The implementation of bedside bladder ultrasound technology: effects on patient and cost postoperative outcomes in tertiary care

Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review

BACKGROUND

Catheter-associated urinary tract infections (CAUTI) are costly, common and often preventable by reducing unnecessary urinary catheter (UC) use.

METHODS

To summarise interventions to reduce UC use and CAUTIs, we updated a prior systematic review (through October 2012), and a meta-analysis regarding interventions prompting UC removal by reminders or stop orders. A narrative review summarises other CAUTI prevention strategies including aseptic insertion, catheter maintenance, antimicrobial UCs, and bladder bundle implementation.

RESULTS

30 studies were identified and summarised with interventions to prompt removal of UCs, with potential for inclusion in the meta-analyses. By meta-analysis (11 studies), the rate of CAUTI (episodes per 1000 catheter-days) was reduced by 53% (rate ratio 0.47; 95% CI 0.30 to 0.64, p<0.001) using a reminder or stop order, with five studies also including interventions to decrease initial UC placement. The pooled (nine studies) standardised mean difference (SMD) in catheterisation duration (days) was -1.06 overall (p=0.065) including a statistically significant decrease in stop-order studies (SMD -0.37; p<0.001) but not in reminder studies (SMD, -1.54; p=0.071). No significant harm from catheter removal strategies is supported. Limited research is available regarding the impact of UC insertion and maintenance technique. A recent randomised controlled trial indicates antimicrobial catheters provide no significant benefit in preventing symptomatic CAUTIs.

CONCLUSIONS

UC reminders and stop orders appear to reduce CAUTI rates and should be used to improve patient safety. Several evidence-based guidelines have evaluated CAUTI preventive strategies as well as emerging evidence regarding intervention bundles. Implementation strategies are important because reducing UC use involves changing well-established habits.

The evaluation and management of delirium among older persons

This article reviews the pathophysiology, prevalence, incidence, and consequences of delirium, focusing on the evaluation of delirium, the published models of care for prevention in patients at risk of delirium, and management of patients for whom delirium is not preventable. Evidence on why physical restraints should not be used for patients with delirium is reviewed. Current available evidence on antipyschotics does not support the role for the general use in the treatment of delirium. An example of a restraint-free, nonpharmacologic management approach [called the TADA approach (tolerate, anticipate, and don't agitate)] is presented.

Differential modes of termination of amygdalothalamic and amygdalocortical projections in the monkey

The amygdala complex participates in multiple systems having to do with affective processes. It has been implicated in human disorders of social and emotional behavior, such as autism. Of the interconnected functional networks, considerable research in rodents and primates has focused on connections between the amygdala and orbitofrontal cortex (OFC). The amygdala projects to OFC by both a direct amygdalocortical (AC) pathway and an indirect pathway through mediodorsal thalamus. In the rat, retrograde tracer experiments indicate that the AC and amygdalothalamic (AT) pathways originate from separate populations, and may therefore convey distinctive information, although the characteristics of these pathways remain unclear. To investigate this issue in monkeys we made anterograde tracer injections in the basolateral amygdala complex (BLC; n = 3). Three distinctive features were found preferentially associated with the AT or AC pathways. First, AT terminations are large (average diameter = 3.5 microm; range = 1.2-7.0 microm) and cluster around proximal dendrites, in contrast with small-bouton AC terminations. Second, AT terminations form small arbors (diameter approximately 0.1 mm), while AC are widely divergent (often >1.0 mm long). The AT terminations features are reminiscent of large bouton, "driver" corticothalamic terminations. Finally, AC but not AT terminations are positive for zinc (Zn), a neuromodulator associated with synaptic plasticity. From these results we suggest that AC and AT terminations originate from distinct populations in monkey as well as in rodent. Further work is necessary to determine the degree and manner of their segregation and how these subsystems interact within a broader connectivity network.

The effectiveness of implementing a bladder ultrasound programme in neurosurgical units

AIM

This paper reports an evaluation of the differences among rates of unnecessary catheterization, urinary retention and urinary tract infection before and after implementing a bladder ultrasound programme to assess urine volume.

BACKGROUND

Bladder ultrasound is a non-invasive alternative to urethral catheterization for the determination of bladder urine volume. Much of the literature available on bladder ultrasound technology addresses the accuracy of the equipment, with little research on the clinical outcomes or benefits of the intervention.

METHODS

A quasi-experimental design was adopted. Data were collected from March 2001 to May 2001 in a control group in two neurosurgical units in Taiwan. During July and August 2001, nurses were taught how to operate a portable ultrasound machine and how to implement the programme. Data were collected from September to November 2001 in the study group.

RESULTS

The rates of unnecessary catheterization in the control group and the study group were 35.3% and 7.0%, respectively. The urine volume (more than 500 mL) in the control group and the study group were 13.4% and 20.3%, respectively. The study group had a statistically significantly lower average catheterization volume than that of the control group (676.9 mL vs. 777.1 mL, t = 1.84, P < 0.05). During 3 months before and after the implementation of the programme, the urinary tract infection rates in the control group and the study group were 3.47% and 2.87%, respectively. After 6 months the urinary tract infection rates decreased to 1.39%.

CONCLUSION

The bladder ultrasound programme was successful and could be used to manage patients with urination disorders in neurosurgical units.

The Use of an Ultrasound Bladder Scanning Device in Women Undergoing Urogynaecologic Surgery

OBJECTIVE

To compare the accuracy of using a bladder scanner to measure post-voiding residual urine volume with measurement by intermittent catheterization in a postoperative urogynaecology population.

METHODS

Prior to implementation of the study, nurses were trained in the use of a bladder ultrasound scanner. Post-void residual urine volume in postoperative patients was assessed by a nurse with the scanner; a second nurse, blinded to the scanner result, then catheterized the patient's bladder. Each patient rated the pain experienced with bladder scanning and with catheterization. A prospective comparison of the volumes assessed by ultrasound and measured by catheterization used 127 pairs of data; each woman served as her own control. The correlation of urine volumes was determined, and the difference in pain score was calculated using the Student t test.

RESULTS

The mean age of patients was 56.5 years (range 40-79). All four bladder quadrants were visualized in 34.4% of scans. The correlation coefficient for volumes measured by scanning and catheterization was 0.70 (P < 0.001; range -349 mL to +692 mL). Consistently, using the scanner resulted in underestimation of the urine volume. The sensitivity of the bladder scanner (0.58 for residual volumes > 200 mL) therefore makes it a poor tool for assessing postoperative urinary retention in women undergoing urogynaecologic surgery. Pain scores recorded with catheterization (2.9/10) were significantly less than those recorded with bladder scanning (4.2/10) (P < 0.001).

CONCLUSIONS

Bladder scanning by staff nurses had limited value in assessing postoperative residual urine volumes. The accuracy of assessment might increase with greater experience with the procedure. The greater discomfort reported by patients with use of the scanner supports continued use of catheterization to assess residual urine volume.

Accuracy of bladder volume determinations by ultrasonography: are they accurate over entire bladder volume range?

OBJECTIVES

To investigate the accuracy of a portable three-dimensional hand-held BladderScan (BS) and two-dimensional conventional ultrasonography (CUS) in the estimation of bladder volumes.

METHODS

The bladder volume of 65 subjects was measured during filling cystometry using two ultrasound modalities. Serial measurements were performed when the infused volume reached 100, 200, 300, and 400 mL; the investigator measured the volumes three times each with BS and CUS. Each corresponding true volume was calculated by interpolation using zero volume and the final catheterized volume at the end of cystometry. The accuracy of the two ultrasound methods was compared using raw scaled values of the volumes and the percentage of differences of volume.

RESULTS

Bladder volumes determined by CUS and BS were underestimated by 21.8% and 3.3% (mean values), respectively. The percentage of differences of volume of BS was not statistically significant (P >0.05), but that of CUS was statistically significant (P <0.00001). No significant percentage of differences of volume change according to the volume status was observed by either ultrasound measurement method (P >0.05). Linear regression analysis between the true volumes and the raw scaled volumes showed that the slope of the BS was closer to 1.0 than that of the CUS, and the difference was statistically significant (P <0.001). The effects of diagnosis, age, sex, and body mass index were not significant in determining the bladder volume by either method (P >0.05).

CONCLUSIONS

Our results demonstrated that a three-dimensional hand-held scanner measures the bladder volume in a reproducible and accurate manner for a wide range of bladder volumes and is superior to two-dimensional stationary ultrasonography.