The effectiveness of implementing a bladder ultrasound programme in neurosurgical units

Comparative Effectiveness of Two Models of Point-of-Care Ultrasound for Detection of Post-Void Residual Urine during Acute Ischemic Stroke: Preliminary Findings of Real-World Clinical Application

We conducted a comparative study of two models of point-of-care ultrasound devices for measuring post-void residual urine (PVRU). We prospectively enrolled 55 stroke inpatients who underwent both real-time B-mode ultrasound (Device A) and automated three-dimensional (3D) scanning ultrasound (Device B), with a total of 108 measurements. The median PVRU volume of Device B was 40 mL larger than that of Device A. The PVRU difference between the devices was positively and linearly correlated with PVRU. The correlation of PVRU volume between the devices was strong, but the agreement level was only moderate. Measurement deviations were observed in 43 (40%) and 11 (10%) measurements with Device B and Device A, respectively. The PVRU volume was low in spherical bladder shapes but sequentially increased in triangular, undefined, ellipsoid, and cuboid bladder shapes. Further comparison of 60 sets of PVRU without measurement deviations revealed higher agreements between the devices at correction coefficients of 0.52, 0.66, and 0.81 for PVRU volumes of <100, 100-200, and >200 mL, respectively. The automated 3D scanning ultrasound is more convenient for learning and scanning, but it exhibits larger measurement deviations. Real-time B-mode ultrasound accurately visualizes the urinary bladder but tends to underestimate the urinary bladder when the PVRU volume is large. Hence, real-time B-mode ultrasound with automated PVRU-based adjustment of calculation formulas may be a better solution for estimating bladder volume.

Point-of-Care Ultrasound in the Intensive Care Unit: Applications, Limitations, and the Evolution of Clinical Practice

The use of point-of-care ultrasonography in the intensive care unit has been rapidly advancing over the past 20 years. This review will provide a broad overview of the discipline spanning lung ultrasonography to advanced critical care echocardiography. It will highlight new research that questions the utility of the inferior vena cava for determining volume responsiveness and will introduce the reader to cutting-edge technology including artificial intelligence, which is likely to revolutionize ultrasound teaching and image interpretation, increasing the reach of this modality for the frontline clinician.

Incidence of urinary retention and relations between patient's complaint, physical examination, and bladder ultrasound

OBJECTIVE

To describe the frequency of urinary complaints, bladder globe, and need for bladder relief catheterization according to ultrasound; to investigate the relationship between the urinary volume estimated by ultrasound and the one drained in catheterization; and to describe the relationship of patient's complaints and detection of bladder globe with the diagnosis of urinary retention.

METHOD

A cross-sectional study with clinical patients with suspected urinary retention in a tertiary hospital, conducted from February to September 2018. Urinary volume ≥500 mL in ultrasound was considered urinary retention.

RESULTS

Two hundred and five evaluations were performed in 44 patients. Urinary retention was detected by ultrasound in 33.2% of the evaluations. There was a strong correlation between ultrasound and bladder catheterization. There was a higher frequency of identification of bladder globe in urinary volumes ≥300 mL.

CONCLUSION

The incidence of urinary retention was higher when ultrasound was used for the diagnosis, when compared to patient's complaint and physical examination. Ultrasound showed to be accurate in establishing urinary volume.

Ultrasonography in the Critical Care Unit

Purpose of Review

This article summarizes the utility and evidence supporting the use of ultrasound exams in the intensive care unit.

Recent Findings

Point-of-care ultrasonography (POCUS) is widely used by intensivists managing critically ill patients whereby they can accurately and rapidly assess for many pathologies such as pneumothorax, pulmonary edema, hydronephrosis, hemoperitoneum, and deep vein thrombosis among others. Basic and advanced critical care echocardiography, including transesophageal echocardiography, are routinely performed to determine the etiology of hemodynamic instability in undifferentiated shock and to guide subsequent therapy. The use of POCUS in the assessment of volume status is controversial with studies demonstrating that respiratory variation of the IVC is not reliable and with analysis of aortic blood flow velocity after passive leg raising maneuvers being the most promising.

Summary

Point-of-care ultrasonography allows frontline clinicians to make real-time diagnoses and treatment decisions. This article will provide the reader with a broad overview of this important topic.

Electronic supplementary material

The online version of this article (10.1007/s11886-020-01393-z) contains supplementary material, which is available to authorized users.

Positioning document on incorporating point-of-care ultrasound in Internal Medicine departments

This positioning document describes the most important aspects of clinical ultrasonography in the internal medicine setting, from its fundamental indications to the recommended training period. There is no question as to the considerable usefulness of this tool in the standard clinical practice of internists in numerous clinical scenarios and settings (emergencies, hospital ward, general and specific consultations and home care). Ultrasonography has a relevant impact on the practitioner's ability to resolve issues, increasing diagnostic reliability and safety and providing important information on the prognosis and progression. In recent years, ultrasonography has been incorporated as a tool in undergraduate teaching, with excellent results. The use of ultrasonography needs to be widespread. To accomplish this, we must encourage structured training and the acquisition of equipment. This document was developed by the Clinical Ultrasonography Workgroup and endorsed by the Spanish Society of Internal Medicine.

TWOC around the clock: a multimodal approach to improving catheter care

BACKGROUND

Urinary tract infections (UTI) are the second-largest group of healthcare-associated infections (HCAI). The Saving Lives Urinary Catheter Care Bundle was introduced to reduce catheter-associated urinary tract infections (CAUTI). In response, we implemented a catheter care group to examine ways to improve catheter care in an acute hospital NHS Trust.

METHODS

We adopted a multimodal approach, revolving around four components: (1) Catheter Care Pathway; (2) HOUDINI checklist; (3) catheter magnets; and (4) use of bladder ultrasound scanners.

RESULTS

The yearly CAUTI prevalence survey showed an annual reduction in CAUTI from 2012-2013 to 2014-2015 (3.5% to 2.4%). Evaluations of the multimodal approach have highlighted limitations, leading to priorities being established around provision of tools, education, and use of measurement and feedback.

CONCLUSIONS

Our multimodal approach demonstrates CAUTI rate improvements are achievable, directly benefiting patients. However, long-term maintenance of multimodal components is required to ensure sustained benefit. Engagement and accountability have emerged as significant challenges to the effectiveness and longevity of the catheter care group. We suggest greater emphasis on such challenges if long-term national or international improvement is to be achieved.

Urinary catheters: history, current status, adverse events and research agenda

For more than 3500 years, urinary catheters have been used to drain the bladder when it fails to empty. For people with impaired bladder function and for whom the method is feasible, clean intermittent self-catheterization is the optimal procedure. For those who require an indwelling catheter, whether short- or long-term, the self-retaining Foley catheter is invariably used, as it has been since its introduction nearly 80 years ago, despite the fact that this catheter can cause bacterial colonization, recurrent and chronic infections, bladder stones and septicaemia, damage to the kidneys, the bladder and the urethra, and contribute to the development of antibiotic resistance. In terms of medical, social and economic resources, the burden of urinary retention and incontinence, aggravated by the use of the Foley catheter, is huge. In the UK, the harm resulting from the use of the Foley catheter costs the National Health Service between £1.0-2.5 billion and accounts for ∼2100 deaths per year. Therefore, there is an urgent need for the development of an alternative indwelling catheter system. The research agenda is for the new catheter to be easy and safe to insert, either urethrally or suprapubically, to be retained reliably in the bladder and to be withdrawn easily and safely when necessary, to mimic natural physiology by filling at low pressure and emptying completely without damage to the bladder, and to have control mechanisms appropriate for all users.

Ultrasound measurement of inferior vena cava diameters by emergency department nurses

Sonographic measurement of the inferior vena cava (IVC) diameter is a potentially important noninvasive estimate of fluid status. We researched whether nurses without prior ultrasonography experience could accurately obtain vena cava diameter measurements on models and subjects in comparison with those obtained by an expert sonographer. The design was a prospective educational study using a pre- and posttest of knowledge and a comparison of imaging performance between a subject and an expert sonographer. The setting was an urban teaching medical center with emergency nurses and a convenience sample of volunteer patients selected from the emergency department (ED). Nurses completed a written survey and a pretest to document prior training and experience in ultrasonography and assess baseline knowledge. A structured training program (3.5 hr in length) was provided over three sessions. Training consisted of didactic presentations, practice on phantoms (manikin models designed to provide the sonographic image of the human body when scanned by a trainee) and classmates, and one volunteer patient in the ED. Each nurse then measured IVC diameters on three different volunteer patients in transverse and longitudinal orientations using frozen images. An expert sonographer, blinded to subject results, performed the same examination. Correlations were determined, and a posttraining written examination was completed and results compared with the pretest using a pair-wise t test. Fourteen nurses, with a mean of 8 years' nursing experience (range = 2-18 years), participated. Nurse-expert R value correlation for the longitudinal orientation was 0.68 (95% confidence interval [CI] [0.35, 0.76]) and 0.59 (95% CI [0.47, 0.81]) for the transverse orientation. Posttest scores improved 8.2 percentage points (95% CI [4.0, 12.4]) from 83.3% to 91.5%. Following a brief training course, nurses with no prior sonography experience show moderately good correlation measuring the IVC diameter as compared with expert measurements, with better performance demonstrated in the longitudinal orientation.

Measurement of post-void residual bladder volumes in hospitalized older adults

BACKGROUND

It is commonly recommended to catheterize or closely follow up patients with post-void residual volumes of 150 mL or more, but the frequency of such findings in geriatric hospitalized patients and the need for intervention are unclear.

METHODS

Post-void residual volumes were measured by ultrasound examination within 14 hours of admission in 464 patients aged 70 years or more who were hospitalized in a regional hospital general internal medicine department. Outcome variables included the need for an indwelling catheter and complications of urinary retention during the hospitalization.

RESULTS

Post-void residual volumes of ≥150 mL were common (23.9%; 111/464) and had the following distribution: 150 to 299 mL, 13.1% (61/464); 300 to 499 mL, 6.4% (30/464); and 500 mL or more, 6% (28/464). The rate of indwelling catheters was 3.2% (15/464). Results of post-void residual volumes did not predict the need for indwelling catheters in those without other criteria, although those with indications for indwelling catheters had a significantly higher frequency of post-void residual volumes ≥500 mL (P < .001) compared with those without such indications.

CONCLUSIONS

We conclude that urinary retention in hospitalized geriatric patients is common, but measurements of post-void residual volumes did not have definite clinical utility. However, the study had limited power to determine the benefits or potential harms of urinary catheterization for elevated post-void residual volumes.

Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review

BACKGROUND

Catheter-associated urinary tract infections (CAUTI) are costly, common and often preventable by reducing unnecessary urinary catheter (UC) use.

METHODS

To summarise interventions to reduce UC use and CAUTIs, we updated a prior systematic review (through October 2012), and a meta-analysis regarding interventions prompting UC removal by reminders or stop orders. A narrative review summarises other CAUTI prevention strategies including aseptic insertion, catheter maintenance, antimicrobial UCs, and bladder bundle implementation.

RESULTS

30 studies were identified and summarised with interventions to prompt removal of UCs, with potential for inclusion in the meta-analyses. By meta-analysis (11 studies), the rate of CAUTI (episodes per 1000 catheter-days) was reduced by 53% (rate ratio 0.47; 95% CI 0.30 to 0.64, p<0.001) using a reminder or stop order, with five studies also including interventions to decrease initial UC placement. The pooled (nine studies) standardised mean difference (SMD) in catheterisation duration (days) was -1.06 overall (p=0.065) including a statistically significant decrease in stop-order studies (SMD -0.37; p<0.001) but not in reminder studies (SMD, -1.54; p=0.071). No significant harm from catheter removal strategies is supported. Limited research is available regarding the impact of UC insertion and maintenance technique. A recent randomised controlled trial indicates antimicrobial catheters provide no significant benefit in preventing symptomatic CAUTIs.

CONCLUSIONS

UC reminders and stop orders appear to reduce CAUTI rates and should be used to improve patient safety. Several evidence-based guidelines have evaluated CAUTI preventive strategies as well as emerging evidence regarding intervention bundles. Implementation strategies are important because reducing UC use involves changing well-established habits.

Nurse-directed interventions to reduce catheter-associated urinary tract infections

BACKGROUND

Catheter-associated urinary tract infections (CAUTIs) are common, morbid, and costly. Nearly 25% of hospitalized patients are catheterized yearly, and 10% develop urinary tract infections. Evidence-based guidelines exist for indwelling urinary catheter management but are not consistently followed.

METHODS

A pre/post intervention design was used in this quality improvement project to test the impact of nurse-driven interventions based on current evidence to reduce CAUTIs in hospitalized patients on 2 medical/surgical units. Interventions consisted of hospital-wide strategies including policy and product improvements and unit-specific strategies that focused on a review of current evidence to guide practice.

RESULTS

The number of catheter days decreased from 3.01 to 2.2 (P = .018) on the surgery unit and from 3.53 to 2.7 (P = .076) on the medical unit. CAUTI rates were too low to achieve significant reduction. Product cost savings were estimated at $52,000/year.

CONCLUSION

Guidelines derived from research and other sources of evidence can successfully improve patient outcomes. Nurse-driven interventions, combined with system-wide product changes, and patient and family involvement may be effective strategies that reduce CAUTI.

Reduction of catheter-associated urinary tract infections among patients in a neurological intensive care unit: a single institution's success

OBJECT

To date, there has been a shortage of evidence-based quality improvement initiatives that have shown positive outcomes in the neurosurgical patient population. A single-institution prospective intervention trial with continuous feedback was conducted to investigate the implementation of a urinary tract infection (UTI) prevention bundle to decrease the catheter-associated UTI rate.

METHODS

All patients admitted to the adult neurological intensive care unit (neuro ICU) during a 30-month period were included. The study consisted of two 1-month preintervention observation periods (approximately 1200 catheter days) followed by a 30-month intervention phase (20,394 catheter days). A comprehensive evidence-based UTI bundle encompassing avoidance of catheter insertion, maintenance of sterility, product standardization, and early catheter removal was enacted.

RESULTS

The urinary catheter utilization rate dropped from 100% to 73.3% during the intervention phase (p < 0.0001) without any increase in the rate of sacral decubitus ulcers or other skin breakdown. The rate of catheter-associated UTI was also significantly reduced from 13.3 to 4.0 infections per 1000 catheter days (p < 0.001). There was a linear relationship between the decreased quarterly catheter utilization rate and the decreased catheter-associated UTI rate (r(2) = 0.79, p < 0.0001).

CONCLUSIONS

This single-center prospective study demonstrated that a comprehensive UTI prevention bundle along with a continuous quality improvement program can significantly reduce the duration of urinary catheterization and rate of catheter-associated UTI in a neuro ICU.

Risk factors of post-operative urinary retention in hospitalised patients

BACKGROUND

Post-operative urinary retention (POUR) is most accurately determined by using ultrasound to measure bladder volume. The aim of this study was to define the risk factors of POUR in the recovery room in hospitalised patients.

METHODS

An ultrasound-determined bladder volume ≥400 ml at arrival in the recovery room was used to define POUR. Multivariate regression analysis was used to identify patient and system factors linked to POUR in 773 consecutive hospitalised patients who had undergone orthopaedic, abdominal, gynaecological or plastic surgery without an indwelling urinary catheter.

RESULTS

We found the incidence of POUR to be 13%. The lack of pre-operative voiding, use of regional anaesthesia, anaesthesia time >2 h and emergency surgery were all independent risk factors for POUR.

CONCLUSIONS

The detected incidence of POUR at arrival in the recovery room was rather high but had easily identifiable risk factors. We recommend pre-operative voiding whenever possible. Routine bladder scanning at arrival in the recovery room should be considered, especially after spinal anaesthesia, emergency surgery or when the anaesthesia time exceeds 2 h.