Urinary Catheters  can cause harm and risk to patients, the most common complication is catheter associated urinary tract infection (CAUTI), in some cases these can lead to blood stream infections. Some people require catheters in the short term following surgery or the long term due to disabilities or inability to empty the bladder. Urinary catheters should be removed as soon as possible to avoid catheter associated urinary tract infection (CAUTI).  This project addressed delay in catheter removal, transformed the trial without catheter (TWOC) hospital service to a nurse led community service. 
The introduction of clinical incident reporting for catheter related incidents was commenced in 2017.  Subsequently root cause analysis reviews was employed to review the incident and for lessons to be learnt.  It became apparent that there were long delays for TWOC appointments. All the TWOC appointments requests from across the organisation were directed to the urology day case department for a secondary care based TWOC appointment. Faxed and paper referrals for TWOC got lost; resulting in patients never receiving an appointment. The capacity in urology could not cope with the widespread demand and patients were waiting months/ too long to have their catheter removed. This raised concerns as every day a catheter is left in-situ it increases the risk of CAUTI.  
Hospital appointments for a TWOC were between 8-12 weeks. Prior to COVID, TWOCs were undertaken in urology and patients remained in hospital for most of the day. Where a TWOC is carried out has a bearing on the success of the outcome (Holroyd 2020).  The pressure to void in a strange environment can exacerbate anxiety (Warrilow et al 2004). A TWOC at home is less pressurised more conducive to successful outcome and community nurses are best placed to facilitate this.

A TWOC protocol was developed guiding community nurses (CNs) to undertake TWOC in patient’s homes expediting removal. CNs were trained and the protocol clarified criteria for TWOC at home to avoid hospital admission.   A pilot was commenced with nurses undertaking TWOCs at home guided by protocol.  Appointments were allocated within a week of discharge. During COVID 19 Urology outpatient attendance was suspended and the Bladder and Bowel Nursing Service (BABNS) undertook the TWOCs in the community. The audit results for this period are displayed below.

Audit April 2020 – March 2021
•	276 referrals (to BABNs) 
•	62 % (182) received community TWOC
•	63% (115) were successful with positive patient experience 
•	32% (59) failed needing urology referral
•	9% (17) taught Intermittent self -catherisation
•	Waiting time for surgery for enlarged prostate, reduced from 14 months to 6 - 8 months.

TWOC carried out in patients own homes has improved the wait time for removal of catheter. Patients were happy to have this procedure undertaken in their own homes.

Conclusion 
Benefits to patient and the organisation: 
•	Admission avoidance	
•	Reduced catheter days/ risk of CAUTI	
•	Reduced time to appointment  	
•	Increased urology capacity 
•	Positive patient experience 
•	Reduced unscheduled CN visits
•	Developing E referral 

On going work to develop TWOC prior to discharge from hospital using HOUDINI principle.

Continence 7S1 (2023) 100735
DOI: 10.1016/j.cont.2023.100735