New Knowledge, Innovations & Improvements
And to think, it started with urinary retention...
My year-long endeavor in preventing postoperative urinary retention (POUR) taught me how I am capable of effecting change through acquiring new knowledge and utilizing it to implement innovations and improvements.
In August 2013, Carolyn Dietrich told me about a PACU risk management case where a patient was discharged home following a successful laparoscopic-assisted bilateral salpingo-oophorectomy. Due to her level of pain and an inability to void, the patient’s husband drove her to the nearest emergency department where she had a Foley catheter placed. The patient was voiding in PACU, but the documentation showed voiding as an occurrence, as opposed to measured output. The patient was probably voiding small amounts indicating overflow (the bladder was full and dumping small amounts of urine). Per PACU charting requirements, the documentation was appropriate. However, the nurse communicated her bladder assessment with the anesthesiologist instead of the surgical team. Based on the clinical documentation, the PACU nurse believed she had covered the care of the patient.
Following the event, I recognized that nursing and physician practices for managing POUR were inconsistent and needed standardization. I began a quality improvement project to reduce the incidences of large bladder volumes in the postoperative patient going home the day of surgery.
In August 2013, an informal survey revealed that 21 out of 39 providers (surgeons and anesthesiologists) assumed patients voided prior to discharge. I also completed a literature review to gain knowledge of POUR and determine the evidence-based recommendations for management and prevention.
Based on literature, I created a voiding algorithm to use as a guideline, which would require patients at a high risk for POUR to void a certain amount prior to discharge. If unable to void or voiding less than 150ml, the nurse bladder scans and contacts the surgical team for further orders (i.e. straight catheterization, Foley catheterization, or discharge). I also wrote an addendum to the PACU discharge order set stating, “Patient voiding prior to discharge instructions.”
By September, I issued a pretest to asses PACU nurses’ knowledge on various aspects of POUR and its management. All 37 active PACU nurses completed the pretest. The test average was 33% demonstrating a knowledge gap.
In October, I emailed department heads, urologists, and general surgeons for approval and feedback on the POUR project. Then, PACU nurses were educated on POUR concepts via a PowerPoint presentation. They were also taught how to use the algorithm as a guideline for high-risk patients. Finally, they were informed of the addendum to the discharge order set.
My year-long endeavor in preventing postoperative urinary retention (POUR) taught me how I am capable of effecting change through acquiring new knowledge and utilizing it to implement innovations and improvements.
In August 2013, Carolyn Dietrich told me about a PACU risk management case where a patient was discharged home following a successful laparoscopic-assisted bilateral salpingo-oophorectomy. Due to her level of pain and an inability to void, the patient’s husband drove her to the nearest emergency department where she had a Foley catheter placed. The patient was voiding in PACU, but the documentation showed voiding as an occurrence, as opposed to measured output. The patient was probably voiding small amounts indicating overflow (the bladder was full and dumping small amounts of urine). Per PACU charting requirements, the documentation was appropriate. However, the nurse communicated her bladder assessment with the anesthesiologist instead of the surgical team. Based on the clinical documentation, the PACU nurse believed she had covered the care of the patient.
Following the event, I recognized that nursing and physician practices for managing POUR were inconsistent and needed standardization. I began a quality improvement project to reduce the incidences of large bladder volumes in the postoperative patient going home the day of surgery.
In August 2013, an informal survey revealed that 21 out of 39 providers (surgeons and anesthesiologists) assumed patients voided prior to discharge. I also completed a literature review to gain knowledge of POUR and determine the evidence-based recommendations for management and prevention.
Based on literature, I created a voiding algorithm to use as a guideline, which would require patients at a high risk for POUR to void a certain amount prior to discharge. If unable to void or voiding less than 150ml, the nurse bladder scans and contacts the surgical team for further orders (i.e. straight catheterization, Foley catheterization, or discharge). I also wrote an addendum to the PACU discharge order set stating, “Patient voiding prior to discharge instructions.”
By September, I issued a pretest to asses PACU nurses’ knowledge on various aspects of POUR and its management. All 37 active PACU nurses completed the pretest. The test average was 33% demonstrating a knowledge gap.
In October, I emailed department heads, urologists, and general surgeons for approval and feedback on the POUR project. Then, PACU nurses were educated on POUR concepts via a PowerPoint presentation. They were also taught how to use the algorithm as a guideline for high-risk patients. Finally, they were informed of the addendum to the discharge order set.
Throughout November, PACU nurses underwent POUR remediation. Through a poster presentation, the results of the pretest were graphed and correct answers were highlighted. Nurses read the results, which reeducated them on POUR and its risk factors. To demonstrate learning, nurses answered two questions on POUR concepts, including the bladder volume that is considered POUR and the minimum amount a patient should void. All 42 active PACU nurses completed the remediation; every nurse scored 100%. Epic was also contacted to create the discharge order set addendum.
In the winter of 2013, the addendum to the order set moved to Epic production. I also facilitated a journal club with 19 PACU nurses to reinforce POUR concepts (see Journal Club in Structural Empowerment).
During the spring of 2014, I presented the POUR PowerPoint to AOP PACU and at the Perianesthesia Quality Improvement Council. After identifying the need to measure urine output on high-risk patients, AOP PACU began to implement the algorithm. I also communicated with other post procedural areas at UCH. In turn, IR implemented the algorithm for appropriate patients.
To standardize POUR implementations, I wrote a guideline for the Voiding Algorithm and updated the Bladder Scan Use guideline (see Unit-Based Guidelines in Transformational Leadership). The guidelines were approved in June 2014.
From March to June, I performed chart audits to assess the efficacy and appropriate use of the POUR algorithm by nurses and the new order by physicians. After the algorithm implementation, nurses almost always measured urine output for patients with a high risk for developing POUR. The order for “patient voiding prior to discharge instructions” was used the majority of the time, too. More importantly, patients with POUR were identified prior to discharge and treated according to the surgeon’s preference.
UCH staff nurses are capable of implementing change by acquiring new knowledge and utilizing it through innovations and improvements. With my POUR implementations, I was dedicated to achieving excellence in patient care and safety. I disseminated knowledge generated through research and enacted change effecting patient care and outcomes.
In the winter of 2013, the addendum to the order set moved to Epic production. I also facilitated a journal club with 19 PACU nurses to reinforce POUR concepts (see Journal Club in Structural Empowerment).
During the spring of 2014, I presented the POUR PowerPoint to AOP PACU and at the Perianesthesia Quality Improvement Council. After identifying the need to measure urine output on high-risk patients, AOP PACU began to implement the algorithm. I also communicated with other post procedural areas at UCH. In turn, IR implemented the algorithm for appropriate patients.
To standardize POUR implementations, I wrote a guideline for the Voiding Algorithm and updated the Bladder Scan Use guideline (see Unit-Based Guidelines in Transformational Leadership). The guidelines were approved in June 2014.
From March to June, I performed chart audits to assess the efficacy and appropriate use of the POUR algorithm by nurses and the new order by physicians. After the algorithm implementation, nurses almost always measured urine output for patients with a high risk for developing POUR. The order for “patient voiding prior to discharge instructions” was used the majority of the time, too. More importantly, patients with POUR were identified prior to discharge and treated according to the surgeon’s preference.
UCH staff nurses are capable of implementing change by acquiring new knowledge and utilizing it through innovations and improvements. With my POUR implementations, I was dedicated to achieving excellence in patient care and safety. I disseminated knowledge generated through research and enacted change effecting patient care and outcomes.
Preventing POUR Timeline
August 2013
8/27 Initial drafts for voiding algorithm and physician order for “patient voiding prior to discharge instructions” completed.
September 2013
AIP PACU nurses took pretest on POUR concepts.
October 2013
10/2 Voiding algorithm completed based on an extensive literature review.
10/8 Phase II committee met to finalize physician order for “patient voiding prior to discharge instructions”
10/17 Department heads and general surgeons emailed for feedback and approval of new order and algorithm to prevent POUR.
10/21 Via PowerPoint presentation, PACU nurses educated at staff meeting on standard definition of POUR, prevention, risk factors, how to use the algorithm, and the new order.
10/23 Patient Service Clerk (Lauren Morrisette) and I found an unused file cabinet, filled it with urinals and hats, and moved it to the Phase II bathroom.
10/24 Bladder scanner relocated to the Phase II area. Algorithm and POUR PowerPoint placed on AIP PACU sharedrive.
November 2013
11/18 Epic Order Set Coordinator (Joann Young) contacted to enter new order.
11/25 Posters delineating POUR pretest results and initial knowledge gap hung in PACU. Nurses read results, reeducated themselves on POUR and associated risks factors, and completed remediation questions to verify knowledge.
January 2014
Approved draft of new order set addendum for “patient voiding prior to discharge instructions” from Epic team.
February 2014
Order addendum to Post Anesthesia Care Unit Discharge instructions moved to production.
Emailed Danielle Schloffman (Magnet Program Director) POUR project results as Magnet submission for structural empowerment.
2/23 Facilitated journal club on POUR management
2/26 Presented POUR interventions to Clinical Quality and Risk Management Committee based on a urinary retention case that occurred in May 2013.
New Epic order for “voiding prior to discharge instructions” available for use.
March 2014
Chart audits conducted to assess use of voiding algorithm and new order.
AIP PACU nurses educated on order set addendum
3/3 Presented POUR PowerPoint, voiding algorithm, and new order at AOP Staff Meeting
3/27 Presented POUR PowerPoint, voiding algorithm, and new order to Perianesthesia Quality Improvement Council.
3/31 Emailed Ashley Walsh for template to write guideline utilizing POUR algorithm
April 2014
Chart audits conducted to assess use of voiding algorithm and new order.
4/1 Emailed GI, IR, and Pre/Post with POUR information and to gauge interest in
implementing algorithm
4/17 Emailed Infection Prevention representative (Beth Carrier) the POUR algorithm as a
reference for preventing postoperative urinary retention after discontinuing a Foley catheter
4/21 Emailed IR Educator (Gabrielle Shamsabadi) about implementing POUR. She discussed with IR RNs and will loosely implement the algorithm in recovery.
4/29 Emailed Joanne Becker to get approval of 2 Unit Based Guidelines:
1. University of Colorado Hospital Guideline: Voiding Algorithm for Preventing Postoperative Urinary Retention
2. Updated: University of Colorado Hospital Guideline for Bladder Scan Use in Post Anesthesia Care Unit
May 2014
Communicated with Joanne Becker to organize Perioperative Guideline Taskforce meeting in order to approve the Voiding Algorithm for Preventing Postoperative Urinary Retention and updates to the Bladder Scan Use in Post Anesthesia Care Unit Guideline.
June 2014
Chart audits conducted to assess use of voiding algorithm and new order.
6/3 PACU Permanent Charge Nurse, Mary Hurlbert, voiced concerns that some PACU nurses are taking the guideline to literally and requiring most outpatients to void prior to
discharge.
6/5 Wrote addendums to the Voiding Algorithm for Preventing Postoperative Urinary Retention guideline to clarify that every patient with risk factors does not have to void.
6/5-6/7 Received approval of guideline by the Perianesthesia Quality and Patient Safety Council.
6/10 Presented the Voiding Algorithm and Updated Bladder Scan Use Guidelines to the Perioperative Guideline Task Force.
6/11 Guidelines approved.
8/27 Initial drafts for voiding algorithm and physician order for “patient voiding prior to discharge instructions” completed.
September 2013
AIP PACU nurses took pretest on POUR concepts.
October 2013
10/2 Voiding algorithm completed based on an extensive literature review.
10/8 Phase II committee met to finalize physician order for “patient voiding prior to discharge instructions”
10/17 Department heads and general surgeons emailed for feedback and approval of new order and algorithm to prevent POUR.
10/21 Via PowerPoint presentation, PACU nurses educated at staff meeting on standard definition of POUR, prevention, risk factors, how to use the algorithm, and the new order.
10/23 Patient Service Clerk (Lauren Morrisette) and I found an unused file cabinet, filled it with urinals and hats, and moved it to the Phase II bathroom.
10/24 Bladder scanner relocated to the Phase II area. Algorithm and POUR PowerPoint placed on AIP PACU sharedrive.
November 2013
11/18 Epic Order Set Coordinator (Joann Young) contacted to enter new order.
11/25 Posters delineating POUR pretest results and initial knowledge gap hung in PACU. Nurses read results, reeducated themselves on POUR and associated risks factors, and completed remediation questions to verify knowledge.
January 2014
Approved draft of new order set addendum for “patient voiding prior to discharge instructions” from Epic team.
February 2014
Order addendum to Post Anesthesia Care Unit Discharge instructions moved to production.
Emailed Danielle Schloffman (Magnet Program Director) POUR project results as Magnet submission for structural empowerment.
2/23 Facilitated journal club on POUR management
2/26 Presented POUR interventions to Clinical Quality and Risk Management Committee based on a urinary retention case that occurred in May 2013.
New Epic order for “voiding prior to discharge instructions” available for use.
March 2014
Chart audits conducted to assess use of voiding algorithm and new order.
AIP PACU nurses educated on order set addendum
3/3 Presented POUR PowerPoint, voiding algorithm, and new order at AOP Staff Meeting
3/27 Presented POUR PowerPoint, voiding algorithm, and new order to Perianesthesia Quality Improvement Council.
3/31 Emailed Ashley Walsh for template to write guideline utilizing POUR algorithm
April 2014
Chart audits conducted to assess use of voiding algorithm and new order.
4/1 Emailed GI, IR, and Pre/Post with POUR information and to gauge interest in
implementing algorithm
4/17 Emailed Infection Prevention representative (Beth Carrier) the POUR algorithm as a
reference for preventing postoperative urinary retention after discontinuing a Foley catheter
4/21 Emailed IR Educator (Gabrielle Shamsabadi) about implementing POUR. She discussed with IR RNs and will loosely implement the algorithm in recovery.
4/29 Emailed Joanne Becker to get approval of 2 Unit Based Guidelines:
1. University of Colorado Hospital Guideline: Voiding Algorithm for Preventing Postoperative Urinary Retention
2. Updated: University of Colorado Hospital Guideline for Bladder Scan Use in Post Anesthesia Care Unit
May 2014
Communicated with Joanne Becker to organize Perioperative Guideline Taskforce meeting in order to approve the Voiding Algorithm for Preventing Postoperative Urinary Retention and updates to the Bladder Scan Use in Post Anesthesia Care Unit Guideline.
June 2014
Chart audits conducted to assess use of voiding algorithm and new order.
6/3 PACU Permanent Charge Nurse, Mary Hurlbert, voiced concerns that some PACU nurses are taking the guideline to literally and requiring most outpatients to void prior to
discharge.
6/5 Wrote addendums to the Voiding Algorithm for Preventing Postoperative Urinary Retention guideline to clarify that every patient with risk factors does not have to void.
6/5-6/7 Received approval of guideline by the Perianesthesia Quality and Patient Safety Council.
6/10 Presented the Voiding Algorithm and Updated Bladder Scan Use Guidelines to the Perioperative Guideline Task Force.
6/11 Guidelines approved.
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