VOL: 101, ISSUE: 29, PAGE NO: 53
Jackie Williamson, RGN, is senior staff nurse, Stracathro Hospital, Brechin, Angus, Scotland
Clinical governance has been described as ‘the total of all factors that make the National Health Service, and the place in which you work, safe (Lilley, 1999).
The term ‘clinical governance’ was used for the first time in the White Paper, The New NHS: modern, dependable (DoH, 1997), in which the government stated its commitment to giving the people of the United Kingdom a quality health service. Clinical governance is the framework for driving this quality service. It encompasses clinical effectiveness, risk management, fitness to practise and a patient-focused culture, all of which are underpinned by an organisation that supports the ethos.
As part of an assignment for the clinical governance module of a degree course, I was asked to look at an area of my practice that needed to be improved and determine how I would implement any changes within the clinical governance framework. I chose to look at the problem of detecting postoperative urinary retention (PUR) and at how it could be treated.
According to Rosseland et al (2002), PUR is widespread and is associated with over-distention of the bladder and subsequently lifelong bladder damage. It can lead to an extended stay in hospital (Johansson, et al, 2002).
In the unit where I work, PUR is diagnosed when it is seen that a patient has a desire to void but is unable to so, when a patient has not passed urine since surgery but is otherwise ready to be discharged, or when a patient has a painful over-distension of the bladder. We confirm it by passing an indwelling catheter into the bladder to drain urine, and this remains in place for varying lengths of time. The development of a urinary tract infection is a side-effect of catheterisation and accounts for 20 per cent of hospital-acquired infections (Wilson, 2001). According to the World Health Organization (2002), the vast majority of these infections are linked to the use of indwelling catheters.
My reason for looking at the problem of PUR was because I felt our unit had no guidelines for its management and as a result of this no attempt had been made to identify patients who were at risk of developing the condition or of finding ways to prevent over-distension of the bladder by early detection. I therefore examined current research about managing PUR, with the aim of reviewing practice in the unit as a result of my findings.
Diagnosing postoperative urinary retention
A patient will be diagnosed as having PUR when her/his bladder has a capacity of approximately 500ml (Walsh, 2002. It has been suggested that over-distension of the bladder for a period of four hours can cause functional and structural bladder deformity (Mayo et al, 1973); Kitada et al, 1989).
Pavlin et al (1999) identified that a transient over-distension of the bladder caused by a volume of urine between 500 and 1000ml will not cause damage if it is detected and treated within one to two hours. This is in contrast to a study by Tammela et al (1986), which showed an increase in the prevalence of persistent urinary retention (at least one further episode of retention requiring catheterisation) in patients who initially had 500ml of urine drained from their bladder following surgery. However, this may be because 51 per cent of patients in the study were not catheterised until 12 hours after their operation and that in 38 per cent of the subjects the volume drained exceeded 1000ml. If PUR had been detected and treated earlier, complications could have been avoided (Pavlin et al (1999).
PUR occurs in four to thirty-eight per cent of patients, depending on the type of surgery they have had, their gender, age and preoperative history of urinary dysfunction (Tammela et al, 1986). It has been identified as a particular problem following hernia repair and anal surgery, and it has been reported that spinal/epidural anaesthesia increases the likelihood of a patient developing PUR (Pavlin et al, 1999).
Detecting patients at risk
Ringdal et al (2003) highlighted the importance of obtaining an accurate urinary history before surgery and the literature suggests that it is good practice to highlight patients who are most at risk of PUR so that it can be detected before painful and damaging over-distension of the bladder occurs.
All patients undergoing surgery in my clinical area are assessed to ensure they are fit to have an anaesthetic and surgery. Although patients are asked whether they have urinary problems, it is not usual practice to obtain an in-depth history unless they are undergoing a urological procedure, when problems might be anticipated. But the literature suggests that it is at this preoperative assessment stage that patients with pre-existing urinary problems and those having surgical procedures that increase the risk of PUR could be identified; for example, patients having anal surgery.
Using bladder scanners - Recent improvements in portable ultrasound equipment have made it possible to measure bladder volumes accurately at the bedside without the need for catheterisation (Pavlin et al, 1999). In a randomised controlled trial, Pavlin et al (1999) found a good association between the volume of urine in the bladder when measured using ultrasound compared with measuring the excreted volume of urine. This finding was supported by a case-controlled study carried out by Rosseland et al (2002), who found that their ultrasound measurements under-estimated the volume of urine in the bladder on average by 21.5ml compared to the actual volume passed via the urethra. Both these studies concluded that ultrasound monitoring was an accurate and satisfactory tool that could be used to prevent over-distension of the bladder and reduce the need for catheterisation.
Intermittent self-catheterisation - According to a best practice statement on urinary catheters and catheter care (NHS Quality Improvement Scotland, 2004), the management of PUR in our unit using an indwelling urinary catheter is not best practice. The document stated that ‘when catheterisation is being considered as a treatment, intermittent catheterisation is always the first option providing this is safe and acceptable for the patient’.
Intermittent catheterisation is a safe and effective technique and there is a lower risk of introducing infection into the urinary tract than when an indwelling catheter is being used. Bakke et al (1997) carried out a case-controlled prospective follow-up study on 180 patients who had been using clean intermittent catheterisation for a mean duration of 105 months. The study confirmed that intermittent catheterisation reduces the incidence of clinical infection and protects the upper urinary tract from infection. Choong and Emberton (2000) in a systematic review also found that intermittent catheterisation was an effective and safe method of emptying the bladder. A case-controlled study carried out by Johansson et al (2002) showed that patients treated with an indwelling catheter were nearly twice as likely to contract a urinary tract infection as those who were being treated by intermittent catheterisation.
Pavlin et al (1999) suggest introducing hourly bladder scanning on high-risk patients in the postoperative recovery ward. These researchers found that the mean voiding time of low-risk patients was 95 minutes following surgery, and that patients having hernia/anal surgery had a mean voiding time of 130 minutes. Patients who had had a spinal/epidural anaesthetic had a mean voiding time of 230 minutes.
It is possible to suggest that intervention is required when a patient’s bladder volume is 400-500ml or when a patient expresses a feeling of having voiding difficulties with smaller urine volumes. Intervention can be very simple and non-invasive. Kulacolu et al (2001) found that nine out of 10 patients who had initial difficulties voiding urine following surgery managed to void after simple interventions such as early mobilisation, providing privacy and applying a bag containing warm water over the suprapubic region. These findings support the results of a study by Gonullu et al (1993). If simple interventions do not work, catheterisation with an intermittent catheter is required to prevent long-term bladder damage.
Using low-friction catheters can be more expensive than using indwelling ones, and it is possible to argue that it is better to leave an indwelling catheter in place rather than risk having to repeat catheterisation using an intermittent catheter. However, according to Plowman et al (1999) the overall cost of hospital-acquired infection in England in 1999 was approximately £986 million. Twenty per cent of these infections are due to urinary tract infections (Wilson, 2001). It would seem prudent, therefore, to use intermittent catheters, so as to reduce the risk of infection and other complications associated with indwelling ones.
By introducing a change in practice for patients at risk of PUR after surgery, damage to their bladder will be minimised and the risks of their contracting a hospital-acquired infection is reduced. Furthermore, there will be more consistency in care, as all nursing staff will be following the same protocol.
The potential risk of nursing interventions must be recognised by nurses (O’Neill, (2000). Engaging in appropriate and safe practice is fundamental to reducing patient exposure to ineffective and possibly damaging interventions.