Thursday, October 16, 2014

First Changes of Suprapubic Catheters. A Need to Change a Stupid Policy

A suprapubic catheter is a tube that is placed through the lower abdomen into the urinary bladder as a way of managing problems associated with the storage of urine or emptying of the bladder.  Placement is a minor surgical procedure and essentially involves filling the bladder to capacity and then literally stabbing the lower abdomen with a sharp pencil like device (trocar) through which the catheter can then be introduced.  A syringe port allows us to inflate a balloon located towards the tip of the catheter with water and this helps hold it in place.

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Within days, a scar tissue type reaction forms around the tube and within a couple of weeks, there is  channel lined with scar tissue which we refer to as a tract.  This channel or tract acts a conduit through which the tube can be easily changed. Patients who have these suprapubic catheters (SPC) ideally should have them changed every 4 to 6 weeks.  Changing these catheters is a simple task and expertly performed by nurses.  In hospitals where there resources do not have such nursing expertise, the task is often relegated to the most junior and least experienced of medical officers, interns.

A policy regarding the first change of a SPC came into being a number of decades ago and the exact origins of this policy are unlikely to ever be determined.  The policy is that the first change of the SPC should be performed in a hospital. And thereafter, SPC changes could then be done in the community. It is one of those unwritten policies that entered healthcare folklore in the total absence of evidence.  It is a folklore tightly held by a number of administrative or officious types who want nothing of a challenge to this dogma.

I recently had a twitter rant over this as a result of an elderly patient of mine being literally forced to return to hospital for a simple change of SPC that could have been done in the community.  I could not care less about the wastage of the precious hospital resources but what I did care about was the enormous disruption associated with having to get the patient prepared and transported to hospital to have a simple procedure that takes about 10 minutes to perform.  We tried reasoning with the person in charge of the local community nurse services to only receive a blunt response that it was POLICY that the first change of SPC be carried out in the hospital.  I asked for where this policy is written but we all know the reason why this request was not responded to  - obviously there is NO SUCH WRITTEN POLICY. 

Okay, are we subjecting the patient to risk by doing the first SPC change in the community or are we placing the community nurse under untenable litigation risk?  Of course not.  What is the worse that arise from a bungled SPC change?  The catheter may not be able to be replaced because the tract was too tortuous or the catheter balloon might be blown up in the middle of the tract instead of in the lumen of the bladder.  This happens rarely and something that could just as likely occur in the hospital.  If a problem occurs, is it a dire medical emergency? No. A urethral catheter can generally be placed until a replacement SPC procedure can be arranged or they can be sent to the hospital.  The long term sequelae from such an event – remote if anything could be thought of. 

Outside hospitals, it is the community nurses who perform regular catheter changes week in week out.  They are highly skilled and to state that they lacked the capability to do a first change of catheter is nothing short of insulting.  I am sure that both you and I would much rather have a skilled community nurse perform a catheter change at home rather than trudging our way to hospital to have a less experience intern medical officer do the change.  Interestingly, many of the community nurses that I have interacted with are in themselves quite happy to do the first change but are not permitted by their superiors who remain opposed to change. 

Lets get back to evidence.  A highly talented urology nurse consultant, Colleen McDonald from Westmead Hospital, performed a study onirst changes of SPC in the community versus that performed in the hospital environment. I really do not need to go into the detail of what the study showed.  The title of the paper says it all.

McDonald.C & McFarland,M. (1999).  First Suprapubic Catheter Change...from Hospital to Community....A Clinical Practice Change.  Journal of Stomal Therapy Australia, 20(3), 14-15

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