[AVBC 2025] Reduce Unplanned Self-Extraction of Indwelling Urinary Catheter by Patients
Care Process & Redesign
Appropriate & Value-based Care Conference
National Healthcare Group
5 December 2025
The aim of the project is to reduce unplanned self-extraction of indwelling urinary catheters (IDC) by 50% among geriatric. The project successfully reduced the incidence of IDC self-extraction, leading to improved patient care and cost savings.
Year Submitted: 2025
Published Date: 05 December 2025
Tags: Care Process ＆ Redesign, Quality Improvement, Workflow Redesign, Productivity, Cost Saving
About this Content
Aims
The aim of the project is to reduce unplanned self-extraction of indwelling urinary catheters (IDC) by 50% among geriatric medicine patients in Wards 7B and 7D over 12 months at Tan Tock Seng Hospital (TTSH).
Background
The initiative was prompted by the increasing IDC dislodgement numbers, particularly in geriatric medicine, which ranked second highest among all disciplines in 2022 compared to 2023.
Methods
A multidisciplinary team was formed, and the Clinical Practice Improvement Programme (CPIP) methodology was applied. Diagnostics used included flowchart, fishbone diagram, and Pareto Chart to identify the vital few root causes to work on. The analysis revealed three primary factors: confusion/delirium patient, poor anchoring technique, and untimely catheter reviews. Through PICK chart prioritization, the team implemented three targeted interventions.
Results
The interventions at Wards 7B and 7D yielded significant results, reducing IDC self-extraction cases from 6 (January-December 2023) to 2 (January-December 2024), achieving a 67% reduction. As of 31 January 2025, the wards maintained 123 IDC dislodgement-free days. Cost analysis demonstrated annual savings of approximately $450.
Conclusion
The project successfully reduced the incidence of IDC self-extraction, leading to improved patient care and cost savings.
Lessons Learnt
The initiative represents a significant step forward in dignified care for elderly patients. Each prevented catheter self-extraction means one less traumatic experience for a vulnerable patient, reduced distress for their families, and increased confidence among healthcare staff.
Keywords
Catheter, Geriatric, Nursing, Quality Improvement
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | National Healthcare Group |
Organization(s) Involved | Tan Tock Seng Hospital |
Platform(s) | Appropriate & Value-based Care Conference |
Healthcare Professional Group(s) | Nursing, Medical |
Applicable Specialty or Discipline | Urology, Geriatric Medicine |
Project Lead(s) | Esther Ho Peiying |
Project Member(s) | Esther Ho Peiying |
Connect with this contributor!
Esther Ho Peiying - esther.peiying.ho@nhghealth.com.sg
Project Attachment
928_TTSH_AVBC_2025_Reduce_Unplanned_Self_Extraction_of_Indwelling_Urinary_Catheter_by_Patients.pdf