James Madison University Bladder Scanner Technology Intersects with Nursing: Where Does It Fit In? Robin Woodson James Madison University NSG

Introduction Catheter-associated urinary tract infections (CAUTI) are the second most common type of hospital-associated infection second to surgical site infections (Wound Ostomy and Continence Nurses Society, 2013). CAUTI is the most common cause of nosocomial infections, accounting for 40% of all hospital acquired infections (Saint et al., 2007, Saint et al., 2009, Poisson et al., 2010).

Introduction Most urinary tract infections (UTIs) in hospitalized patients are the result of indwelling urinary catheters with more than 1 million cases each year in US hospitals and nursing homes (Poisson et al., 2010). Complications include: cystitis, periurethral abscess, prostatitis, epididymitis, pylelonephritis, gram negative bacteremia, and urosepsis.

Introduction The Centers for Medicare and Medicaid Services (CMS) deemed catheter-associated urinary tract infections as one of the preventable complications which hospitals will not receive compensation related to the extra cost of treatment (Saint et al., 2009). With the high rate of CAUTI, preventative efforts are aimed at reduction in incidence and cost

Introduction Intermittent catheterization is the “Gold Standard” for post void residual determination due to its accuracy in absolute bladder volumes.

Introduction Bladder scanner technology offers a non-invasive alternative to catheterization in the bladder management of patients. Potential to prevent CAUTI and change nursing practice.

Advantages of Bladder Ultrasound Technology Accuracy, reliability, and sensitivity Greater sensitivity in detection with ultrasound (19.4%) versus palpation (1.4%) (Warner et al., 2000). Recent advancement in technology RPI imaging (real-time pre-scan imaging)—reduces variability and improves accuracy by pre-localization of bladder

Role in CAUTI prevention Bladder ultrasound can decrease CAUTI by: Decreasing the incidence of intermittent catheterizations or avoiding them altogether Decreasing risk of UTI By avoiding urinary retention and bladder overdistention Eliminating the cost associated with supplies, nursing salary related to placement and catheter management and treatment of CAUTI

Hopital Investment Cost of Portable Bladder ultrasound = $8300 Compared to CAUTI treatment per episode= $600 If just 12 UTI are avoided using the portable bladder ultrasound, the cost of the equipment would be recovered ($8300/$600=12.21) (Frederickson et al., 2010, Palese et al., 2010, Saint et al., 2009 )

Other Benefits Patient satisfication Avoid physical and psychological discomfort Embarrassment Preserving patient dignity

Limitations Several case studies have reported large PVR measurements that were not corroborated by intermittent catheterizations (Alagiakrishnan & Valpreda, 2009, Cooperberg et al., 1999, Elsamra et al., 2010). Practitioners need to be aware of limitations and investigate any discrepancy. In each case, the result of the discrepancy required further testing which revealed was cystic pelvic pathology. Low quality images are also produced in obese patients.

Demonstration Short video with Diane Newman (DNP, FAAN, BCB-PMD) Co-director, Penn Cent for Continence and Pelvic Health as she demonstrates the use of the BladderScan BVI-9400 portable ultrasound http://www.youtube.com/watch?v=UOhbMih33fY

Further Points Despite the evidence on the usefulness of the bladder scanner in UTI prevention only 1/3 of hospitals used the technology (Saint et al.,2007). Implementation of bladder monitoring protocols in postoperative patients to minimize urinary retention is supported by literature (Lee et al., 2007)

Conclusions CAUTI is a costly complication leading to longer hospitalization high cost associated with treatment With the emerging CMS reimbursement rule changes, more emphasis placed on preventative measures related to CAUTI Hospital investment offset by long term cost savings in prevention of CAUTI

Conclusions Bladder ultrasound technology Immediate, reliable, non-invasive device for management of urinary retention and distention through a bladder monitoring protocol by the bedside nurse Assess need for catheter Helps reduce CAUTI by: Decreasing intermittent catheterizations Decreasing risk factors for UTI (urinary retention and distention)

References Alagiakrishnan, K., & Valpreda, M. (2009). Ultrasound bladder scanner presents falsely elevated postvoid residual volumes. Canadian Family Physician, 55, 163-164. Cooperberg, M. R., Chambers, S. K., Rutherford, T. I., & Foster, H. E. (2000). Cystic pelvic pathology presenting as falsely elevated postvoid residual urine measured by portable ultrasound bladder scanning: Report of 3 cases and review of the literature. Urology, 55(4), 590xii-590xiv. Elsamra, S. E., Gordon, Z., & Ellsworth, P.I. (2011). The pitfalls of BladderScan PVR in evaluating bladder volume in adolescent females. Journal of Pediatric Urology, 7, 95-97. doi: 10.1016/j.jpurol.2010.10.007. Frederickson, M., Neitzel, J.J., Miller, E.H., Reuter, S., Graner, T., & Heller, J. (2010). The implementation of bedside bladder ultrasound technology: effects on patient and cost postoperative outcomes in tertiary care. Orthopaedic Nursing, 19(3), 79-87. Lee, Y.Y., Wen-Lin, T., Lou, M.F. & Dai, Y.T. (2007). The effectiveness of implementing a bladder ultrasound programme in neurosurgical units. Journal of Advanced Nursing, 57(2), 192-200.

References Poisson, S.N., Johnston, C., & Josephson. A. (2010). Urinary tract infections complicating stroke: Mechanisms, consequences, and possible solutions. Stroke, 41, 180-184. Saint, S., Meddings, J.A., Calfee, D., Kowalski, C.P., and Krein, S.L. (2009). Catheter-associated urinary tract infection and the Medicare rule changes. Annals of Internal Medicine, 150, 877-884. Saint, S., Kowalski, C.P., Kaufman, S.R., Hofer, T.P., Kauffman, C.A., Olmsted, R.N., Forman, J., Banaszak-Holl, J., Damschroder, L., and Krein, S.L. (2007). Preventing hospital-acquired urinary tract infections in the United States: A national study. Clinical Infectious Diseases, 46, 243-250. Warner, A. J., Phillips, S., Riske, K., Haubert, M., & Lash, N. (2000). Postoperative bladder distention: measurement with bladder ultrasonography. Journal of PeriAnesthesia Nursing, 15(1), 20-25. Wound Ostomy and Continence Nurses Society. (2013). Catheter associated urinary tract infections (CAUTI): Fact sheet. Retrieved from http://www.wocn.org/.