The effect of appropriate bladder management on urinary tract infection rate in patients with a new spinal cord injury: a prospective observational study

Analysis of facilitators and barriers to early urinary catheter removal in postoperative patients by spine surgery nurses: a qualitative study based on the COM-B model in China

BACKGROUND

The high utilization rate of indwelling urinary catheters in patients after spine surgery poses an increased risk for a range of associated complications. Evidence-based recommendations suggest that urinary catheters should be removed early, yet spine surgery nurses are not positive about the behavior of removing catheters early after the surgery.

OBJECTIVES

The aim of this study was to explore the facilitators and barriers to early catheter removal by spine surgery nurses in postoperative patients, guided by the COM-B model.

METHODS

This study employed a qualitative study with a descriptive research design. In-depth and semi-structured interviews were carried out to explore facilitators and barriers to early catheter removal in postoperative patients by 18 spine surgery nurses in China. Data were analyzed using traditional content analysis methods.

RESULTS

We identified 10 barriers and facilitators from capability, opportunity, and motivation based on the COM-B model. (1) capability: lack of knowledge, Lack of standardized protocols, Changes in workload; (2) opportunity: Increase in the demand for human and material resources, Lack of effective communication, Lack of prioritization of early catheter removal; and (3) motivation: Promote patients' early recovery, Conflicting emotions.

CONCLUSIONS

Nurses encountered barriers from capability, opportunity, and motivation, which were not isolated but interrelated. Future interventions need to incorporate facilitators and barriers to address the issue of early indwelling urinary catheter removal in patients after spine surgery by taking a holistic approach at multiple levels, including nurses, doctors, patients, and health systems.

Evaluation of a new model of care for bladder management in a statewide spinal cord service

STUDY DESIGN

Registry-based cohort study.

OBJECTIVES

To evaluate the impact of the introduction of a new bladder management model of care at the Victorian Spinal Cord Service (VSCS) on the incidence of subsequent emergency department presentations and readmissions to hospital for urinary tract infection (UTI) in the first 2 years after injury.

SETTING

VSCS, Austin Health, Melbourne, Australia.

METHODS

A new model of care that prioritized intermittent self-catheterization was implemented at the VSCS on 1 August 2017. Data from the Victorian State Trauma Registry and Austin Health medical record were used to compare the rate of readmissions, emergency department (ED) presentations and hospitalisations for UTI in the first two years post-injury before and after practice was changed.

RESULTS

A total of 333 cases were included; 149 cases pre-model of care change and 184 cases after. 143 males and 41 females with a mean (SD) age of 48.9 (19.7) were admitted to the VSCS following the change in model of care. The rate of any subsequent hospitalisation for UTI (ED presentation or admission) was lower following the introduction of the new bladder management model of care (Incidence rate ratio 0.30, 95% CI 0.12-0.73).

CONCLUSIONS

Our data demonstrates the real-world impact of a change in bladder management after new SCI. These data strengthen the consensus recommendation in current practice guidelines.

Construction and Verification of Urinary Tract Infection Prediction Model for Hospitalized Rehabilitation Patients with Spinal Cord Injury

OBJECTIVE

To explore the influencing factors of urinary tract infection (UTI) in hospitalized patients with spinal cord injury and to construct and verify the nomogram prediction model.

METHODS

This study is a retrospective cohort study. From January 2017 to March 2022, 558 patients with spinal cord injury admitted to the Department of Rehabilitation Medicine of a tertiary hospital in Anhui Province, China, were selected as the research objects, and they were randomly divided into training group (n = 390) and verification group (n = 168) according to the ratio of 7:3, and clinical data including socio-demographic characteristics, disease-related data, and laboratory examination data were collected. Univariate analysis and multivariate logistic regression were used to analyze the influencing factors of UTI in hospitalized patients with spinal cord injuries. Based on this, a nomogram prediction model was constructed with the use of R software, and the risk prediction efficiency of the nomogram model was verified by the receiver operating characteristic curve and calibration curve.

RESULTS

Logistic regression analysis showed that the American Spinal Cord Injury Association (ASIA)-E grade (compared with ASIA-A grade) was an independent protective factor for UTI in hospitalized patients with spinal cord injury (odds ratio < 1, P < 0.05), while white blood cell count and indwelling catheter were independent risk factors for UTI in hospitalized patients with spinal cord injury (odds ratio > 1, P < 0.05). Based on this, a nomogram risk predictive model for predicting UTI in hospitalized rehabilitation patients with spinal cord injury was constructed, which proved to have good predictive efficiency. In the training group and the verification group, the area under the receiver operating characteristic curve of the nomogram model is 0.808 and 0.767, and the 95% confidence interval of the area under the receiver operating characteristic curve of the nomogram in the training group and the verification group is 0.760∼0.856 and 0.688∼0.845, respectively, indicating the nomogram model has good discrimination. According to the calibration curve, the prediction probability of the nomogram model and the actual frequency of UTI in the training group and the verification group are in good consistency, and the results of the Hosmer-Lemeshow bias test also suggest that the nomogram model has a good calibration degree in both the training group and the verification group (P = 0.329, 0.067).

CONCLUSIONS

ASIA classification level, white blood cell count, and indwelling catheter are independent influencing factors of UTI in hospitalized patients with spinal cord injury. The nomogram prediction model based on the above factors can simply and effectively predict the risk of UTI in hospitalized patients with spinal cord injury, which is helpful for clinical medical staff to identify high-risk groups early and implement prevention, treatment, and nursing strategies in time.

Risk factors of video urodynamics and bladder management for long-term complications in patients with chronic spinal cord injury

This study explores 15-year urological complications in chronic spinal cord injury (SCI) patients and investigates the predictive factors from video-urodynamic study (VUDS) and bladder management. Analyzing 864 SCI patients with a mean 15.6-year follow-up, we assessed complications and utilized multivariate logistic regression for risk evaluation. VUDS factors such as autonomic dysreflexia, detrusor sphincter dyssynergia, vesicourethral reflux (VUR), contracted bladder, and high voiding detrusor pressure significantly increased the likelihood of recurrent urinary tract infections (rUTI). Low bladder compliance, VUR, and contracted bladder notably raised the risk of hydronephrosis, while contracted bladder and detrusor overactivity with detrusor underactivity heightened chronic kidney disease risk. Volitional voiding reduced rUTI and VUR risk, whereas Valsalva maneuver-assisted voiding increased hydronephrosis risk. In conclusion, a contracted bladder identified in VUDS is associated with long-term urological complications in SCI, we propose that patients already experiencing a contracted bladder should prioritize volitional voiding as their preferred bladder management strategy to minimize the risk of additional complications such as rUTI and VUR. These findings unveil previously unexplored aspects in research, emphasizing the need for proactive management strategies in this patient population.

Complications of different methods of urological management in people with neurogenic bladder secondary to spinal cord injury

OBJECTIVE

To investigate the association between multiple types of urological management and urological complications in patients with spinal cord injury (SCI).

DESIGN

A retrospective cohort study.

SETTING

Single medical center.

METHODS

Medical records of SCI patients with regular follow-up of more than two years were reviewed. Urological management was classified into five groups: indwelling urethral catheter (IUC), clean intermittent catheterization (CIC), reflex voiding, suprapubic catheter (SPC), and self-voiding. We analyzed the incidence of urinary tract infection (UTI), epididymitis, hydronephrosis, and renal stone across the different urological-management groups.

RESULTS

Of 207 individuals with SCI, the most common management type was self-voiding (n = 65, 31%) followed by CIC (n = 47, 23%). The IUC and SPC groups included more people with complete SCI than the other management groups. Compared with the IUC group, the SPC and self-voiding groups had lower risks of developing UTI (relative risk [RR] = 0.76, 95% CI, 0.59-0.97 and RR = 0.39, 95% CI, 0.28-0.55, respectively). The SPC group tended to have a lower risk of epididymitis than the IUC group (RR = 0.55, 95% CI, 0.18-1.63).

CONCLUSION

Long-term IUC use was associated with a higher incidence of UTI in people with SCI. As compared to those with IUC, a lower risk of UTI was found in persons with SPC. These findings may have implications for shared clinical decision-making.

Prediction of early bladder outcomes after spinal cord injury: The HALT score

AIMS

Neurogenic bladder (NB) is a prevalent and debilitating consequence of spinal cord injury (SCI). Indeed, the accurate prognostication of early bladder outcomes is crucial for patient counseling, rehabilitation goal setting, and personalized intervention planning.

METHODS

A retrospective exploratory analysis was conducted on a cohort of consecutive SCI patients admitted to a rehabilitation facility in China from May 2016 to December 2022. Demographic, clinical, and electrophysiological data were collected within 40 days post-SCI, with bladder outcomes assessed at 3 months following SCI onset.

RESULTS

The present study enrolled 202 SCI patients with a mean age of 40.3 ± 12.3 years. At 3 months post-SCI, 79 participants exhibited complete bladder emptying. Least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression analyses identified the H-reflex of the soleus muscle, the American Spinal Injury Association Lower Extremity Motor Score (ASIA-LEMS), and the time from lesion to rehabilitation facility (TLRF) as significant independent predictors for bladder emptying. A scoring system named HALT was developed, yielding a strong discriminatory performance with an area under the receiver operating characteristics curve (aROC) of 0.878 (95% CI: 0.823-0.933). A simplified model utilizing only the H-reflex exhibited excellent discriminatory ability with an aROC of 0.824 (95% CI: 0.766-0.881). Both models demonstrated good calibration via the Hosmer-Lemeshow test and favorable clinical net benefits through decision curve analysis (DCA). In comparison to ASIA-LEMS, both the HALT score and H-reflex showed superior predictive accuracy for bladder outcome. Notably, in individuals with incomplete injuries, the HALT score (aROC = 0.973, 95% CI: 0.940-1.000) and the H-reflex (aROC = 0.888, 95% CI: 0.807-0.970) displayed enhanced performance.

CONCLUSION

Two reliable models, the HALT score and the H-reflex, were developed to predict bladder outcomes as early as 3 months after SCI onset. Importantly, this study provides hitherto undocumented evidence regarding the predictive significance of the soleus H-reflex in relation to bladder outcomes in SCI patients.

Factors associated with urinary tract infection in the early phase after performing intermittent catheterization in individuals with spinal cord injury: a retrospective study

Objectives

To investigate the occurrence rate of urinary tract infections (UTIs) in the early phase after performing intermittent catheterization (IC) and to explore the possible factors associated with UTIs after performing IC among people with spinal cord injury (SCI).

Setting

An inpatient rehabilitation department of a teaching hospital in China.

Design

Retrospective chart review.

Methods

A retrospective chart review was carried out for traumatic and non-traumatic SCI patients after performing IC during their inpatient stay. Demographic information, comorbidity of diabetes, urine analysis results before IC, method of IC (sterile or clean), use of bladder irrigation, cessation of IC and its reasons, and UTI events were collected.

Results

A total of 183 adult individuals were included, of which 60 (32.8%) of them were women. The median age was 49.0 years. The median time post-injury was 2 months. The overall occurrence rate of UTI after performing IC was 1.31 (95% confidence intervals: 0.96-1.77) events per 100 days. Sixty-nine (37.7%) patients discontinued IC during hospitalization, and UTIs were the leading reason for cessation (50.7%). Female sex, use of antibiotics for infections other than UTI, and use of bladder irrigation were found to be associated with a lower occurrence rate of UTI in the early phase after performing IC, with an odds ratio of 0.38 (p = 0.019), 0.20 (p = 0.022), and 0.24 (p < 0.001), respectively.

Conclusion

UTI after performing IC is prevalent among people with SCI. The study indicated that antibiotic prophylaxis and routine bladder irrigation might be associated with the reduction in UTI in the early phase after performing IC. Further research is needed to provide more evidence.

Urodynamic findings and therapeutic approaches for neurogenic lower urinary tract dysfunction in patients with thoracic spinal cord injury

OBJECTIVES

To evaluate urodynamic examination results and treatment methods of neurogenic lower urinary tract dysfunction (NLUTD) in patients with traumatic thoracic spinal cord injury (SCI).

METHODS

Ninety-one patients with traumatic thoracic SCI were included in the study. The urodynamic analyses of the patients were conducted retrospectively using their laboratory outcomes. The patients were divided into subgroups according to the sensory innervation of the bladder (T1-10/T11-12), the preservation of sensory functions in the sacral segment (complete lesion/incomplete lesion), and the duration of injury (< 6 months/ ≥ 6 months) and evaluations in subgroups were carried out.

RESULTS

A total of 91 patients (69 males, 22 females) were included in the study. When comparing between the subgroups, the sense of bladder fullness was preserved more in the T11-T12 group with a statistically significant difference (p < 0.001). While storage disorder, the rate of indwelling catheter use during hospitalization, bacterial growth of 105 CFU/ml in the urine culture, and anticholinergic drug recommendation after urodynamic examination were higher in the complete lesion group, the rate of spontaneous/catheter-free voiding, the number of patients in which sense of bladder fullness was preserved-partially preserved, and alpha-blocker drug recommendation after urodynamic examination was higher in the incomplete lesion group, with a statistically significant difference in all parameters (all p values < 0.05).

CONCLUSION

Our results demonstrate that there are differences in neurogenic lower urinary tract dysfunction features in subgroups of traumatic thoracic SCI patients. Regular urinary system evaluation and necessary changes in treatment should be carried out in this patient group.

Reasons for Altering Bladder Management and Satisfaction with Current Bladder Management in Chronic Spinal Cord Injury Patients

Patients with spinal cord injury (SCI) often require bladder management. However, patients routinely change their bladder management for better satisfaction. The reasons for altering a bladder management method in SCI patients remain insufficiently understood. The purposes of this study are to assess current satisfaction with bladder management and the reasons for changing bladder management in SCI patients. A prospective cross-sectional survey with a convenience sampling method was used. The study was conducted from January 2018 to December 2019. The inclusion criteria included an age ≥18 years and a diagnosis of SCI more than one year previously. The questionnaires were self-administered and collected from eligible patients during a free clinic service. A total of 515 SCI participants were enrolled. Two hundred and eighty-three (55.0%) participants had experienced changing their bladder management. The most used method of current bladder management was self-voiding. About 84.7% of participants reported being satisfied with their current bladder management. Bladder management changes were most often made due to frequent urinary tract infections. Furthermore, the participants dissatisfied with their management had more urological complications. This study indicates that appropriate bladder management can improve the subjective satisfaction of patients. For long-term care, preventing urinary tract infections is a helpful strategy for patients' satisfaction with bladder management.

Bladder Management With Chronic Indwelling Catheter is Associated with Elevated Mortality in Patients with Spinal Cord Injury

OBJECTIVE

To evaluate the impact of bladder management method, specifically chronic indwelling catheter (IndC), on survival in patients with spinal cord injury (SCI) in Spinal Cord Injury Model System database.

METHODS

Spinal Cord Injury Model System is a multicenter longitudinal database since 1970 with >40,000 patients with SCI. Adult patients (>18 at the time of injury) were screened. Patients who died within 1 year of injury and had 2 or more changes in method of bladder management, or reported normal volitional void were excluded. Outcome of interest was death from nonpulmonary, nonwound related sepsis (NPNWS). Left truncation cox regression method using age as the time-scale was used to calculate hazard ratios.

RESULTS

A total of 13,616 patients were included. Comparison was performed between "IndC" group (n = 4872; 36.1%) vs "Other" (n = 8744; 63.9%). After adjusting for age and change in bladder management method, "IndC" is associated with elevated NPNWS mortality (2.10; 95% confidence interval 1.72-2.56, P < .001). Multivariable analysis, adjusting for age at injury, gender, race, education, insurance status, etiology of SCI, injury level, neurologic impairment level, and change in bladder management method, showed IndC was associated with significantly higher risk of death from NPNWS compared to other methods of bladder management.

CONCLUSION

In a large cohort of SCI patients, bladder management with IndC is predictive of significantly propagated NPNWS related mortality compared to other methods of bladder management. While identifying IndC is an independent mortality risk factor, a better understanding of the underlying mechanisms could inform strategies to improve neurourological care and survival after SCI.

Urinary system complications and long-term treatment compliance in chronic traumatic spinal cord injury patients with neurogenic lower urinary tract dysfunction

Objectives

The aim of this study was to evaluate upper and lower urinary tract complications and the compliance of long-term treatment in patients with spinal cord injury (SCI) by urodynamic examination.

Patients and methods

Between January 1997 and May 2007, a total of 89 patients with SCI (79 males, 19 females; mean age: 39.8±12.2 years; range, 19 to 72 years) who were admitted to physical medicine and rehabilitation clinic were retrospectively analyzed. Demographic, neurological, and urodynamic data of the patients with the diagnosis of neurogenic lower urinary tract dysfunction (NLUTD) in their initial urodynamic examination and without regular follow-up were recorded.

Results

The mean time to the first urodynamic examination was 8.6±5.4 months. Sixty-seven patients who had neurogenic detrusor overactivity (NDO) in their first urodynamic tests were recommended anticholinergics. Clean intermittent catheterization (CIC) was recommended after initial urodynamic examination in all patients. Thirty-nine patients of 67 who had NDO were taking medications, while 28 were not. In the patients who continued anticholinergic treatment, bladder capacity was found to statistically significantly increase, compared to the initial measurement values and detrusor pressures significantly decreased (p<0.001). The compliance rate with CIC and anticholinergic treatment was 79.8% and 58.2%, respectively. Sixteen of the patients had calculus in the urinary system. Forty-two patients had infections more than once a year and used antibiotics.

Conclusion

Neurogenic bladder should be evaluated at the beginning of SCI and, then, followed on a regular basis. Urodynamic tests should be performed immediately after spinal shock and can be repeated, as indicated.

Burden of illness the first year after diagnosed bladder dysfunction among people with spinal cord injury or multiple sclerosis - a Danish register study

BACKGROUND

People with spinal cord injury (SCI) or multiple sclerosis (MS) are often living with some degree of bladder and/or bowel dysfunction due to acquired neurogenic damage. The objective was to estimate the burden of illness of SCI and MS the first year after diagnosed bladder dysfunction.

METHODS

Data were extracted from registers covering all Danish citizens. People with SCI or MS were indexed at diagnosis of bladder dysfunction. Inclusion period was 2002-2015 and cases and matched controls were followed for one year.

RESULTS

A total of 2,132 subjects with SCI and 1,887 subjects with MS were identified. Healthcare utilization and societal costs per patient-year were significantly higher for cases compared to controls driven primarily by inpatient care. Cases with urinary tract infection had significantly higher inpatient costs per patient-year compared to controls (SCI: 544 EUR vs 23, p < 0.05; MS: 497 EUR vs 6, p< 0.05) and medication for constipation was significantly more costly per patient-year (SCI: 178 EUR vs 3, p < 0.05; MS: 78 vs 1, p < 0.05).

CONCLUSIONS

The study demonstrates heavy societal and personal costs in the first year after bladder dysfunction in people with SCI or MS. This emphasizes the need for medical and social interventions to reduce the burden of illness.

Barriers and facilitators to optimising inpatient bladder management after spinal cord injury

STUDY DESIGN

Qualitative survey.

OBJECTIVES

Examine clinicians' perspectives on adherence to published evidence-based guidelines and clinician-perceived barriers, and facilitators to optimising inpatient bladder management within one Spinal Cord Injury (SCI) service.

SETTING

Surgical Hospital (acute care) and SCI Unit (sub-acute, rehabilitation) in Western Australia (WA).

METHODS

Clinicians reviewed an 'Evidence Matrix' summarising published clinical practice guidelines and recommendations for SCI bladder management. Focus groups examined the extent to which current practice adhered to recommendations and identified perceived barriers and facilitators to optimal management. Data were analysed thematically using a deductive approach.

RESULTS

Current management closely mirrors published recommendations. Key facilitators included long-standing prioritisation of rapid progression from urethral indwelling (IDC) to a 6 hourly intermittent catheterisation (IC) protocol; regular competency audits of catheterisation technique; and a Spinal Urology Clinical Nurse Consultant (CNC) position. Barriers included limited resources/staffing; restricted access to Neuro-urology consultation; inter-disciplinary communication gaps; and delays in determining and implementing long-term bladder management.

CONCLUSIONS

Inpatient SCI bladder care in WA closely emulates published evidence, although adherence at other sites may reveal different practices. Bladder management was found to have been facilitated by a strong culture of practice led by Neuro-urologists, informed by evidence and embraced by Senior Clinicians. Further reduction in duration of initial IDC, provision of early and ongoing Neuro-urology consultations as part of standard care, increased interdisciplinary communication and dedicated SCI Urology theatre lists would further optimise management.