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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-C
Vallire Hooper, PhD, RN, CPAN, FAAN
Mission Hospital
Asheville, NC
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.
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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)
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.
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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.
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
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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.
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
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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.
Data Collection Tool & Process
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
Intraoperative Catheter Status
Catheter Status
In/Out
1%
Foley
20%
No Catheter
78%
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Missing data
1%
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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Voiding Status on PACU Discharge
Scan Resolution
Voided
Cathed
Transferred
4%
40%
56%
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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)
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Scan Resolution
Void
Cathed
Other
24%
Other =
Foley placement
44%
Incontinent/unmeasured urine
No void but refusal of catheter
Scan repeated at a later time
32%
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Mission Results Compared to National Trends
Mission
National
•
•
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*
(*p < 0.05)
• Male gender*
• Intraop fluid volume greater
than 750 ml
– POUR
• Procedure duration
• Intraop fluid volume greater
than 750 ml
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?
References
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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