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.

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 1. Baldini et al. 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.

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. Surgeons heard “foley bad” message loud and clear. TJA order sets had order to DC foley AM of pod #1

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.

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?

Prospective descriptive correlational design 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. Sample size based on power analysis α < 0.01 at a power of 0.80 with a medium effect size

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 No difference by gender on type of anesthesia or volume…was a difference on surgical duration

Intraoperative Catheter Status No difference on cath status by gender….in and out throws us off a bit….remind me to discuss ***Mention decrease in foley usage between then slide and first PI data collection

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 86 of 98 patients….missing data on 12

Voiding Status on PACU Discharge

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)

Mission Results Compared to National Trends 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 Incidence: 52% Risk Factors Age over 50 Intraop fluid volume greater than 750 ml Regional anesthesia Surgical duration longer than 120 min (*p < 0.05) Factors significantly correlated with POUR (p < 0.05) Anesthesia type and Gender accounted for the most significant amounts of variance (27% & 22% respectively)

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 Baldini, G., Bagry, H., Aprikian, A., & Carli, F. (2009). Postoperative urinary retention: Anesthetic and perioperative considerations. Anesthesiology, 110(5), 1139-1157. 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. 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 Validation Studies]. Revista Espanola de Anestesiologia y Reanimacion, 56(8), 479-484. Cohen, J. (1992). A power primer. Psychological Bulletin, 112(1), 155-159. 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. 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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