Analysis and Recommendation
The POUR remediation showed that nurses gained basic knowledge of urinary retention and management. Every active PACU nurse answered the remediation questions correctly. Following the success of the poster and remediation questions, I was interested in the application of the voiding algorithm and physician order to void prior to discharge.
Analyzing the New Order: Patient voiding prior to discharge instructions
In March, the first round of chart audits demonstrated that 68% of high-risk patients had an order for voiding prior to discharge. In April, the order use increased to 74.4% of high-risk cases. By June, the order was used in 81% of cases audited. Prior to the order addendum to the Post Anesthesia Care Discharge Order Set, surgeons did not have an explicit order with voiding instructions. Currently, the vast majority of surgeons are appropriately using the order.
The principal reason some surgeons did not select the “voiding prior to discharge” order was that they failed to select the Post Anesthesia Discharge Order Set. Without choosing the order set, they are not reminded of the voiding requirements. In the upcoming months, PACU nurses will have to remind the new residents to use the appropriate order set and advocate for patients who should void prior to discharge.
Analyzing the New Order: Patient voiding prior to discharge instructions
In March, the first round of chart audits demonstrated that 68% of high-risk patients had an order for voiding prior to discharge. In April, the order use increased to 74.4% of high-risk cases. By June, the order was used in 81% of cases audited. Prior to the order addendum to the Post Anesthesia Care Discharge Order Set, surgeons did not have an explicit order with voiding instructions. Currently, the vast majority of surgeons are appropriately using the order.
The principal reason some surgeons did not select the “voiding prior to discharge” order was that they failed to select the Post Anesthesia Discharge Order Set. Without choosing the order set, they are not reminded of the voiding requirements. In the upcoming months, PACU nurses will have to remind the new residents to use the appropriate order set and advocate for patients who should void prior to discharge.
Measuring Urine Output
Chart audits conducted from March through June revealed that PACU nurses documented the amount voided for high-risk cases 80-93% of the time. Following chart audits, eleven PACU nurses were reeducated on the voiding algorithm; three of which were new hires who had not been taught about POUR prevention. Nurses also stated that certain times, the patient missed the hat while voiding.
Prior to the POUR project, rarely did PACU nurses measure the amount voided. It wasn’t a standard or requirement to measure urine output in Phase II patients. Now, PACU nurses are cognizant of high-risk patients and make every effort to measure urine output.
Chart audits conducted from March through June revealed that PACU nurses documented the amount voided for high-risk cases 80-93% of the time. Following chart audits, eleven PACU nurses were reeducated on the voiding algorithm; three of which were new hires who had not been taught about POUR prevention. Nurses also stated that certain times, the patient missed the hat while voiding.
Prior to the POUR project, rarely did PACU nurses measure the amount voided. It wasn’t a standard or requirement to measure urine output in Phase II patients. Now, PACU nurses are cognizant of high-risk patients and make every effort to measure urine output.
Bladder Scanning
Through chart audits, I assessed if nurses were bladder scanning high-risk patients who were unable to void or voided less than 150ml. In March, PACU nurses scanned 100% of applicable cases. One of the 25 patients audited required straight catheterization to alleviate POUR.
The following month, 76.5% of patients unable to void or voiding less than 150ml were bladder scanned. Four PACU nurses were reeducated on utilizing the algorithm; one was a new hire who had not been trained in POUR prevention. In one case, the surgical team said that the patient could be discharged home without voiding. In the month of April, seven out of 55 patients had POUR and were catheterized.
Through chart audits, I assessed if nurses were bladder scanning high-risk patients who were unable to void or voided less than 150ml. In March, PACU nurses scanned 100% of applicable cases. One of the 25 patients audited required straight catheterization to alleviate POUR.
The following month, 76.5% of patients unable to void or voiding less than 150ml were bladder scanned. Four PACU nurses were reeducated on utilizing the algorithm; one was a new hire who had not been trained in POUR prevention. In one case, the surgical team said that the patient could be discharged home without voiding. In the month of April, seven out of 55 patients had POUR and were catheterized.
Without the voiding algorithm, eleven out of 132 Phase II patients would have been discharged home with POUR. The voiding algorithm potentially prevented permanent bladder damage, readmissions, and Emergency Department visits in 8.3% of high-risk patients audited. More importantly, POUR prevention guided nurses to provide safe patient care.
Recommendations
In June I discussed a concern about the voiding algorithm with PACU Permanent Charge Nurse, Mary Hurlburt. Mary told me that a few PACU nurses were
taking the POUR risk factors too literally, causing them to assume that
every Phase II patient had a high risk for POUR and should void. To clarify the confusion, I
made an addendum to the guideline prior to its approval. The Voiding Algorithm for Preventing Postoperative Urinary Retention states:
Phase II patients with multiple risk factors should void at least 150 ml.
With this addendum, I sought to communicate that the algorithm is a guideline and that the nurse has to look at the big picture while thinking critically about the patient. Every patient has some risk for developing POUR, but that doesn't mean every patient should void before discharge. It's not practical, nor a good use of resources. The procedural risk factors are the more important ones. Still, POUR is not a black and white issue.
Currently, I am working with PACU's nurse educator to add POUR prevention to the new hire orientation checklist. Once added to the orientation, every new hire would receive education on postoperative urinary retention, utilizing the algorithm for high-risk patients, and the implications of the order for "patient voiding prior to discharge instructions."
Phase II patients with multiple risk factors should void at least 150 ml.
- If the patient has an MD order stating, "Patient voiding prior to discharge instructions: If unable to void within ___ hours post procedure, bladder scan and notify surgeon," then the patient must void at least 150ml.
- Without an order to void, the PACU nurse assesses the patient's risk. The procedure- related risk factors are the most significant. If the PACU nurse believes the patient has a high risk for POUR, then he/she encourages the patient to void and advocates for an MD order stating, “Must void prior to discharge."
With this addendum, I sought to communicate that the algorithm is a guideline and that the nurse has to look at the big picture while thinking critically about the patient. Every patient has some risk for developing POUR, but that doesn't mean every patient should void before discharge. It's not practical, nor a good use of resources. The procedural risk factors are the more important ones. Still, POUR is not a black and white issue.
Currently, I am working with PACU's nurse educator to add POUR prevention to the new hire orientation checklist. Once added to the orientation, every new hire would receive education on postoperative urinary retention, utilizing the algorithm for high-risk patients, and the implications of the order for "patient voiding prior to discharge instructions."
Synopsis
A year ago, the PACU did not have a standardized approach for managing POUR. Nurses were not knowledgeable about urinary retention, the contributing factors, and methods of prevention. Voiding occurrences were not measured. Furthermore, many physicians assumed patients voided prior to discharge without writing an order. Inconsistencies allowed for incidences where patients went home with full bladders putting them at risk for permanent bladder damage or being readmitted.
Now there is a process in place.
Through education and multiple implementations, PACU nurses consistently measure urine output and bladder scan appropriate patients. For the majority of high-risk cases, surgical physicians utilize an order signifying the patient must void prior to discharge. Above all,
patient care and safety improved in PACU by managing POUR.
Now there is a process in place.
Through education and multiple implementations, PACU nurses consistently measure urine output and bladder scan appropriate patients. For the majority of high-risk cases, surgical physicians utilize an order signifying the patient must void prior to discharge. Above all,
patient care and safety improved in PACU by managing POUR.
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