253 - Scanning for Success: A Tool to Predict Postoperative Urinary Retention and Incontinence in Knee Arthroplasty Patients

Description: Clinical Question: In total knee arthroplasty patients that receive mepivacaine spinals, does a bladder scan and straight catheter prior to PACU transfer help to reduce urinary retention?

Problem: Anesthesia switched to a shorter-acting spinal medication to help facilitate earlier ambulation and patient discharge, but staff was unsure how this would affect urination. Surgeons believed that straight catheters were no longer necessary in the OR. PACU nurses reported some patients were having problems with bladder distension and incontinence.

Goal: Bladder scan patients in the OR and perform straight catheters per the urinary protocol (> 400 ml) to increase patient comfort. Increase communication between nurses by documenting and communicating patient void times.

Background/Evidence Summary: TKA patients routinely receive spinal anesthesia during their surgical procedure, which helps with pain control, but it can also cause delayed bladder innervation. Surgical patients are at an increased risk of post-operative urinary retention (POUR) and patients that receive spinals are at a higher risk. Hospitals want to reduce the number of urinary catheters to reduce infection rates, but urinary retention can also lead to infections. Bladder scans can be beneficial to determine if a straight catheter is needed.

Strategies for Implementation:
(1) The EBP team provided surgical services (pre-op, OR, and PACU) staff with information about our project with an in-service, email, and verbal communications.
(2) Three surgeons agreed to have their patients' bladders scanned in the OR. The other patients served as a control group to see if there were differences in post-op urination.
(3) Pre-op placed data collection sheets on all total knee patients' charts and documented the last void time. Information was collected in the OR and PACU about the spinals, patient void times, bladder scan results, and any issues with urination.
(4) Data was collected over four months and we received information on 93 patients.
(5) Data was analyzed to see:
* How many patients received a bladder scan and the percentage that needed a straight catheter
* How many hours were between pre-op and post-op voids
* How many patients had urinary complications in PACU or on the floor

Results/Outcomes:
* 15 patients who were bladder scanned needed a straight catheter because urine was over 400 ml (16%)
* 23 patients who were bladder scanned did not need a straight catheter (26%)
* 54 patients did not receive a bladder scan in the OR (58%)
* 58 patients had documented pre and post procedure void times
* 59% of these did not have post procedure documentation of void within 6 hours nor bladder scan or straight catheterization
* This incidental finding is outside of the Surgery RN scope and was shared with the post procedure units for follow up

Conclusion/Translation of Evidence into Practice
Bladder scanning appears to be more beneficial after surgery when patients can communicate their need to void.
It was a challenge getting some nurses to adjust their charting and collect data for our EBP project, but it led to increased communication about patient void times.
It was hard to analyze all our data due to incomplete charting and missing information on patient void times.
Nurses should follow their hospital's urinary protocol to determine if a bladder scan or straight catheter is necessary.
Patients' urinary needs are different based on a variety of factors and nurses should assess and treat each patient according to their needs.