of the new NHS Commissioning Board. Reports of incidents are, however, still encouraged at www.npsa.nhs.uk.
Contributors: TL wrote the first draft, based on NPSA work led by TL, MS-P, and SP, with input from SH, who led on the detailed British Association of Urological Surgeons’ guidelines. All authors reviewed the draft. TL is the guarantor.
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that all authors had: no financial support for the submitted work from anyone other than their employer; no financial relationships with commercial entities that might have an interest in the submitted work; no non-financial interests that may be relevant to the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.