1. 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

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.

3. Normal bladder function
Adult bladder has capacity of ml
Urge to void on 150 ml
Sense of fullness on 300 ml
Bladder volume > 500 ml increases risk for:
Over-distension
Atony
Incomplete bladder emptying
UTI
1. Baldini et al.
Baldini, et al (2009)

4. 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.

5. 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

6. 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

7. 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 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.

8. 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

9. 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?

10. 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

11. Data Collection Tool & Process

12. 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: min (+ 38.7)
Male: min ( )
Female: min (+ 37.0) (p < 0.022)
Range: 60 to 310 min
Intraoperative volume
ml ( )
Range: ml
No difference by gender on type of anesthesia or volume…was a difference on surgical duration

13. 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

14. PACU Bladder Volume 88% of PACU patients without a Foley scanned
Mean bladder volume: ml ( )
Time to 1st scan from PACU arrival:  1:27 + 0:48
86 of 98 patients….missing data on 12

15. Voiding Status on PACU Discharge

16. 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: ml ( )

18. 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)

19. 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?

20. References
Baldini, G., Bagry, H., Aprikian, A., & Carli, F. (2009). Postoperative urinary retention: Anesthetic and perioperative considerations. Anesthesiology, 110(5),
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),
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),
Cohen, J. (1992). A power primer. Psychological Bulletin, 112(1),
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),
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),

21. References
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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,
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),
National Association of Orthopaedic Nurses. (2010). Practice Points: Postoperative Urinary Retention Retrieved July 16, 2012, from