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Exploration of the Incidence of & Risk Factors for Postoperative Urinary Retention (POUR) in the Orthopaedic Total Joint Patient: A Pilot Study
Jan Bailey, MSN, RN, OCNS-CVallire Hooper, PhD, RN, CPAN, FAAN
Mission HospitalAsheville, NC
2
The Dilemma of Bladder Management for the Total Joint Arthroplasty (TJA) Surgery Patient
• Catheter Pros:– POUR incidence following TJA has been reported to be as high as
67%.– No evidence that catheter use increases incidence of catheter
associated urinary tract infection (CAUTI) when duration is less than 24 hours.
– May prevent bladder over-distension which can lead to permanent bladder dysfunction.
– Short-term use can decrease patient discomfort and nursing time (if intermittent catheter required).
– National Association of Orthopaedic Nurses (NAON) guidelines recommends use of indwelling catheter for first 24 hours following TJA.
Normal bladder function
• Adult bladder has capacity of 400-600 ml• Urge to void on average @ 150 ml• Sense of fullness on average @ 300 ml• Bladder volume > 500 ml increases risk for:
– Over-distension – Atony – Incomplete bladder emptying – UTI
Baldini, et al (2009)
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Catheter Cons: Pressure to Eliminate Indwelling Catheter Use
Large body of evidence supports correlation between CAUTI and duration of catheter dwell time.
CDC published guidelines (2009) discouraging routine catheters during surgery & recommended removal in PACU with some exceptions that did not include total joint arthroplasty procedures.
Surgical Care Improvement Project (SCIP) calls for catheter removal on day 1 or 2 with day of surgery being day zero (2010).
Hospital reimbursement affected through Centers for Medicare and Medicaid Services (CMS) hospital-acquired condition program.
Prevention of CAUTI is a 2012 Joint Commission Patient Safety Goal.
MESSAGE RECEIVED: Do not use indwelling urinary catheters.
Our Problems
• Use of indwelling catheters for TJA patients had decreased dramatically.
• While post-operative orders include Q4 hour bladder scan with guidelines for catheterization if no void, this protocol was not initiated until arrival to the orthopaedic unit.
• Staff perception was that patients were arriving from PACU requiring immediate in & out catheterization and were requiring multiple intermittent catheterizations before resolution of urinary retention.
• Our in and out cath protocol was not being utilized in PACU.
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Mission Intermittent Urinary Catheterization Protocol
If no void or voids < 250 ml within 4hours:• Perform bladder scan every 4 hours until spontaneous voiding
resumes.• If bladder volume ≥ 350 ml, perform straight cath.• If bladder volume <350, rescan in 2 hours if patient has not
voided; cath if volume > 350 ml.• If straight cath is required X 2, call MD for further orders• Call MD if urinary output < 250 ml over 8 hours• If bladder volume < 250 ml and pt voiding continue to monitor
I & O
Preliminary PI Project
• A team of orthopaedic nurses collected data for one week to see if an opportunity for improvement would be identified.
• Information was collected for 30 postoperative total knee replacment patients. .– 60% (N=18) did not have a foley placed during the perioperative period.
• Of patients without Foley:– Only 3 patients voided while in PACU.– No patients were scanned or catheterized in PACU.– 10 patients were able to void on arrival to unit.– 8 patients had to be catheterized on arrival.– 9 patients arrived to unit with bladder volume exceeding 500 ml (range
500-1000 ml) measured by bladder scan.• This information was shared at a joint meeting with PACU and a team
developed a plan for the research project.• The research was given exempt status by our community IRB.
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Research Goal
• Explore the incidence of POUR in the total knee and hip replacement population in the Orthopaedic Units at Mission Hospital– POUR: The inability to empty the bladder, not withstanding it
being full, in the immediate to early postoperative period– The literature identified the following risk factors for POUR:
• Age over 50• Intraoperative fluid volume over 750 ml• Surgery duration over 2 hours• Spinal anesthesia• Bladder volume over 270 ml on admission to the PACU
Research Questions
• What is the mean bladder volume on first bladder scan in the PACU?
• What is the incidence of postoperative catheterization in the PACU?
• What is the incidence of postoperative urinary retention (POUR) in total hip and knee arthroplasty patients?
• What are risk factors for POUR in this population?
Study Design
• Prospective descriptive correlational design• Convenience sample (126 patients) of all adult
patients having total knee and/or hip replacements admitted to the orthopaedic unit.
• PACU nurse initiated data collection tool and it was completed by the orthopaedic unit nurse at the time of patient’s first void or catheterization after arrival to unit.
Results
• Mean age: 63.9 yrs (+10.18)• Gender
– 45.2% male– 54.8% female
• Type anesthesia– 63.2% general– 36.8% regional or
general/regional combo
• Surgical duration– Mean: 124.75 min (+ 38.7)
• Male: 133.42 min (+ 39.21)
• Female: 117.58 min (+ 37.0) (p < 0.022)
– Range: 60 to 310 min• Intraoperative volume
– 1590.78 ml (+ 482.49)– Range: 200-3300 ml
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PACU Bladder Volume
• 88% of PACU patients without a Foley scanned
• Mean bladder volume: 383.99 ml (+ 237.80)
• Time to 1st scan from PACU arrival: 1:27 + 0:48
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Ortho Bladder Scan Volume
• 26 (59.1%) of the 44 patients that did not void or were not cathed prior to transfer from PACU to Ortho were scanned based on the intermittent cath protocol directions.
• Mean Volume: 340.46 ml (+
181.63)
17
24%
32%
44%
Scan Resolution
Void Cathed Other
Other =
Foley placement
Incontinent/unmeasured urine
No void but refusal of catheter
Scan repeated at a later time due to bladder volume not meeting catheter threshold
Mission Results Compared to National Trends
National Mission• Incidence: 52%• Risk Factors
– Age over 50– Intraop fluid volume greater than
750 ml– Regional anesthesia– Surgical duration longer than 120
min
• Incidence:– Bladder distension (> 350 ml):
46.5%– POUR (Distension + Cath): 41%
• Correlated factors– Distension
• Regional anesthesia*• Male gender*• Intraop fluid volume greater than
750 ml– POUR
• Procedure duration• Intraop fluid volume greater than
750 ml
(*p < 0.05)
Future Analysis/Future Research
– What is the average number of post-operative catheterizations for patients who develop urinary retention?
– What is the mean time to spontaneous void once cath is required?
– Can POUR incidence be reduced by use of indwelling catheter during surgery or until morning of post-operative day 1?
– Does the incidence of CAUTI differ among groups with intermittent catheterization, catheter during OR only, and indwelling catheter for 24 hours or less? Is there a cost difference?
– Does risk of CAUTI within first 24 hours post-op outweigh potential patient comfort, adverse outcomes, and costs associated with ultrasound use, intermittent cath supplies, and nursing time?
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References
1. Baldini, G., Bagry, H., Aprikian, A., & Carli, F. (2009). Postoperative urinary retention: Anesthetic and perioperative considerations. Anesthesiology, 110(5), 1139-1157.
2. Brouwer, T. A., Eindhoven, B. G., Epema, A. H., & Henning, R. H. (1999). Validation of an ultrasound scanner for determing urinary volumes in surgical patients and volunteers. Journal of Clinical Monitoring & Computing, 15(6), 379-385.
3. Cabezon Gil, P., Lopez Yepes, L., Fernandez Perez, C., Barreales Tolosa, L., Montoya Gonzalez, P., & Lopez Timoneda, F. (2009). [Validity and reliability of bladder ultrasound imaging for noninvasive estimation of urine volume in a major outpatient surgery department]. [English Abstract
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6. Feliciano, T., Montero, J., McCarthy, M., & Priester, M. (2008). A restrospective, descriptive, exploratory study evaluating incidence of postoperative urinary retention after spinal anesthesia and its effect of PACU discharge. Journal of PeriAnesthesia Nursing, 23(6), 394-400.
7. Gallo, S., DuRand, J., & Pshon, N. (2008). A study of naloxone effect on urinary retention in the patient receiving morphine patient-controlled analgesia. [Randomized Controlled Trial]. Orthopaedic Nursing, 27(2), 111-115.
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References
8. Hebl, J. R., Dilger, J. A., Byer, D. E., Kopp, S. L., Stevens, S. R., Pagnano, M. W., . . . Horlocker, T. T. (2008). A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. [Evaluation Studies
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10. Hughson, J., Newman, J., & Pendleton, R. C. (2011). Hip fracture management for the hospital-based clinician: a review of the evidence and best practices. [Review]. Hospital practice (1995) Hospital practice, 39(1), 52-61.
11. Keita, H., Diouf, E., Tubach, F., Brouwer, T., Dahmani, S., Mantz, J., & Desmonts, J. M. (2005). Predictive factors of early postoperative urinary retention in the postanesthesia care unit. Anesthesia & Analgesia, 101, 592-596.
12. Lamonerie, L., Marret, E., Deleuze, A., Lembert, N., Dupont, M., & Bonnet, F. (2004). Prevalence of postoperative bladder distension and urinary retention detected by ultrasound measurement. British Journal of Anaesthesia, 92(4), 544-546.
13. National Association of Orthopaedic Nurses. (2010). Practice Points: Postoperative Urinary Retention Retrieved July 16, 2012, from http://www.orthonurse.org/ResearchPractice/NAONPracticePoints/tabid/640/Default.aspx