Optimising safety of catheterisation

Incorrect insertion of suprapubic catheters can be catastrophic, as a recent warning from the National Patient Safety Agency (NPSA) has highlighted. The agency revealed that three people died and seven were severely injured, pointing to an urgent need to minimise the risks associated with this procedure. The report follows an earlier survey of British urologists, carried out by the British Association of Urological Surgeons (BAUS) in 2003, which found that one third of respondents had experienced suprapubic catheter-associated bowel perforation in the past 10 years. Suprapubic catheters are designed to drain patients’ bladders when blocked or when a urinary catheter cannot be inserted, and are also used in patients with spinal injuries, neurological conditions such as multiple sclerosis, as well as those undergoing surgery. Suprapubic catheterisation is a common procedure (in both elective and emergency situations), which may be undertaken by a range of clinicians in a variety of settings. According to the NPSA, the technique should be used when urethral catheterisation is contraindicated or where it is technically not possible to relieve urinary retention in both acute and chronic conditions. It may also be chosen to improve patient comfort, dignity or convenience, and to prevent complications such as catheterinduced urethral injury, e.g. in patients with neurological disease or diminished genital sensation. Although this procedure is not always perceived to be high-risk, the NPSA has pointed out that the risks include injury to the intestine and haemorrhage due to perforation of vascular structures in the pelvis. Kevin Cleary, medical director for the NPSA, warned against complacency, commenting: “Although the procedure is relatively common and carried out in most hospitals, the risks are not always understood. The data we received between September 2005 and June 2009 concluded that, on occasions, the technique was conducted by staff without proper support, training or equipment. “When errors do occur, it can lead to patients suffering internal bleeding or experiencing other complications. As we have seen through our reports, in the most extreme cases, patients have died.”

Training

Ian Pearce, consultant urological surgeon, Central Manchester University Hospitals NHS Foundation Trust, stated: “There are very few complications with suprapubic catheters – in terms of interventions by urologists, it is one of the safest procedure we do. However, like anything else, it must be performed by properly trained individuals who know exactly what they are doing.” He added: “There is no certification for competency and the problems appear when it is performed by non-urologists who only occasionally carry out the procedure; the concern is that they do not get sufficient training and experience.” Dr Iqbal Shergill, senior specialist registrar in urology, London Deanery, shares Ian Pearce’s concerns over inadequate training and has developed a model which can be used to safely teach the procedure.1 He commented: “Insertion of traditional suprapubic catheters (SPCs) is quite difficult and there can be a high risk of complications – especially if the patient has had previous surgery. Moreover, there isn’t sufficient awareness and understanding of the procedure, as students are not taught it at medical school.” He further highlighted the difficulties of performing the procedure “blind” – a factor that the NPSA’s Rapid Response Report has addressed. The guidance recommends that clinicians use ultrasound wherever possible to visualise the bladder and guide the insertion of the catheter, to avoid piercing the bowel. Other technology solutions are also helping to improve safety, however. In particular, the NHS National Technology Apdoption Centre is seeking to encourage increased adoption of the Seldinger SPC kit, from Mediplus, which is designed to help minimise the associated risks. Unlike traditional suprapubic catheterisation procedures performed in the operating theatre, the Seldinger SPC kit allows trained staff to insert the catheter accurately into the bladder under local anaesthetic in an outpatient setting. The operating principle behind the device involves use of a guide-wire, which removes any “guess work” during insertion.