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Raelyn Nicholson, RN, BSN, PCCN, BAUniversity of Colorado Hospital
United States of America
SERVICE AREA (Edit this in the Master Slide Area)
•Define postoperative urinary retention (POUR).
•Identify risk factors for developing POUR.
•Utilize a voiding algorithm to standardize management of POUR in phase II patients.
SERVICE AREA (Edit this in the Master Slide Area)
Four-time ANCC Magnet-recognized (2002, 2005, 2010, 2014)
•Inpatient Pavilion
- 611 Licensed Beds
•In 2015
-Over 13,900 OR cases
-Over 4,000 outpatients
SERVICE AREA (Edit this in the Master Slide Area)
•Risk management case in 2013- Patient discharged home after a gynecologic
procedure.
- Later, patient went to emergency department (ED) due to pain and an inability to void.
- Catheter placed in ED yielding over 3 liters of urine.
•PACU nurse documentation- Patient voided, but amount not measured.
- Nurse communicated exclusively with the anesthesiologist.
SERVICE AREA (Edit this in the Master Slide Area)
•Nursing and physician practices for managing POUR were inconsistent and needed standardization.
SERVICE AREA (Edit this in the Master Slide Area)
Baldini, G., Bagry, H., Aprikian, A., & Carli, F. (2009). Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology, 110(5), 1139-1157.
Beatty, A.M., Martin, D.E., Couch, M., & Long, N. (1997). Relevance of oral intake an necessity to void as ambulatory surgical discharge criteria. Journal of PeriAnesthesia Nursing, 12(6), 413-421.
Buchko, B.L. & Robinson, L.E. (2012). An evidence-based approach to decrease early post-operative urinary retention following urogynecologic surgery. Urologic Nursing, 32(5), 260-273.
Buchko, B.L., Robinson, L.E., & Bell, T.D. (2013). Translating an evidence-based algorithm to decrease early post-operative urinary retention after urogynecologic surgery. Urologic Nursing, 33(1), 24-32. doi: 10.7257/1053-816X2013.33.1.24
DiBlasi, S.M. (2013). Planned cesarean delivery and urinary retention associated with spinal morphine. Journal of PeriAnesthesiaNursing, 28(3), 128-135. doi: 10.1016/j.jopan.2012.07.012
Dreijer, B., Moller, M.H., & Bartholdy, J. (2011). Post-operative urinary retention in a general surgical population. European Journal of Anaesthesiology, 28(3), 190-194. doi: 10.1097/EJA.0b013e328341ac3b
Hansen, B.S., Soreide, E., Warland, A.M., & Nilsen, O.B. (2011). Risk factors of post-operative urinary retention in hospitalised patients. Acta Anaesthesiologica Scandinavica, 55, 545-548. doi: 10.1111/j.1399-6576.2011.02416.x
Feliciano, T., Montero, J., McCarthy, M., & Priester, M. (2008). A retrospective, descriptive, exploratory study evaluating incidence of postoperative urinary retention after spinal anesthesia and its effect on PACU discharge. Journal of PeriAnesthesia Nursing, 23(6), 394-400. doi: 10.1016/j.jopan.2008.09.006
McLeod, L., Southerland, K., & Bond, J. (2013). A clinical audit of postoperative urinary retention in the postanesthesia care unit. Journal of PeriAnesthesia Nursing, 28(4), 210-216. doi: 10.1016/j.jopan.2013.10.0006
Warner, A.J., Phillips, S., Riske, K., Haubert, M., & Lash, N. (2000). Postoperative bladder distension: Measurement with bladder ultrasonography. Journal of PeriAnesthesia Nursing, 15(1), 20-25.
SERVICE AREA (Edit this in the Master Slide Area)
Postoperative bladder volume
> 400 ml &
and unable to void
> 150 ml
SERVICE AREA (Edit this in the Master Slide Area)
•Patient safety issue
•Increased lengths of stay
•Increased readmissions and ED visits
•Decreased patient satisfaction
SERVICE AREA (Edit this in the Master Slide Area)
•Restlessness
•Confusion
•Anxiety
•Hypertension
•Tachypnea
•Tachycardia, Bradycardia, or other Arrhythmias
•Or Asymptomatic
SERVICE AREA (Edit this in the Master Slide Area)
•Obstruction
•Inability to sense bladder fullness
•Bladder hypotonia
SERVICE AREA (Edit this in the Master Slide Area)
• Type of Anesthesia- Spinal Blocks
• Type of Surgery- Urologic Procedures
- Inguinal Hernia Repair
- Rectal Procedures
- Gynecologic Procedures
- Emergent Surgery
• Medications- Opioids
- Anticholinergics
- Sympathomimetics
- Beta Blockers
• Male
• > 65 years-old
• Length of Procedure > 60 min
• Intraoperative Fluid Volume > 1000 ml
SERVICE AREA (Edit this in the Master Slide Area)
• Informal survey of physicians
- 21 out of 39 (54%) physicians assumed that patients voided prior to discharge.
• Informal survey of RNs to identify barriers to measuring urine output and bladder scanning.
• All 37 PACU nurses completed a ten question multiple choice test on POUR concepts to assess baseline knowledge.
- Test average was 33%
- Knowledge Gap!
SERVICE AREA (Edit this in the Master Slide Area)
Write an addendum to the PACU discharge order set, where “voiding prior to discharge instructions” automatically populates.
Create an algorithm for PACU nurses to serve as a guideline for managing POUR.
Educate RNs on POUR concepts.
Eliminate physical barriers to measuring urine outputand post void residuals.
SERVICE AREA (Edit this in the Master Slide Area)
•Patient must void prior to discharge due to:- Spinal
- Hernia Repair
- Rectal Procedure
- Urologic Procedure
- Gynecologic/Laparoscopic Procedure
- Past Medical History
- Other (Specify): _______
•If unable to void within ___ hours post procedure, bladder scan and notify surgeon.
SERVICE AREA (Edit this in the Master Slide Area)
Write an addendum to the PACU discharge order set, where “voiding prior to discharge instructions” automatically populates.
Create an algorithm for PACU nurses to serve as a guideline for managing POUR.
Educate RNs on POUR concepts.
Eliminate physical barriers to measuring urine outputand post void residuals.
SERVICE AREA (Edit this in the Master Slide Area)
Risk Factors Spinal Anesthesia Type of Surgery Length of Procedure > 65 years-old Male Meds: Opioids,
Anticholinergics, Sympathomimetics, Beta Blockers
Intraoperative FluidVolume > 1000 ml
SERVICE AREA (Edit this in the Master Slide Area)
Write an addendum to the PACU discharge order set, where “voiding prior to discharge instructions” automatically populates.
Create an algorithm for PACU nurses to serve as a guideline for managing POUR.
Educate PACU nurses on POUR concepts.
Eliminate physical barriers to measuring urine outputand post void residuals.
SERVICE AREA (Edit this in the Master Slide Area)
• PACU nurses educated on POUR concepts via a PowerPoint presentation.
- Nurses instructed on implementing the voiding algorithm in Phase II patients with a high-risk for POUR.
- Introduced to the new order for “voiding prior to discharge instructions.”
SERVICE AREA (Edit this in the Master Slide Area)
• Nurses reviewed pre-implementation test results and POUR concepts.
SERVICE AREA (Edit this in the Master Slide Area)
• To verify knowledge, nurses answered 2 questions regarding voiding requirements.
• Post-education test results increased to 100%.
SERVICE AREA (Edit this in the Master Slide Area)
Write an addendum to the PACU discharge order set, where “voiding prior to discharge instructions” automatically populates.
Create an algorithm for PACU nurses to serve as a guideline for preventing POUR.
Educate RNs on POUR concepts.
Eliminate physical barriers to measuring urine outputand post void residuals.
SERVICE AREA (Edit this in the Master Slide Area)
SERVICE AREA (Edit this in the Master Slide Area)
0
10
20
30
40
50
60
70
80
90
100
Yes No
%
Documentation of amount voided
0
10
20
30
40
50
60
70
80
90
100
Yes No
%
Bladder scanned if voided less than 150 ml
Chart Audits 2014 data
N = 243
SERVICE AREA (Edit this in the Master Slide Area)
55%45%
Yes
No
Chart Audits 2014 data
N = 243
Physician order to void prior to discharge
SERVICE AREA (Edit this in the Master Slide Area)
• Phase II patient returned to Emergency Department with POUR in summer of 2014.
- No physician order for “voiding prior to discharge instructions.”
- The Phase I and Phase II PACU nurses assumed that since an order was not written, the patient was not required to void before going home.
Is patient at risk for POUR?
Outpatient with low risk
for POUR
Discharge
Outpatient with high
risk for POUR. Advocate for
"voiding prior to discharge" order if not already written.
Unable to void
Assess volume by
bladder scan
Bladder volume
> 400 ml
Call surgeon for catheterization
order
Bladder volume
≤ 400 ml
Notify surgeon of scanned volume. MD must clear
patient for discharge.
Advise patient to seek medical assistance if
unable to void within 6-8 hours.
Discharge
Void
< 150 ml ≥ 150 ml
Additional Risk Factors• Medications: Opioids, Beta Blockers,
Anticholinergics, Sympathomimetics• Length of Procedure > 60 min• Intraoperative fluid > 1000 ml• History of Benign Prostatic
Hyperplasia (BPH)• Age > 65 years old
High Risk Procedures• Spinal Blocks• Urologic Procedures• Inguinal Hernia Repair • Rectal Procedures • Gynecologic Procedures• Emergent Surgery
SERVICE AREA (Edit this in the Master Slide Area)
56%
14%
30%
Yes
ClinicianCommunication
No
Chart Audits
2015 data (post revised algorithm)
Physician order to void prior to discharge
SERVICE AREA (Edit this in the Master Slide Area)
Chart Audits
2014 N=243 (original algorithm)
2015 N=169 (post revised algorithm)
0
10
20
30
40
50
60
70
80
90
100
Yes No
%
Documentation of amount voided
0
10
20
30
40
50
60
70
80
90
100
Yes No
%
Bladder scanned if voided less than 150 ml
SERVICE AREA (Edit this in the Master Slide Area)
Since the 2015 revised voiding algorithm:
•There have been NO recorded readmissions from POUR
•PACU nurses consistently measure urine output and bladder scan appropriate patients.
•Patient care and safety improved in PACU by managing POUR.
SERVICE AREA (Edit this in the Master Slide Area)
•You are your patient’s advocate.
•Recognize risk factors for POUR and if patient needs to void prior to discharge.
•Use the voiding algorithm.
•Measure and bladder scan.
SERVICE AREA (Edit this in the Master Slide Area)
SERVICE AREA (Edit this in the Master Slide Area)
Baldini, G., Bagry, H., Aprikian, A., & Carli, F. (2009). Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology, 110(5), 1139-1157.
Beatty, A.M., Martin, D.E., Couch, M., & Long, N. (1997). Relevance of oral intake an necessity to void as ambulatory surgical discharge criteria. Journal of PeriAnesthesia Nursing, 12(6), 413-421.
Buchko, B.L. & Robinson, L.E. (2012). An evidence-based approach to decrease early post-operative urinary retention following urogynecologic surgery. Urologic Nursing, 32(5), 260-273.
Buchko, B.L., Robinson, L.E., & Bell, T.D. (2013). Translating an evidence-based algorithm to decrease early post-operative urinary retention after urogynecologic surgery. Urologic Nursing, 33(1), 24-32. doi: 10.7257/1053-816X2013.33.1.24
DiBlasi, S.M. (2013). Planned cesarean delivery and urinary retention associated with spinal morphine. Journal of PeriAnesthesia Nursing, 28(3), 128-135. doi: 10.1016/j.jopan.2012.07.012
Dreijer, B., Moller, M.H., & Bartholdy, J. (2011). Post-operative urinary retention in a general surgical population. European Journal of Anaesthesiology, 28(3), 190-194. doi: 10.1097/EJA.0b013e328341ac3b
Hansen, B.S., Soreide, E., Warland, A.M., & Nilsen, O.B. (2011). Risk factors of post-operative urinary retention in hospitalised patients. Acta Anaesthesiologica Scandinavica, 55, 545-548. doi: 10.1111/j.1399-6576.2011.02416.x
Feliciano, T., Montero, J., McCarthy, M., & Priester, M. (2008). A retrospective, descriptive, exploratory study evaluating incidence of postoperative urinary retention after spinal anesthesia and its effect on PACU discharge. Journal of PeriAnesthesia Nursing, 23(6), 394-400. doi: 10.1016/j.jopan.2008.09.006
McLeod, L., Southerland, K., & Bond, J. (2013). A clinical audit of postoperative urinary retention in the postanesthesia care unit. Journal of PeriAnesthesia Nursing, 28(4), 210-216. doi: 10.1016/j.jopan.2013.10.0006
Warner, A.J., Phillips, S., Riske, K., Haubert, M., & Lash, N. (2000). Postoperative bladder distension: Measurement with bladder ultrasonography. Journal of PeriAnesthesia Nursing, 15(1), 20-25.
