Continence management in acute stroke: a survey of current practices in Australia

Evaluating methods of detecting and determining the type of urinary incontinence in adults after stroke: A systematic review

INTRODUCTION

Urinary incontinence (UI) affects over half of people with stroke. It is unclear which methods are accurate in assessing presence and type of UI to inform clinical management. Diagnosis of UI based on inaccurate methods may lead to unnecessary interventions. The aims of this systematic review were to identify, for adults with stroke, clinically accurate methods to determine the presence of UI and type of UI.

METHOD

We searched seven electronic databases and additional conference proceedings. To be included, studies had to be primary research comparing two or more methods, or use a reference test.

RESULTS

We identified 3846 studies with eight eligible for inclusion. We identified 11 assessment methods within the eight studies. Only five studies had sufficient comparator data for synthesis. Due to heterogeneity of data, results on the following methods were narratively synthesized: Core Lower Urinary Tract Symptom Score (CLSS), clinical history and physical examination, Barthel Activities of Daily Living Index, International Consultation Incontinence Questionnaire Short Form (ICiQ-SF) and urodynamic studies (UDS). Most studies were small and of low to medium quality. All reported differences in sensitivity, and none compared the same assessment methods.

CONCLUSION

Current evidence is insufficient to support recommendations on the most accurate UI assessment for adults with stroke. Further research is needed.

Improving Practice for Urinary Continence Care on Adult Acute Medical and Rehabilitation Wards: A Multi-Site, Co-Created Implementation Study

Many adult inpatients experience urinary continence issues; however, we lack evidence on effective interventions for inpatient continence care. We conducted a before and after implementation study. We implemented our guideline-based intervention using strategies targeting identified barriers and evaluated the impact on urinary continence care provided by inpatient clinicians. Fifteen wards (acute = 3, rehabilitation = 7, acute and rehabilitation = 5) at 12 hospitals (metropolitan = 4, regional = 8) participated. We screened 2298 consecutive adult medical records for evidence of urinary continence symptoms over three 3-month periods: before implementation (T₀: n = 849), after the 6-month implementation period (T₁: n = 740), and after a 6-month maintenance period (T₂: n = 709). The records of symptomatic inpatients were audited for continence assessment, diagnosis, and management plans. All wards contributed data at T₀, and 11/15 wards contributed at T₁ and T₂ (dropouts due to COVID-19). Approximately 26% of stroke, 33% acute medical, and 50% of rehabilitation inpatients were symptomatic. The proportions of symptomatic patients (T₀: n = 283, T₁: n = 241, T₂: n = 256) receiving recommended care were: assessment T₀ = 38%, T₁ = 63%, T₂ = 68%; diagnosis T₀ = 30%, T₁ = 70%, T₂ = 71%; management plan T₀ = 7%, T₁ = 24%, T₂ = 24%. Overall, there were 4-fold increased odds for receiving assessments and management plans and 6-fold greater odds for diagnosis. These improvements were sustained at T₂. This intervention has improved inpatient continence care.

Effectiveness of repetitive transcranial magnetic stimulation against poststroke urinary incontinence: a study protocol for a randomized controlled trial

Background and purpose

Poststroke urinary incontinence (PSI) is prevalent in stroke survivors, and high-quality evidence is required to guide clinical practice. Previous studies have demonstrated the curative effect of repetitive transcranial magnetic stimulation (rTMS) for urinary incontinence in individuals with multiple sclerosis (MS), Parkinson’s disease (PD), and spinal cord injury (SCI). Here, we describe the protocol for a randomized controlled trial to evaluate the efficacy and safety of low-frequency rTMS on the contralesional primary motor cortex (M1) for the treatment of PSI.

Methods and analysis

In this single-centre randomized controlled trial for poststroke urinary incontinence, a total of 140 eligible patients will be randomly allocated into two groups. The rTMS group (n = 70) will receive low-frequency rTMS at the M1 along with routine medical care, while the control group will receive sham rTMS along with routine medical care. All participants will undergo 20 treatment sessions, five times a week for 4 weeks. The primary outcome measures will be the changes in the urodynamic test at baseline versus 4 weeks after intervention. The secondary outcomes include the International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form (ICIQ-UI SF), Overactive Bladder Symptom Score (OABSS), and pelvic floor muscle function.

Ethics and dissemination

The Institutional Review Board and Hospital Research Ethics Committee of the Second Affiliated Hospital of Chongqing Medical University approved this trial, and the approval number is No. 2020-153. All methods will be carried out in accordance with the principles of the Declaration of Helsinki and relevant ethical guidelines covering informed consent, confidentiality, and data storage. After the study had been thoroughly described to the participants by a physician, all participants will provide written informed consent indicating their willingness to participate. The results will be disseminated to most of the population, including participants, researchers, healthcare providers, and sponsors.

Trial registration

URL: https://www.chictr.org.cn; Unique identifier: ChiCTR2100042688. Date of Registration: 2021-01-26.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06535-y.

Improving Assessment, Diagnosis, and Management of Urinary Incontinence and Lower Urinary Tract Symptoms on Acute and Rehabilitation Wards That Admit Adult Patients: Protocol for a Before-and-After Implementation Study

Background

Urinary incontinence (UI) and lower urinary tract symptoms (LUTS) are commonly experienced by adult patients in hospitals (inpatients). Although peak bodies recommend that health services have systems for optimal UI and LUTS care, they are often not delivered. For example, results from the 2017 Australian National Stroke Audit Acute Services indicated that of the one-third of acute stroke inpatients with UI, only 18% received a management plan. In the 2018 Australian National Stroke Audit Rehabilitation Services, half of the 41% of patients with UI received a management plan. There is little reporting of effective inpatient interventions to systematically deliver optimal UI/LUTS care.

Objective

This study aims to determine whether our UI/LUTS practice-change package is feasible and effective for delivering optimal UI/LUTS care in an inpatient setting. The package includes our intervention that has been synthesized from the best-available evidence on UI/LUTS care and a theoretically informed implementation strategy targeting identified barriers and enablers. The package is targeted at clinicians working in the participating wards.

Methods

This is a pragmatic, real-world, before- and after-implementation study conducted at 12 hospitals (15 wards: 7/15, 47% metropolitan, 8/15, 53% regional) in Australia. Data will be collected at 3 time points: before implementation (T₀), immediately after the 6-month implementation period (T₁), and again after a 6-month maintenance period (T₂). We will undertake medical record audits to determine any change in the proportion of inpatients receiving optimal UI/LUTS care, including assessment, diagnosis, and management plans. Potential economic implications (cost and consequences) for hospitals implementing our intervention will be determined.

Results

This study was approved by the Hunter New England Human Research Ethics Committee (HNEHREC Reference No. 18/10/17/4.02). Preimplementation data collection (T₀) was completed in March 2020. As of November 2020, 87% (13/15) wards have completed implementation and are undertaking postimplementation data collection (T₁).

Conclusions

Our practice-change package is designed to reduce the current inpatient UI/LUTS evidence-based practice gap, such as those identified through national stroke audits. This study has been designed to provide clinicians, managers, and policy makers with the evidence needed to assess the potential benefit of further wide-scale implementation of our practice-change package.

International Registered Report Identifier (IRRID)

DERR1-10.2196/22902

Factors associated with stroke survivors' inconsistent uptake of physiotherapy interventions at Turton Community Health Centre, KwaZulu-Natal

Background

Stroke is one of the major causes of physical disability worldwide. Whilst physiotherapy interventions are important for the recovery of stroke survivors, the uptake remains inconsistent and factors contributing to these inconsistencies are not well documented, especially in South Africa.

Objectives

The overall objective was to determine the intrinsic and extrinsic factors associated with adult stroke survivors’ inconsistent uptake of physiotherapy interventions at Turton Community Health Centre, Ugu District, KwaZulu-Natal, South Africa.

Methods

This was a cross-sectional study involving 50 stroke survivors who missed one or more of their physiotherapy appointments and 25 who attended all their appointments (comparison group) within a 2-year period. A researcher-administered semi-structured questionnaire was used to collect data, which was captured and analysed using SPSS v25. Results were summarised using descriptive statistics. Pearson’s chi-square test was used for bivariate analysis.

Results

Only two intrinsic factors were significantly associated with the outcome variable, namely: believed in exercises recommended by physiotherapists (χ² = 3.86, p = 0.049) and improvements noted from the start of recommended exercises (χ² = 9.439, p = 0.007). Transportation, including hiring of private cars (74%) and being far away from the health facility (48%), were key extrinsic challenges affecting access to health facilities.

Conclusion

Personal reasons and the difficulty in accessing health facilities were main factors affecting stroke survivors’ uptake of physiotherapy interventions.

Clinical implications

Design of patient-tracking and family support systems may potentially improve the stroke survivors’ uptake of physiotherapy interventions.

Impairment in toileting behavior after a stroke

AIM

Dependence for toileting is the most problematic aspect for patients after a stroke. However, the relative difficulty of each component of toileting and the predictors for independent performance of these activities are unknown. We investigated these issues in stroke patients using Boltzmann sigmoid and generalized linear modeling.

METHODS

We carried out a cross-sectional correlation study, including 107 adult inpatients, hospitalized for a stroke. We assessed the activity components of toileting, as well as evaluated physical impairment using the Fugl-Meyer Assessment, impairments in balance using the Berg Balance Scale, cognitive impairments using the Mini-Mental State Examination and the presence or absence of unilateral spatial neglect or aphasia.

RESULTS

Boltzmann sigmoid modeling showed that the total scores required to obtain a response at 50% of the maximal value for the required components of toileting ranged between 2.691 and 34.962 points, for the components of "wearing pants" and "cutting the toilet paper," respectively. A generalized linear model showed that the Berg Balance Scale score was a significant predictor for independent performance on most component activities of toileting.

CONCLUSIONS

The component of toileting that was easiest to carry out was cutting the toilet paper, and the most difficult was wearing pants. Balance impairment was an independent predictor of independent toileting after stroke. This detailed toileting assessment enabled us to document the most difficult components of toileting, and to assess the motor and process skills required for independent toileting. Geriatr Gerontol Int 2018; 18: 1166-1172.

Dementia and Death After Stroke in Older Adults During a 10-year Follow-up: Results from a Competing Risk Model

OBJECTIVES

To investigate the association between stroke and incident dementia in the presence of a competing risk of death.

METHODS

This study used the National Health Insurance Service-Senior (NHIS-Senior) claim database from 2002 to 2013 (n = 22,792). Stroke (I69.0-I69.9) and dementia (F01-F03, G30, G31.1) patients were defined by the International Classification of Disease 10th revision. The association of stroke with dementia or death was assessed with Cox proportional hazards model and competing-risk model.

RESULTS

During the 10-year follow-up period, there were 1,307 dementia events (5.7%) and 9,272 deaths (40.7%). In the Cox model, the adjusted hazard ratio (HR) for dementia was 2.37 times higher in those who experienced strokes, compared with the non-stroke group (95% CI: 2.23, 2.51). In the presence of death as competing event, stroke was associated with an elevated dementia incidence (HR = 2.06, 95% CI: 1.92, 2.20).

CONCLUSION

Stroke was significantly associated with an increased risk of incident dementia, with the magnitude of the association being attenuated in the competing risk model.

Implementing a Systematic Voiding Program for Patients With Urinary Incontinence After Stroke

We explored health professionals' views of implementing a systematic voiding program (SVP) in a multi-site qualitative process evaluation in stroke services recruited to the intervention arms of a cluster randomized controlled feasibility trial during 2011-2013. We conducted semi-structured group or individual interviews with 38 purposively selected nursing, managerial, and care staff involved in delivering the SVP. Content analysis of transcripts used normalization process theory (NPT) as a pre-specified organization-level exploratory framework. Barriers to implementing the SVP included perceived lack of suitability for some patient groups, patient fear of extending hospital stay, and difficulties with SVP enactment, scheduling, timing, recording, and monitoring. Enablers included the guidance provided by the SVP, patient and relative involvement, extra staff, improved nursing skill and confidence, and experience of success. Three potential mechanisms of consistency, visibility, and individualization linked the SVP process with improvements in outcome, and should be emphasized in SVP implementation.

Urinary incontinence as a predictor of death after new-onset stroke: a meta-analysis

BACKGROUND AND PURPOSE

Urinary incontinence (UI) could be an indicator of increased mortality after new-onset stroke. The aim of the present meta-analysis was to characterize this association.

METHODS

A systematic search retrieved all studies exploring the post-stroke period and comparing death among patients suffering from UI with those without UI. Hazard ratios (HRs) were extracted or estimated from the published proportion of deaths. Various meta-analyses pooled unadjusted HRs, HRs adjusted for confounders and HRs stratified by subgroups of strokes (ischaemic or haemorrhagic), using models with random effects. Heterogeneity was explored through stratification of studies and meta-regression of predefined parameters.

RESULTS

The meta-analysis included 24 studies. UI increased the mortality among the general stroke patients in pooled unadjusted (HR, 5.1; 95% CI, 3.9-6.7) and adjusted (HR, 2.2; 95% CI, 1.8-2.7) analyses. This association was also found among ischaemic (HR, 8.5; 95% CI, 4.6-15.7) and haemorrhagic (HR, 3.9; 95% CI, 1.4-11.3) subgroups of strokes. Studies including indwelling catheters, published more than 10 years ago or with the highest quality on the selection criteria of the Newcastle-Ottawa Quality Assessment scale were associated with a greater effect of UI on mortality. Funnel plots showed a clear asymmetry for adjusted associations. After correcting for this potential publication bias, the pooled HRs still demonstrated a positive association between UI and mortality.

CONCLUSIONS

Urinary incontinence indicates high risk of death after a new-onset stroke. Validity of the analyses on adjusted models is limited by an obvious publication bias.

Caring for continence in stroke care settings: a qualitative study of patients' and staff perspectives on the implementation of a new continence care intervention

OBJECTIVES

Investigate the perspectives of patients and nursing staff on the implementation of an augmented continence care intervention after stroke.

DESIGN

Qualitative data were elicited during semi-structured interviews with patients (n = 15) and staff (14 nurses; nine nursing assistants) and analysed using thematic analysis.

SETTING

Mixed acute and rehabilitation stroke ward.

PARTICIPANTS

Stroke patients and nursing staff that experienced an enhanced continence care intervention.

RESULTS

Four themes emerged from patients' interviews describing: (a) challenges communicating about continence (initiating conversations and information exchange); (b) mixed perceptions of continence care; (c) ambiguity of focus between mobility and continence issues; and (d) inconsistent involvement in continence care decision making. Patients' perceptions reflected the severity of their urinary incontinence. Staff described changes in: (i) knowledge as a consequence of specialist training; (ii) continence interventions (including the development of nurse-led initiatives to reduce the incidence of unnecessary catheterisation among patients admitted to their ward); (iii) changes in attitude towards continence from containment approaches to continence rehabilitation; and (iv) the challenges of providing continence care within a stroke care context including limitations in access to continence care equipment or products, and institutional attitudes towards continence.

CONCLUSION

Patients (particularly those with severe urinary incontinence) described challenges communicating about and involvement in continence care decisions. In contrast, nurses described improved continence knowledge, attitudes and confidence alongside a shift from containment to rehabilitative approaches. Contextual components including care from point of hospital admission, equipment accessibility and interdisciplinary approaches were perceived as important factors to enhancing continence care.

Impact of repetitive transcranial magnetic stimulation on post-stroke dysmnesia and the role of BDNF Val66Met SNP

Background

Little is known about the effects of low-frequency repetitive transcranial magnetic stimulation (rTMS) on dysmnesia and the impact of brain nucleotide neurotrophic factor (BDNF) Val66Met single-nucleotide polymorphism (SNP). This study investigated the impact of low-frequency rTMS on post-stroke dysmnesia and the impact of BDNF Val66Met SNP.

Material/Methods

Forty patients with post-stroke dysmnesia were prospectively randomized into the rTMS and sham groups. BDNF Val66Met SNP was determined using restriction fragment length polymorphism. Montreal Cognitive Assessment (MoCA), Loewenstein Occupational Therapy of Cognitive Assessment (LOTCA), and Rivermead Behavior Memory Test (RBMT) scores, as well as plasma BDNF concentrations, were measured at baseline and at 3 days and 2 months post-treatment.

Results

MoCA, LOTCA, and RBMT scores were higher after rTMS. Three days after treatment, BDNF decreased in the rTMS group but it increased in the sham group (P<0.05). Two months after treatment, RMBT scores in the rTMS group were higher than in the sham group, but not MoCA and LOTCA scores.

Conclusions

Low-frequency rTMS may improve after-stoke memory through various pathways, which may involve polymorphisms and several neural genes, but not through an increase in BDNF levels.

Identifying continence options after stroke (ICONS): a cluster randomised controlled feasibility trial

Background

Urinary incontinence (UI) affects half of patients hospitalised after stroke and is often poorly managed. Cochrane systematic reviews have shown some positive impact of conservative interventions (such as bladder training) in reducing UI, but their effectiveness has not been demonstrated with stroke patients.

Methods

We conducted a cluster randomised controlled feasibility trial of a systematic voiding programme (SVP) for the management of UI after stroke. Stroke services were randomised to receive SVP (n = 4), SVP plus supported implementation (SVP+, n = 4), or usual care (UC, n = 4).

Feasibility outcomes were participant recruitment and retention. The main effectiveness outcome was presence or absence of UI at six and 12 weeks post-stroke. Additional effectiveness outcomes included were the effect of the intervention on different types of UI, continence status at discharge, UI severity, functional ability, quality of life, and death.

Results

It was possible to recruit patients (413; 164 SVP, 125 SVP+, and 124 UC) and participant retention was acceptable (85% and 88% at six and 12 weeks, respectively). There was no suggestion of a beneficial effect on the main outcome at six (SVP versus UC: odds ratio (OR) 0.94, 95% CI: 0.46 to 1.94; SVP+ versus UC: OR: 0.62, 95% CI: 0.28 to 1.37) or 12 weeks (SVP versus UC: OR: 1.02, 95% CI: 0.54 to 1.93; SVP+ versus UC: OR: 1.06, 95% CI: 0.54 to 2.09).

No secondary outcomes showed a strong suggestion of clinically meaningful improvement in SVP and/or SVP+ arms relative to UC at six or 12 weeks. However, at 12 weeks both intervention arms had higher estimated odds of continence than UC for patients with urge incontinence.

Conclusions

The trial has met feasibility outcomes of participant recruitment and retention. It was not powered to demonstrate effectiveness, but there is some evidence of a potential reduction in the odds of specific types of incontinence. A full trial should now be considered.

Trial registration

ISRCTN Registry, ISRCTN08609907, date of registration: 7 July 2010.

Electronic supplementary material

The online version of this article (doi:10.1186/1745-6215-15-509) contains supplementary material, which is available to authorized users.

Electroacupuncture at points Baliao and Huiyang (BL35) for post-stroke detrusor overactivity

Acupuncture is used extensively in China for the treatment of stroke and other neurological disorders. The National Institutes of Health recommends acupuncture as an adjunctive therapy for stroke recovery. This study included patients with post-stroke detrusor overactivity who were treated in the Department of Neurology, Fourth Hospital of Harbin Medical University, China. Subjects received either electroacupuncture or sham electroacupuncture at points Baliao [including bilateral Shangliao (BL31), bilateral Ciliao (BL32), bilateral Zhongliao (BL33), and bilateral Xialiao (BL34)] and Huiyang (BL35). Our results showed that electroacupuncture significantly improved cystometric capacity and bladder compliance, decreased detrusor leak point pressure, ameliorated lower urinary tract symptoms, and decreased the risk of upper urinary tract damage. These findings indicate that electroacupuncture at points Baliao and Huiyang is an effective treatment for post-stroke detrusor overactivity.

The experience of urinary incontinence in stroke survivors: A follow-up qualitative study

Background.

No previous qualitative exploration of urinary incontinence (UI) or post-stroke urinary incontinence (PSUI) has been undertaken in an Australian population.

Purpose.

The purpose of this study is to explore the experiences of community-dwelling stroke survivors who were living with UI/PSUI and understand how context shaped those experiences.

Methods.

A pragmatic approach using thematic analysis was employed for this study.

Findings.

Four themes emerged from the data: “I’ve got to go”: onset and daily experience of UI; “No one ever mentioned it”: lack of advice and information from the health system; “You can’t enjoy something if you’ve got to go the toilet”: experience of occupational restrictions; and “It’s just a matter of planning”: management strategies.

Implications.

UI continued well beyond discharge and was shaped by limited advice, distress, and role loss. Occupational therapists are encouraged to engage in assessment, management, and treatment of UI, including the provision of education that promotes continence, attenuates negative experiences, and enhances community participation.

Evaluating a systematic voiding programme for patients with urinary incontinence after stroke in secondary care using soft systems analysis and Normalisation Process Theory: findings from the ICONS case study phase

BACKGROUND

Urinary incontinence (UI) affects between 40 and 60% of people in hospital after stroke, but is often poorly managed in stroke units.

OBJECTIVES

To inform an exploratory trial by three methods: identifying the organisational context for embedding the SVP; exploring health professionals' views around embedding the SVP and measuring presence/absence of UI and frequency of UI episodes at baseline and six weeks post-stroke.

DESIGN

A mixed methods single case study included analysis of organisational context using interviews with clinical leaders analysed with soft systems methodology, a process evaluation using interviews with staff delivering the intervention and analysed with Normalisation Process Theory, and outcome evaluation using data from patients receiving the SVP and analysed using descriptive statistics.

SETTING

An 18 bed acute stroke unit in a large Foundation Trust (a 'not for profit' privately controlled entity not accountable to the UK Department of Health) serving a population of 370,000.

PARTICIPANTS

Health professionals and clinical leaders with a role in either delivering the SVP or linking with it in any capacity were recruited following informed consent. Patients were recruited meeting the following inclusion criteria: aged 18 or over with a diagnosis of stroke; urinary incontinence (UI) as defined by the International Continence Society; conscious; medically stable as judged by the clinical team and with incontinence classified as stress, urge, mixed or 'functional'. All patients admitted to the unit during the intervention period were screened for eligibility; informed consent to collect baseline and outcome data was sought from all eligible patients.

RESULTS

Organisational context: 18 health professionals took part in four group interviews. Findings suggest an environment not conducive to therapeutic continence management and a focus on containment of UI. Embedding the SVP into practice: 21 nursing staff took part in six group interviews. Initial confusion gave way to embedding of processes facilitated by new routines and procedures. Patient outcome: 43 patients were recruited; 28 of these commenced the SVP. Of these, 6/28 (21%) were continent at six weeks post-stroke or discharge.

CONCLUSION

It was possible to embed the SVP into practice despite an organisational context not conducive to therapeutic continence care. Recommendations are made for introducing the SVP in a trial context.

Post-stroke urinary incontinence

AIM

To provide a comprehensive review of the current evidence on post-stroke urinary incontinence.

METHOD

An electronic database search was performed to identify relevant studies and review articles related to Urinary Incontinence (UI) in the stroke population between the years 1966 and 2012.

FINDINGS

Urinary incontinence following stroke is a common problem affecting more than one-third of acute stroke patients and persisting in up to a quarter at 1 year. It is well established that this condition is a strong marker of stroke severity and is associated with poorer functional outcomes and increased institutionalisation and mortality rates compared with those who remain continent. Despite evidence linking better outcomes to those patients who regain continence, the results of national audits have demonstrated that the management of UI following stroke is suboptimal, with less than two-thirds of stroke units having a documented plan to promote continence.

CONCLUSION

Current evidence supports a thorough assessment to categorise the type and severity of post-stroke urinary incontinence. An individually tailored, structured management strategy to promote continence should be employed. This has been associated with better stroke outcomes and should be the aim of all stroke health professionals.

A survey of short- and long-term pre-lubricated intermittent catheters

The prospect of having to undertake clean intermittent self-catheterisation (CISC) for a short time, or for the rest of a patient's life, can be very daunting. It has an impact on their social, sexual, work and family life. Despite the challenges of the practical performance of the procedure, CISC has many advantages and is a means of reducing the subsequent problems and cost implications associated with long-term indwelling catheter use. There are many different products available on prescription for patients performing CISC and it can be a challenge to choose the right one. This article discusses the impact CISC has on the individual and focuses on a regional survey conducted in a district in the UK of nearly 100 patients who agreed to complete a confidential questionnaire about their experiences using a pre-lubricated CISC catheter (Actreen®). It also discusses the challenges facing nurses with patients practising CISC and offers advice to help patients come to terms with this procedure and its effect on their daily life.

Significance of urinary incontinence, age, and consciousness level on arrival among patients with stroke

Purpose:

We retrospectively investigated prognostic factors including urinary incontinence on arrival among the patients with stroke.

Materials and Methods:

A medical chart review was retrospectively performed for patients with stoke admitted between January 2010 and December 2010 in Ken-o Tokorozawa Hospital which had stroke care unit. The subjects were divided into a control group (functional outcome with modified Rankin scale (mRS) 0-3 at 3 months) and a poor group (severe disability or death, mRS 4-6).

Results:

There were 160 cases that had favorable outcome (the Control group) and 77 cases that had poor outcome (the Poor group). There were no significant differences between the two groups concerning the sex ratio, systolic blood pressure, heart rate, temperature, ratio of diabetes mellitus. However, the average age, ratio of hemorrhagic stroke, ratio of patients with a previous stroke, ratio of urinary incontinence upon admission, and duration of hospitalization in the Poor group was significantly higher than in the Control group. The Glasgow Coma Scale upon admission and ratio of hypertension in the Poor group were significantly lower than that in the Control group. Using a multiple logistic regression analysis, urinary incontinence (odds ratio, 3.17; 95% confidence interval, 1.45-6.93; P = 0.002), age (odds ratio, 1.04; 95% confidence interval, 1.01-1.07; P = 0.003) and Glasgow Coma Scale (odds ratio, 0.87; 95% confidence interval, 0.78-0.97; P = 0.01) were found to be factors independently associated with a poor outcome.

Conclusion:

Among the patients with strokes, the presence of urinary incontinence on arrival, the old age, and the level of consciousness are important prognostic factors. Physicians should therefore check for these factors when evaluating a patient who has experienced a stroke or suspected stroke.

Indwelling urinary catheterization after acute stroke

AIMS

Prolonged indwelling urinary catheterization (IUC) increases risk of urinary tract infection. We aimed to investigate the incidence and risk factors associated with IUC following acute stroke, and its impact on stroke outcome.

METHODS

We prospectively enrolled stroke patients hospitalized within 10 days after onset from August 2006 to December 2008. Kaplan-Meier method was used to estimate the cumulative incidence of IUC, and Cox regression analysis to evaluate the independent predictors. The impact of IUC on poor outcome (modified Rankin Scale >2 or dead) at 3 months was studied by logistic regression.

RESULTS

Of 2,803 patients, 697 (25%) received indwelling urinary catheters. Catheterization was carried out mostly within 1-2 days of admission (86%), with estimated cumulative incidence of 13% (95% confidence interval, 11-14%) at 2 days in patients with ischemic stroke (IS), and 57% (53-61%) in patients with intracerebral hemorrhage (ICH). In IS patients, IUC was significantly associated with increasing age, baseline stroke severity, and neurological deterioration. In ICH patients, stroke severity on admission was the only significant predictor after adjustment. We assessed the 3-month outcome in 2,388 patients, after excluding 177 (6%) dead at discharge, 164 (6%) without providing informed consent, and 74 (3%) lost to follow-up. IUC during acute hospitalization was significantly associated with unfavorable 3-month outcome after adjustment.

CONCLUSIONS

IUC was common in acute stroke care and associated with unfavorable outcome at 3 months. Whether judicious use of urinary catheters in acute stroke patients would improve outcomes may warrant further studies.

Urinary catheterization in acute stroke: clinical realities. A mixed methods study

Objective: To determine what influences the decision to insert an indwelling urinary catheter in acute stroke patients.

Design: A prospective casenote review and semi-structured interviews were conducted and corporate catheterization policy in the study sites was investigated.

Setting: Three teaching hospitals, typical of stroke service provision in most developed countries.

Subjects: Casenotes from 70 consecutive acute stroke admissions; 50 doctors, nurses and physiotherapists working in acute stroke units and medical receiving units.

Results: Stroke patients were catheterized for output monitoring, relief of urinary retention or, especially for older patients, continence-related issues. Half of all catheterizations occurred in acute stroke units. Continence and catheterization were considered less important than other aspects of acute stroke care. No catheterization policy or standardized continence assessment tool was in use. Documentation was often lacking. Patients and relatives were not fully involved in the decision to catheterize. Continence assessment and catheterization practices varied widely. Complex unwritten rules relating to gender proliferated. Such rules demonstrated heuristic problem-solving could potentially cause conflict. Decisions to catheterize ‘belonged’ to doctors or nurses depending upon clinical indications. Clinical assessment and specialist referrals were often seen as ‘not my job’.

Conclusions: Clear corporate policy on catheterization is required to direct practice. Use of standardized continence assessment tools is recommended to set and monitor standards of care. Documentation relating to urinary catheterization needs to improve.