How a catheter removal project improved care for patients while saving money and carbon emissions

Summary

The Green Nursing Challenge Showcase was held on 20 October 2025 celebrating the outstanding work of teams from hospital and social care settings—an award-winning leadership and engagement programme dedicated to transforming healthcare.

One of the teams that competed in the Green Nursing Challenge was the Bladder, Bowel and Pelvic Health community team in Lewisham, London, with their project: ‘Trial without catheter (TWOC) using a structured approach’. The team have shared their project with the hub.

Content

The Centre for Sustainable Healthcare supported the Bladder, Bowel and Pelvic Health community team in Lewisham by undertaking a sustainable quality improvement project: a ‘Trial without catheter (TWOC) using a structured approach’. The team (consisting of the clinical lead, catheter lead nurse and a graduate management trainee) worked with the district nursing teams and urgent care service as part of the Green Nursing Challenge to improve care for patients, whilst saving money and carbon emissions.

The challenge

Indwelling urinary catheters are among the most used invasive medical devices in the UK, and an estimated 90,000 people in community settings require long-term catheter use. Evidence suggests that the longer a catheter remains in place, the higher the risk of infection, and around 2,100 deaths per year are directly attributed to catheter-related infections. The financial burden of catheter-associated urinary tract infections (CaUTIs) is approximately £2,000 per episode and the total annual cost of Foley catheter use estimated between £1 billion and £2.5 billion.

A TWOC is conducted when a catheter, which is a tube inserted into the bladder to drain urine, is removed to determine if the patient can urinate normally without it. This procedure is essential for evaluating bladder function and ensuring that the patient can manage without ongoing catheterisation

The team found that there was a lack of knowledge around standardised TWOC protocol, and a lack of clear evidence on how to manage the process. They identified problems with repeated catheter use, unnecessary district nurse visits, ambulance callouts and avoidable hospital stays. These inefficiencies not only compromise patient care, comfort and quality of life, but also generate considerable plastic waste from catheters, gloves, aprons and maintenance solutions.

Removing catheters as soon as possible has many advantages, but it is vital that removals are planned and effective to prevent adverse events, unnecessary emergency call outs or attendances to the emergency department. Avoiding the cycle of failed TWOC and repeated catheter insertion is key.

The Green Nursing Challenge helped the team in the successful implementation and evaluation of a project to develop a structured TWOC process, and measure the impact from a social, financial and environmental perspective. They implemented a classification system for TWOC suitability, together with corresponding TWOC strategies.  The project saw the team training staff and evaluating their results across the community of Lewisham and the wider Trust.

Results

Monthly figures were collected before and after the project and showed clear improvements in the following: 

Reductions in:

• Catheter-related ambulance call outs by 25%, suggesting more timely community interventions. 
• Catheter-related hospital stays (bed days) by 32%.
• Catheter-related hospital admissions by 12.5%, indicating fewer acute deterioration events. 

No catheter associated urinary tract infections were reported.

Environmental sustainability 

• The projected annual saving is 42,156.40 CO2e, equivalent to driving 124,026 miles in an average car.

Economic sustainability

• On average, the initiative contributed to projected net annual savings of £441,708.

Social sustainability

• The reduction in bed days meant that patients spent less time in hospital and more time at home which linked to improved emotional wellbeing.
• Reduction in staff pressures due to TWOC attempts and urgent visits for catheter-related complications.
• Increased staff confidence in catheter management contributing to a working environment that was less reactive and more focused on delivering high quality, consistent care.
• Improved integration, communication and patient pathways helped to ensure accurate referrals, faster and more effective communication.

Next steps

The team are continuing to develop their project hoping to see further improvements in emergency attendance, hospital stays, CaUTI rates, use of catheter materials and speed of catheter removals. They hope developing more comprehensive guidelines will lead to faster assessment and TWOC, or referral elsewhere, with the net result being a significant reduction in catheter usage overall.

For more information please see Green Nursing Challenge Trial without catheter - a structured approach.

Do you have a project you would like to share on the hub? We'd love to hear from you. Please email [email protected].