Urinary catheter use in patients with hip fracture: Are current guidelines appropriate? A retrospective review

Risk factors for urinary tract infection in geriatric hip fracture patients: a systematic review and meta-analysis

Background

Urinary tract infection (UTI) is a prevalent and consequential complication in hip fracture patients, leading to significant disability and heightened healthcare expenditures. Consequently, there is a critical need for a comprehensive systematic review to identify risk factors and establish early and effective preventive measures.

Methods

A comprehensive search was performed across the PubMed, Cochrane, Embase, Web of Science, and Scopus databases (up to August 31, 2023). Article screening, data extraction, and quality assessment were independently completed by two reviewers.

Results

Forty-four studies were eligible for inclusion, yielding an overall incidence rate of 11% (95% CI: 8%-14%). Our pooled analysis revealed 18 significant risk factors, including being female (OR = 2.23, 95% CI: 1.89-2.63), advanced age (MD = 1.35, 95% CI: 0.04-2.66), obesity (OR = 1.21, 95% CI: 1.11-1.31), catheterization (OR = 3.8, 95% CI: 2.29-6.32), blood transfusion (OR = 1.39, 95% CI: 1.21-1.58), American Society of Anesthesiologists ≥III (OR = 1.28, 95% CI: 1.18-1.40), general anesthesia (OR = 1.26, 95% CI: 1.11-1.43), intertrochanteric fracture (OR = 1.25, 95% CI: 1.01-1.54), hemiarthroplasty (OR = 1.43, 95% CI: 1.19-1.69), prolonged length of hospital stay (MD = 1.44, 95% CI: 0.66-2.23), delirium (OR = 2.66, 95% CI: 2.05-3.47), dementia (OR = 1.82, 95% CI: 1.62-2.06), Parkinson's disease (OR = 1.53, 95% CI: 1.46-1.61), diabetes (OR = 1.27, 95% CI: 1.13-1.43), hypertension (OR = 1.14, 95% CI: 1.03-1.26), congestive heart failure (OR = 1.35, 95% CI: 1.10-1.66), history of sepsis (OR = 7.13, 95% CI: 5.51-9.22), and chronic steroid use (OR = 1.29, 95% CI: 1.06-1.57).

Conclusion

Our study identifies numerous risk factors strongly associated with UTI, offering compelling evidence and actionable strategies for improving clinical prediction, enabling early intervention, and facilitating targeted UTI management.

Systematic review registration

identifier [CRD42023459600], https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=459600.

Incidence of urinary incontinence after hip fracture surgery and associated risk factors: a prospective study

BACKGROUND

The contribution of the postoperative process to developing or worsening urinary incontinence (UI) after hip fracture surgery (HFS) remains unclear. We aimed to evaluate UI incidence and worsening among older patients undergoing HFS, and explore associated risk factors.

METHODS

This prospective cohort study included patients ≥ 75 years admitted between October 2019 and October 2021 to the Traumatology Service of three hospitals in the Consorci Sanitari de Alt-Penedès i Garraf (Barcelona, Spain) with hip fracture requiring surgical treatment. UI was assessed using the first two questions of the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) at baseline and at days 30 (± 3 days) and 90 (± 3 days) after HFS. Surgery-related data and post-surgical complications were recorded.

RESULTS

A total of 248 patients with a mean (SD) age of 85.8 (6.78) years were included; 77.8% were female and 154 (62.1%) had UI at baseline. After HFS, 3.24% experienced urinary tract infections (UTIs), 3.64%, acute urinary retention (AUR), 8.57%, constipation, and 53.9%, prolonged catheterization (> 24 h). Fifty-eight patients without baseline UI developed UI at 30 days, resulting in a UI incidence of 61.7% (95% CI 51.1-71.54) between days 0 and 30. Of the 248 patients, 146 (59.1%) experienced worsening of UI. AUR and UTIs were identified as risk factors for UI development and worsening after HFS, respectively.

CONCLUSION

The incidence of UI in older patients after HFS is significant. Patient management protocols should consider AUR and UTIs to reduce or eliminate the incidence of UI in older patients undergoing HFS.

Outcomes Following Hemiarthroplasty for Femoral Neck Fracture in Patients Who Have Hemiparesis

BACKGROUND

Hemiparesis increases the risk of femoral neck fracture (FNF) in the elderly, which frequently necessitates hemiarthroplasty. There are limited reports on the outcomes of hemiarthroplasty in patients who have hemiparesis. The purpose of this study was to evaluate hemiparesis as a potential risk factor for medical and surgical complications following hemiarthroplasty.

METHODS

Hemiparetic patients who have concomitant FNF and underwent hemiarthroplasty with at least 2 years of follow-up were identified using a national insurance database. A 10:1 matched control cohort of patients who did not have hemiparesis was created for comparison. There were 1,340 patients who have and 12,988 patients who did not have hemiparesis undergoing hemiarthroplasty for FNF. Multivariate logistic regression analyses were used to evaluate rates of medical and surgical complications between the 2 cohorts.

RESULTS

Aside from increased rates of medical complications including cerebrovascular accident (P < .001), urinary tract infection (P = .020), sepsis (P = .002), and myocardial infarction (P < .001), patients who have hemiparesis also experienced higher rates of dislocation within 1 and 2 years (Odds Ratio (OR) 1.54, P = .009; OR 1.52, P = .010). Hemiparesis was not associated with higher risk of wound complications, periprosthetic joint infection, aseptic loosening, and periprosthetic fracture, but was associated with higher incidence of 90-day ED-visits (OR 1.16, P = .031) and 90-day readmission (OR 1.32, P < .001).

CONCLUSION

While patients who have hemiparesis do not have increased risk of implant-related complications other than dislocation, they are at increased risk of developing medical complications following hemiarthroplasty for FNF.

Patients' experiences of urinary retention and bladder care - A qualitative study in orthopaedic care

BACKGROUND

Urinary retention is a common complication associated with hip surgery. There are easily available, evidence-based clinical practice guidelines prescribing how to prevent both urinary retention and other voiding issues, by means of bladder monitoring and risk assessments. A detected lack of adherence to such guidelines increases risks for unnecessary suffering among patients but a greater understanding of patients' experiences can benefit tailored interventions to address quality and safety gaps in orthopaedic nursing and rehabilitation.

PURPOSE

The aim was to describe patients' experiences of urinary retention, bladder issues, and bladder care in orthopaedic care due to hip surgery.

METHOD

This was a qualitative study with a descriptive design: content analysis with an inductive approach was applied to interviews (n = 32) and survey free-text responses (n = 122) across 17 orthopaedic units in Sweden.

RESULTS

The patients had received no or limited details for the recurrent bladder care interventions (such as bladder scans and prompted voiding) while at the hospital. They relied on the staff for safe procedures but were left to themselves to manage and comprehend prevailing bladder issues. Despite the patients' experiences of bladder issues or the risk of urinary retention postoperatively, the link to hip surgery remained unknown to the patients, leaving them searching for self-management strategies and further care.

CONCLUSIONS

Patients' perspectives on bladder care, urinary retention and bladder issues can serve as a means for increased understanding of procedures and issues, reinforcing improved implementation of guidelines, including person-centred information. Safer bladder procedures imply further patient engagement, highlighted in guidelines.

The effect of tamsulosin in postoperative urinary retention: a meta-analysis of randomized controlled trials

Tamsulosin is a therapeutic drug of alpha-adrenergic antagonists. Previous randomized controlled trials and retrospective analyses have proved the efficacy of tamsulosin on many urinary system diseases. However, there is still a conflict about whether tamsulosin could prevent postoperative urinary retention (POUR). This meta-analysis aims to probe into the efficacy of tamsulosin for preventing POUR versus placebo. We searched MEDLINE, EMBASE, and Cochrane Library from December 31, 1999 to April 30, 2022, for randomized controlled trials (RCTs). Studies that were not RCTs or without negative controls were excluded. Cochrane Collaboration harmonized criteria were used to assess the risk of bias in included studies. Revman (version 5.3) software was invited to synthesize the results. We performed subgroup analyses to explore the factors that could influence tamsulosin's efficacy in POUR prevention. Our meta-analysis pooled 13 RCTs with 2163 patients. We concluded that tamsulosin brought about a significant reduction in the risk of POUR versus placebo (13.54% vs 20.88% for tamsulosin vs placebo, RR = 0.63, 95% CI 0.47 to 0.84, P = 0.002). Tamsulosin could significantly reduce the risk of POUR in abdominal (11.52% vs 20.25% for tamsulosin vs placebo, RR = 0.52, 95% CI 0.31 to 0.88, P = 0.02) and female pelvic surgery (15.57% vs 31.50% for tamsulosin vs placebo, RR = 0.51, 95% CI 0.31 to 0.82, P = 0.006) but not in spinal surgery (13.45% vs 12.75% for tamsulosin vs placebo, RR = 1.07, 95% CI 0.72 to 1.60, P = 0.73) and lower limb surgery (21.43% vs 33.33% for tamsulosin vs placebo, RR = 0.64, 95% CI 0.35 to 1.14, P = 0.13). The preventive effect of postoperative (17.70% vs 33.93% for tamsulosin vs placebo, RR = 0.53, 95% CI 0.33 to 0.85, P = 0.008) and postoperative with preoperative tamsulosin (13.96% vs 23.44% for tamsulosin vs placebo, RR = 0.64, 95% CI 0.43 to 0.93, P = 0.02) on POUR were significantly better than preoperative management (11.95% vs 14.63% for tamsulosin vs placebo, RR = 0.62, 95% CI 0.23 to 1.65, P = 0.34). Postoperative catheter placement appears to have a negative impact on the POUR-preventive effect of tamsulosin. (9.37% vs 16.46% for tamsulosin vs placebo, RR = 0.51, 95% CI 0.31 to 0.83, P = 0.007) Tamsulosin showed significantly effect on POUR prevention in patients during spinal (15.07% vs 26.51% for tamsulosin vs placebo, RR = 0.52, 95% CI 0.31 to 0.90, P = 0.02) and epidural anesthesia (12.50% vs 29.79% for tamsulosin vs placebo, RR = 0.42, 95% CI 0.18 to 1.00, P = 0.05) but not in general anesthesia (12.40% vs 18.52% for tamsulosin vs placebo, RR = 0.68, 95% CI 0.45 to 1.03, P = 0.07). Tamsulosin shows better outcomes for preventing POUR than placebo. Besides, tamsulosin showed a different effect on POUR prevention in the various surgical sites, anesthesia, medication management, and catheter use. However, our conclusions still have some limitations due to the lack of evidence.

A co-created nurse-driven catheterisation protocol can reduce bladder distension in acute hip fracture patients - results from a longitudinal observational study

Background

Urinary retention is common in elderly patients undergoing acute hip fracture surgery. Avoiding overfilling the urinary bladder is important to avoid detrusor muscle damage and associated motility problems. The aim of this study was to analyse associations between the co-creation of a nurse-driven urinary catheterisation protocol and the incidence of bladder distension in patients undergoing hip fracture surgery.

Methods

This is a single-centre implementation intervention with a retrospective longitudinal observation design, using five measures points, spanning from June 2015 to March 2020. The intervention was theory driven and the participants, together with the facilitators and researcher, co-created a nurse-driven urinary catheterisation protocol. Data were retrieved from the hip fracture register. Uni- and multivariable logistic regressions were used for analyses of changes in bladder distension and urinary volume of ≥500 ml over the years.

Results

A total of 3078 patients were included over a five-year period. The implementation intervention was associated with a reduction in the proportion of patients with bladder distension of 31.5% (95% confidence interval 26.0–37.0), from year 1 to year 5. The multivariable analysis indicated a 39% yearly reduction in bladder distension, OR 0.61 (95% confidence interval 0.57–0.64, p <  0001). There was a reduction in the proportion of patients with a bladder volume of ≥500 ml of 42.8% (95% confidence interval 36.2–49.4), from year 1 to year 5. The multivariable analysis found a 41% yearly reduction in patients with a bladder volume of ≥500 ml, OR 0.59 (95% confidence interval 0.55–0.64, p <  0.0001). The intervention was associated with improved documentation of both catheter indications and removal plans.

Conclusion

The use of predefined catheter indications and a tighter bladder scanning schedule were associated with a reduction in the incidence of both bladder distension and urine volume ≥ 500 ml in hip fracture patients. Registered nurses can play an active role in the facilitation of timely and appropriate catheter treatment in patients with hip fractures.

Trial registration

Clinical Trial Registry ISRCTN 17022695 registered retrospectively on 23 December 2021, in the end of the study, after data collection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-01057-z.