Reduce Unplanned Self-Extraction of Indwelling Urinary Catheter by Patients
Care Process & Redesign
National Healthcare Group Quality Improvement
National Healthcare Group
24 December 2025
To reduce the number of unplanned self-extractions of indwelling urinary catheters by 50% (from 6 to 3 pull-outs) among. The interventions show promise in reducing IDC dislodgement incidents, enhancing patient safety, and improving IDC management protocols.
Year Submitted: 2025
Published Date: 24 December 2025
Tags: Care Process ＆ Redesign, Workflow Redesign, Quality Improvement, Cost Saving, Productivity
About this Content
Aims
To reduce the number of unplanned self-extractions of indwelling urinary catheters by 50% (from 6 to 3 pull-outs) among geriatric medicine patients admitted to Ward 7B and Ward 7D within 12 months.
Background
IDC dislodgement incidents increased by 80% among geriatric medicine patients on Level 7 between 2022 and 2023, highlighting the need for targeted interventions.
Methods
Interventions include refining anchoring techniques, flagging using bright stickers, and objective delirium detection using the 4AT tool by nurses. Training and reinforcement strategies were also implemented.
Results
As of January 31, 2025, there were 123 days free of IDC dislodgement. Pull-out cases reduced from 6 in 2023 to 2 in 2024.
Conclusion
The interventions show promise in reducing IDC dislodgement incidents, enhancing patient safety, and improving IDC management protocols
Lessons Learnt
Quality improvement requires patience, time, and teamwork. Sustainable culture change needs ongoing reinforcement and consistent engagement.
Additional Information
Sponsors, Adj Asst Prof Tan Huei Nuo and Ms. Hnin Nwe Oo.
Keywords
Catheter, Geriatric, Nursing, Patient Safety, IDC Dislodgement
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | National Healthcare Group |
Organization(s) Involved | Tan Tock Seng Hospital |
Platform(s) | National Healthcare Group Quality Improvement |
Healthcare Professional Group(s) | Nursing |
Applicable Specialty or Discipline | Geriatric Medicine |
Project Lead(s) | Ho Peiying Esther |
Project Member(s) | Nio Bee Hong |
Connect with this contributor!
Group Quality - nhggroup.QRM@nhghealth.com.sg