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J Nurs Care Qual Vol. 30, No. 2, pp. 175–180 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Implementing a Clinical Practice Guideline to Manage Postpartum Urinary Retention Angela Y. Stanley, DNP, MA, APRN-BC, FNP-BC, PHCNS-BC, RNC-OB, C-EFM; Brian T. Conner, PhD, RN, CNE Postpartum urinary retention is a common condition in obstetric units. A Clinical Practice Guideline was implemented in a high-risk obstetrical unit to decrease variance of clinical practice, rate of postpartum urinary retention, and number of urinary catheterizations and increase awareness of this common condition. Guideline implementation met the 4 aims, including a decreased rate of urinary retention. Key words: bladder care, childbirth, clinical practice guidelines, postpartum, urinary retention
P
OSTPARTUM URINARY RETENTION (PUR) is a condition that plagues women in the immediate postpartum period, with incidence ranging from 1.7% to 17.9%.1 It is defined as the inability to void spontaneously within 6 hours of either vaginal delivery or catheter removal after delivery.2 While all women in the immediate postpartum period have the potential to experience urinary problems, several studies have identified risk factors, such as primiparity, episiotomy, vaginal tearing, and length of labor,
Author Affiliations: Walter Reed National Military Medical Center, Bethesda, Maryland (Dr Stanley); and Undergraduate Programs, College of Nursing, Medical University of South Carolina, Charleston (Dr Conner). The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: CDR Angela Y. Stanley, DNP, MA, APRN-BC, FNP-BC, PHCNS-BC, RNC-OB, C-EFM, US Navy, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, Virginia, 23708. (klemson@ earthlink.net). Accepted for publication: July 16, 2014 Published online before print: August 27, 2014 DOI: 10.1097/NCQ.0000000000000087
as increasing the incidence of urinary retention. Additional risk factors for PUR include infant birth weight more than 4kg, large fetal head circumference, prolonged second stage of labor, and extensive perineal trauma.3 Although anatomical alterations occur in the pelvic floor following pregnancy and vaginal delivery, the long-term effects of pregnancy, the alterations’ relationships with mode of delivery, and the development of urinary complications remain controversial.4 The goals of postpartum bladder care are to assess bladder function, detect any deviation(s) from normal, and carry out timely preventative measures to avoid complications of urinary dysfunction following birth. A delay in the recognition and/or management of PUR may lead to subsequent urinary complications such as recurrent urinary tract infections, upper urinary tract damage, and permanent voiding difficulties. One of the major problems regarding treatment of PUR, however, is the lack of guidelines.1 Despite the low incidence, PUR has the potential to affect any woman who experiences childbirth. Researchers continue to explore causal relationships between various obstetric parameters and urinary retention. Many studies have examined the relationship of epidural analgesia and duration of labor to the development 175
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of urinary retention.5−7 These have successfully demonstrated the increased risk of developing PUR after the administration of epidural analgesia. As women continue to elect epidural or spinal anesthesia as a method of pain control, the importance of early diagnosis and timely intervention becomes a requirement to prevent adverse urinary complications. The impetus for this project stems from anecdotal reports by the nursing and physician staff regarding the variance in clinical practice and an increased number of women requiring urinary catheterization within the immediate postpartum period. The need for a national guideline exists. EVIDENCE REVIEW AND SYNTHESIS A review of literature revealed 4 Clinical Practice Guidelines that address the recognition and management of PUR. Canterbury District Health Board8 and East Kent Hospitals University9 published guidelines to establish consistency of bladder care during the intrapartum and postpartum periods at their respective facilities. In addition to inpatient guidelines, authors addressed discharge planning for failed attempts at voiding and mechanisms to monitor compliance. The 2 remaining guidelines, published in Australia, focused on prevention and treatment of bladder dysfunction. The Women’s Clinical Guideline from the Royal Women’s Hospital10 indicated failure to diagnose bladder distension and incomplete bladder emptying as common occurrences in the early peripartum period. The South Australian Perinatal Practice Guidelines from the Government of South Australia11 included an algorithm for instructing women about intermittent self-catheterization. The intent of the guideline was to establish consistency of practice using a multidisciplinary approach.11 Both Australian-based articles used real-time ultrasonographic bladder assessment, or bladder scanning, as a technique to estimate residual urine volume. Scanning is faster than urethral catheterization, carries a lower risk of infection, costs less, and is minimally invasive.
Zaki et al12 conducted the only study that assessed the need for Clinical Practice Guidelines across maternity units. Questionnaires were mailed to the heads of Midwifery and Labor & Delivery unit managers of 189 maternity units in England and Wales. Questions were selected to assess the use of urinary catheterizations in association with regional analgesia, vaginal delivery, operative delivery, manual removal of placenta, and repair of third-degree perineal tears. The study results demonstrated an association between epidural analgesia/instrumental delivery and an increased risk of postpartum urinary retention in 43% of women with a diagnosis of abnormal postpartum voiding. Zaki et al12 found a lack of evidence-based guidelines and protocols implemented among the maternity units and recommended implementing protocols and staff education regarding risk factors and clinical symptoms of urinary retention. Although evidence-based international guidelines addressing the management of PUR do exist, there were no national guidelines identified during the literature review. This lack of guidelines and standardization of definitions has been cited as a contributing factor to poor understanding of this common obstetrical complication. The variance has also created difficulties with regard to reporting incidence and prevalence, thus complicating comparisons of study results. The evidence supports the need for a clear and comprehensive evidence-based recommendation incorporating current information and practices for health care providers in the obstetrical community. The primary purpose of this project was to implement a Clinical Practice Guideline to support clinical decision making and quality health care delivery to women who were unable to void spontaneously within 6 hours of vaginal delivery. Secondary gains included opportunities to decrease variance of clinical practice, decrease frequency and timing interval of urinary catheterization, and increase clinical staff awareness of the condition. How does the implementation of a Clinical Practice Guideline on the management of postpartum
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Managing Postpartum Urinary Retention
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urinary retention affect women in a high-risk obstetrical unit?
Forces: Army, Marine Corps, Navy, and Air Force.
METHODS
Implementation
Setting/sample The project was conducted in a high-risk obstetrical unit in the mid-Atlantic region of the United States. As one of the largest birthing centers in the Department of Defense medical system, the unit averages more than 1800 deliveries per year. The facility serves as the US military’s worldwide tertiary referral center for casualty and beneficiary care. The unit staff comprises physicians (staff and residents), registered nurses, and hospital corpsmen. Approval was granted by a tertiary Military Treatment Facility’s Expedited Institutional Review Board to conduct this as a quality improvement project. The population of interest consisted of women with an inability to void spontaneously within 6 hours of either vaginal delivery or urinary catheter removal after delivery. Project participants included all patients who experienced childbirth by vaginal mode of delivery. Any women who experienced an operative delivery such as cesarean delivery or forceps- or vacuum-assisted delivery were excluded. Other exclusion criteria included medical history of urinary-related surgical procedures or chronic medical conditions. By virtue of the inpatient unit being designated as a referral center for beneficiaries in the geographical area, high-risk women were included in the project. In 2012, a total of 985 (64%) of births at the project site were by vaginal mode of delivery. The total population ranged from 17 to 47 years of age. Demographics included 64% (n = 857) white, 6% (n = 80) Asian-Pacific Islander, 18% (n = 241) black, 1% (n = 13) unknown race, 10% (n = 134) other race, and less than 1% (n = 12) Western Hemisphere Indian. In 2013, a total of 875 (64%) of births were by vaginal mode of delivery. There was little variation in the unit’s demographics in 2013. Twenty-four percent of the population comprised members of the US Armed
The PDSA (Plan-Do-Study-Act) format was used as the project framework. The selected guideline, published by the Canterbury District Health Board, specifically addresses intrapartum and postpartum bladder care. The Canterbury District Health Board is a hospital and health care provider for the Canterbury region of New Zealand. Considerations for guideline selection were based upon facility services, similarities to existing clinical practice at the project site, credibility of references, and recent publishing date (February 2012). For the purpose of this project, staff members were provided training and education to address postpartum bladder care only (see Supplemental Digital Content, Figure, available at: http://links.lww.com/JNCQ/A128). Prior to guideline implementation, the urinary system was evaluated in accordance with the recommendations of the American Congress of Obstetricians and Gynecologists, the Association of Certified Nurse Midwives, and the Association of Women’s Health, Obstetrics, and Neonatal Nurses: 2 spontaneous voids greater than 250 mL each. Implementation was expected to decrease variance of clinical practice, decrease the rate of PUR, decrease the number of urinary catheterizations, and increase awareness of this common condition in obstetrical units. The preintervention measurements included mode of urine output (spontaneous/ straight catheter/indwelling catheter), estimated urine volume(s) within 6 hours of vaginal delivery, and number of urinary catheters, if indicated. The postintervention measurements consisted of the described preintervention measurements, estimated residual volume(s) using the bladder scan or straight catheter, if indicated, and staff compliance regarding guideline implementation. Education and training were provided to the nursing staff in accordance with the guideline for postpartum bladder care (see
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Supplemental Digital Content, Figure, available at: http://links.lww.com/JNCQ/A128). Before training, meetings were conducted with unit leadership to communicate the initiative’s purpose and process for implementation. Unit leadership consisted of the Assistant Service Chief, Service Chief, and Ward Medical Officer. The Ward Medical Officer, a Maternal-Fetal Medicine specialist, served as the clinical expert and liaison with the physician staff. As the sole communicator to the physician staff, the role of the Ward Medical Officer was a key component in the success of the practice improvement project. As one of the nation’s largest military medical centers for health care and graduate medical education, strategic communication played an integral role in the guideline implementation to approximately 70 providers (physician staff, residents, and certified nurse midwives) and 80 nursing staff. The provider staff met twice weekly for education and training purposes. As the prime opportunity for maximum attendance by all providers, unit leadership determined this to be the optimum forum for the Ward Medical Officer to educate and train providers. Staff members were provided a copy of the new guideline, given an opportunity for questions and answers, and trained to use ultrasound equipment in accordance with manufacturer protocol. Return demonstration was required to ensure understanding and compliance of the intervention. The training and education provided by the unit’s clinical nurse specialist to the nursing staff did not differ. Timely recognition of clinical signs and symptoms is critical to the management and development of urinary complications and/or permanent voiding difficulties. The guideline identifies bladder pain, dysuria, frequency and passing of small amounts of urine, inability or hesitancy to void, and a palpable distended bladder as clinical signs and symptoms of urinary retention. Suspicion of urinary retention is confirmed using a bladder scanner to assess residual volume. If a bladder scanner was not available, nursing staff members were advised
to insert a straight catheter and document the estimated residual volume in the electronic medical record (EMR). Data collection and analysis Data collection occurred in May through July 2012 and May through July 2013. The facility’s electronic birth log was used to identify project participants in accordance with inclusion and exclusion criteria. A Microsoft Excel spreadsheet was designed to capture the pre- and postintervention measurements from Essentris. Essentris is an electronic health record used in the inpatient setting across the Navy Medicine Enterprise. Preintervention measurements included mode of urine output, estimated urine volume(s) within 6 hours of vaginal delivery, and number of urinary catheters (indwelling and straight). Postintervention measurements included those measured during preintervention, as well as estimated residual volume(s) using the bladder scan or in-and-out catheter (if indicated), and staff compliance with guidelines. Run charts were used to display results. RESULTS A retrospective medical record review of 391 EMRs provided preintervention measurements and that of 301 EMRs provided postintervention measurements. The incidence of PUR preintervention ranged from 27.63% to 40.54% and that of PUR postintervention ranged from 17.30% to 35.00% (Figure). Implementation of the Clinical Practice 40.00 35.00 30.00 25.00 20.00 15.00 10.00 5.00 0.00 Jun-13
Jul-13
Aug-13
Figure. Postpartum urinary retention rates postintervention. Guideline implemented at project site in May 2013.
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Managing Postpartum Urinary Retention Guideline to address the management of PUR resulted in a decreased number of urinary catheterizations. Within 30 days of guideline implementation, the number of urinary catheterizations decreased by 4.19% (n = 1) when compared with the June 2012 data. However, within 60 and 90 days, the change in value was 0.76% (n = 9) and 11.05% (n = 10), respectively. On the basis of a review of 301 EMRs postintervention, guideline compliance was measured at 52.5% (June 2013), 62% (July 2013), and 57.69% (August 2013). Compliance was determined by the facility parameters: documentation of 2 spontaneous voids within 6 hours of vaginal delivery, utilization/documentation of a bladder scanner or straight catheter to determine estimated residual volume, and meeting minimal amount of spontaneous void (250 mL). DISCUSSION Decreased variance of clinical practice For the purpose of this project, staff compliance with the guideline was based on documentation in the EMR: if the woman was able to spontaneously void greater than 250 mL on 2 separate occasions and/or the documentation of the estimated residual volume using an ultrasound scan or passing a straight urinary catheter. Variance of compliance and/or clinical practice at the project site may be attributed to differing practices among physicians, inconsistency of nursing documentation, and utilization of the bladder scanner or straight catheter to determine estimated residual volume(s). The project site employs more than 150 health care providers, including physicians, certified nurse midwives, and nursing staff. The frequent clinical rotations of graduate medical education and allied health trainees lead to a greater chance that patient care may not be administered in full accordance with respective facility/unit policies and procedures. Poor documentation of urinary output leads to an assumption that nursing care was not in
179
compliance with clinical recommendations. Seventy-nine of 182 records reflected 0 to 1 spontaneous void. The guideline specifies that a woman must spontaneously void 2 times within 6 hours of vaginal delivery or catheter removal. In addition to poor documentation, nursing staff did not demonstrate consistency regarding utilization of a bladder scanner versus straight catheter to estimate residual volume(s). Budget constraints and equipment malfunctions limited the availability of ultrasound equipment. This limitation prompted a shift to the alternate mode of verifying estimated residual volume using a straight catheter. Documentation in several records acknowledged a woman’s inability to void, however, did not reflect the estimated residual volume and mode of assessment. Decreased rate of PUR Implementation of a Clinical Practice Guideline to address postpartum bladder care resulted in a decreased rate of PUR. Of interest, the high preintervention rate of PUR at the project site relative to the incidence cited in the literature (1.7%- 17.9%) may be attributed to the high-risk obstetrical setting and/or the number of employed health care providers assigned to the unit.1 Decreased number of urinary catheterization(s) By decreasing the rate of PUR, implementation of a guideline also decreased the frequency of urinary catheterization. The number and frequency of urinary catheterizations were dependent upon clinical factors and accuracy of nursing documentation. A common clinical factor was provider practice using a straight catheter during repair of periurethral lacerations. Increased awareness regarding the medical condition Documented rates of compliance and anecdotal feedback further demonstrated the ability to recognize and manage this common condition that plagues obstetrical units. During
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the period of implementation, members of the nursing staff conducted literature reviews as an opportunity to self-educate, and potentially identify, national and/or international standards of practices or protocols for the medical condition. CONCLUSIONS There are no published national guidelines to address and/or manage PUR by our professional organizations that promote a standard
of quality care to women. Implementation of a uniform guideline to address PUR will significantly address the health and well-being of women’s health and the obstetrical population. This practice improvement project resulted in an increased awareness at the project site and decreased frequency of urinary catheterizations. The project’s success at implementing a guideline in a high-risk obstetrical unit in the United States demonstrates the need to replicate this project in a low-risk obstetrical setting.
REFERENCES 1. Leach S. Have you had a wee yet? Postpartum urinary retention. Pract Midwife. 2011;14(1):23-25. 2. Kearney R, Cutner A. Review of postpartum voiding dysfunction. RCOG. 2008;10(2):71-74. 3. Swamy S, Wise B, Shervington J, et al. Bladder Care Guidelines for the Labour and Postpartum Period. Canterbury, Kent, England: East Kent Hospitals University; 2009. 4. Panayi D, Khullar V. Urogynaecological problems in pregnancy and postpartum sequelae. Curr Opin Obstet Gynecol. 2009;21(1):97-100. 5. Ching-Chung L, Shuenn-Dhy C, Ling-Hong T, et al. Postpartum urinary retention: assessment of contributing factors and long-term clinical impact. Aust N Z J Obstet Gynaecol. 2002;42(4):367-370. 6. Foon R, Toozs-Hobson P, Millns P, et al. The impact of anesthesia and mode of delivery on the urinary bladder in the post delivery period. Int J Gynaecol Obstet. 2010;110(2):114-117. 7. Musselwhite K, Ferris P, Moore K, et al. Use of epidural anesthesia and the risk of acute postpartum urinary retention. Am J Obstet Gynecol. 2007;196:472.e1472.e5. 8. Intrapartum and postnatal bladder care. Canterbury District Health Board Web site. http://www.cdhb
9.
10.
11.
12.
.health.nz/Hospitals-Services/Health-Professionals/ maternity-care-guidelines/Documents/GLM0038 IntrapartumandPostnatalBladderCare.pdf. Accessed June 14, 2013. About East Kent Hospitals. East Kent Hospitals University NHS Foundation Trust Web site. http:// www.ekhuft.nhs.uk/patients-and-visitors/about-us. Published 2013. Accessed March 7, 2013. The Royal Women’s Hospital. Intrapartum and postpartum bladder management. https://thewomens.r .worldssl.net/images/uploads/downloadable-records/ clinical-guidelines/bladder-management-intrapartumand-postpartum.pdf. Published 2010. Accessed January 3, 2013. Government of South Australia. Chapter 108. Postpartum bladder dysfunction. http://www.sahealth.sa .gov.au/wps/wcm/connect/a013c0804ee55f67a91 cadd150ce4f37/Postpartum-bladder-dysfunctionWCHN-PPG-18092012.pdf?MOD=AJPERES& CACHEID=a013c0804ee55f67a91cadd150ce4f37. Accessed January 3, 2013. Zaki M, Pandit M, Jackson S. National survey for intrapartum and postpartum bladder care: assessing the need for guidelines. BJOG. 2004;111(8):874876.
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J Nurs Care Qual Vol. 30, No. 2, pp. 175–180 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Implementing a Clinical Practice Guideline to Manage Postpartum Urinary Retention Angela Y. Stanley, DNP, MA, APRN-BC, FNP-BC, PHCNS-BC, RNC-OB, C-EFM; Brian T. Conner, PhD, RN, CNE Postpartum urinary retention is a common condition in obstetric units. A Clinical Practice Guideline was implemented in a high-risk obstetrical unit to decrease variance of clinical practice, rate of postpartum urinary retention, and number of urinary catheterizations and increase awareness of this common condition. Guideline implementation met the 4 aims, including a decreased rate of urinary retention. Key words: bladder care, childbirth, clinical practice guidelines, postpartum, urinary retention
P
OSTPARTUM URINARY RETENTION (PUR) is a condition that plagues women in the immediate postpartum period, with incidence ranging from 1.7% to 17.9%.1 It is defined as the inability to void spontaneously within 6 hours of either vaginal delivery or catheter removal after delivery.2 While all women in the immediate postpartum period have the potential to experience urinary problems, several studies have identified risk factors, such as primiparity, episiotomy, vaginal tearing, and length of labor,
Author Affiliations: Walter Reed National Military Medical Center, Bethesda, Maryland (Dr Stanley); and Undergraduate Programs, College of Nursing, Medical University of South Carolina, Charleston (Dr Conner). The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: CDR Angela Y. Stanley, DNP, MA, APRN-BC, FNP-BC, PHCNS-BC, RNC-OB, C-EFM, US Navy, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, Virginia, 23708. (klemson@ earthlink.net). Accepted for publication: July 16, 2014 Published online before print: August 27, 2014 DOI: 10.1097/NCQ.0000000000000087
as increasing the incidence of urinary retention. Additional risk factors for PUR include infant birth weight more than 4kg, large fetal head circumference, prolonged second stage of labor, and extensive perineal trauma.3 Although anatomical alterations occur in the pelvic floor following pregnancy and vaginal delivery, the long-term effects of pregnancy, the alterations’ relationships with mode of delivery, and the development of urinary complications remain controversial.4 The goals of postpartum bladder care are to assess bladder function, detect any deviation(s) from normal, and carry out timely preventative measures to avoid complications of urinary dysfunction following birth. A delay in the recognition and/or management of PUR may lead to subsequent urinary complications such as recurrent urinary tract infections, upper urinary tract damage, and permanent voiding difficulties. One of the major problems regarding treatment of PUR, however, is the lack of guidelines.1 Despite the low incidence, PUR has the potential to affect any woman who experiences childbirth. Researchers continue to explore causal relationships between various obstetric parameters and urinary retention. Many studies have examined the relationship of epidural analgesia and duration of labor to the development 175
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of urinary retention.5−7 These have successfully demonstrated the increased risk of developing PUR after the administration of epidural analgesia. As women continue to elect epidural or spinal anesthesia as a method of pain control, the importance of early diagnosis and timely intervention becomes a requirement to prevent adverse urinary complications. The impetus for this project stems from anecdotal reports by the nursing and physician staff regarding the variance in clinical practice and an increased number of women requiring urinary catheterization within the immediate postpartum period. The need for a national guideline exists. EVIDENCE REVIEW AND SYNTHESIS A review of literature revealed 4 Clinical Practice Guidelines that address the recognition and management of PUR. Canterbury District Health Board8 and East Kent Hospitals University9 published guidelines to establish consistency of bladder care during the intrapartum and postpartum periods at their respective facilities. In addition to inpatient guidelines, authors addressed discharge planning for failed attempts at voiding and mechanisms to monitor compliance. The 2 remaining guidelines, published in Australia, focused on prevention and treatment of bladder dysfunction. The Women’s Clinical Guideline from the Royal Women’s Hospital10 indicated failure to diagnose bladder distension and incomplete bladder emptying as common occurrences in the early peripartum period. The South Australian Perinatal Practice Guidelines from the Government of South Australia11 included an algorithm for instructing women about intermittent self-catheterization. The intent of the guideline was to establish consistency of practice using a multidisciplinary approach.11 Both Australian-based articles used real-time ultrasonographic bladder assessment, or bladder scanning, as a technique to estimate residual urine volume. Scanning is faster than urethral catheterization, carries a lower risk of infection, costs less, and is minimally invasive.
Zaki et al12 conducted the only study that assessed the need for Clinical Practice Guidelines across maternity units. Questionnaires were mailed to the heads of Midwifery and Labor & Delivery unit managers of 189 maternity units in England and Wales. Questions were selected to assess the use of urinary catheterizations in association with regional analgesia, vaginal delivery, operative delivery, manual removal of placenta, and repair of third-degree perineal tears. The study results demonstrated an association between epidural analgesia/instrumental delivery and an increased risk of postpartum urinary retention in 43% of women with a diagnosis of abnormal postpartum voiding. Zaki et al12 found a lack of evidence-based guidelines and protocols implemented among the maternity units and recommended implementing protocols and staff education regarding risk factors and clinical symptoms of urinary retention. Although evidence-based international guidelines addressing the management of PUR do exist, there were no national guidelines identified during the literature review. This lack of guidelines and standardization of definitions has been cited as a contributing factor to poor understanding of this common obstetrical complication. The variance has also created difficulties with regard to reporting incidence and prevalence, thus complicating comparisons of study results. The evidence supports the need for a clear and comprehensive evidence-based recommendation incorporating current information and practices for health care providers in the obstetrical community. The primary purpose of this project was to implement a Clinical Practice Guideline to support clinical decision making and quality health care delivery to women who were unable to void spontaneously within 6 hours of vaginal delivery. Secondary gains included opportunities to decrease variance of clinical practice, decrease frequency and timing interval of urinary catheterization, and increase clinical staff awareness of the condition. How does the implementation of a Clinical Practice Guideline on the management of postpartum
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LWW/JNCQ
JNCQ-D-14-00025
January 31, 2015
17:59
Managing Postpartum Urinary Retention
177
urinary retention affect women in a high-risk obstetrical unit?
Forces: Army, Marine Corps, Navy, and Air Force.
METHODS
Implementation
Setting/sample The project was conducted in a high-risk obstetrical unit in the mid-Atlantic region of the United States. As one of the largest birthing centers in the Department of Defense medical system, the unit averages more than 1800 deliveries per year. The facility serves as the US military’s worldwide tertiary referral center for casualty and beneficiary care. The unit staff comprises physicians (staff and residents), registered nurses, and hospital corpsmen. Approval was granted by a tertiary Military Treatment Facility’s Expedited Institutional Review Board to conduct this as a quality improvement project. The population of interest consisted of women with an inability to void spontaneously within 6 hours of either vaginal delivery or urinary catheter removal after delivery. Project participants included all patients who experienced childbirth by vaginal mode of delivery. Any women who experienced an operative delivery such as cesarean delivery or forceps- or vacuum-assisted delivery were excluded. Other exclusion criteria included medical history of urinary-related surgical procedures or chronic medical conditions. By virtue of the inpatient unit being designated as a referral center for beneficiaries in the geographical area, high-risk women were included in the project. In 2012, a total of 985 (64%) of births at the project site were by vaginal mode of delivery. The total population ranged from 17 to 47 years of age. Demographics included 64% (n = 857) white, 6% (n = 80) Asian-Pacific Islander, 18% (n = 241) black, 1% (n = 13) unknown race, 10% (n = 134) other race, and less than 1% (n = 12) Western Hemisphere Indian. In 2013, a total of 875 (64%) of births were by vaginal mode of delivery. There was little variation in the unit’s demographics in 2013. Twenty-four percent of the population comprised members of the US Armed
The PDSA (Plan-Do-Study-Act) format was used as the project framework. The selected guideline, published by the Canterbury District Health Board, specifically addresses intrapartum and postpartum bladder care. The Canterbury District Health Board is a hospital and health care provider for the Canterbury region of New Zealand. Considerations for guideline selection were based upon facility services, similarities to existing clinical practice at the project site, credibility of references, and recent publishing date (February 2012). For the purpose of this project, staff members were provided training and education to address postpartum bladder care only (see Supplemental Digital Content, Figure, available at: http://links.lww.com/JNCQ/A128). Prior to guideline implementation, the urinary system was evaluated in accordance with the recommendations of the American Congress of Obstetricians and Gynecologists, the Association of Certified Nurse Midwives, and the Association of Women’s Health, Obstetrics, and Neonatal Nurses: 2 spontaneous voids greater than 250 mL each. Implementation was expected to decrease variance of clinical practice, decrease the rate of PUR, decrease the number of urinary catheterizations, and increase awareness of this common condition in obstetrical units. The preintervention measurements included mode of urine output (spontaneous/ straight catheter/indwelling catheter), estimated urine volume(s) within 6 hours of vaginal delivery, and number of urinary catheters, if indicated. The postintervention measurements consisted of the described preintervention measurements, estimated residual volume(s) using the bladder scan or straight catheter, if indicated, and staff compliance regarding guideline implementation. Education and training were provided to the nursing staff in accordance with the guideline for postpartum bladder care (see
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Supplemental Digital Content, Figure, available at: http://links.lww.com/JNCQ/A128). Before training, meetings were conducted with unit leadership to communicate the initiative’s purpose and process for implementation. Unit leadership consisted of the Assistant Service Chief, Service Chief, and Ward Medical Officer. The Ward Medical Officer, a Maternal-Fetal Medicine specialist, served as the clinical expert and liaison with the physician staff. As the sole communicator to the physician staff, the role of the Ward Medical Officer was a key component in the success of the practice improvement project. As one of the nation’s largest military medical centers for health care and graduate medical education, strategic communication played an integral role in the guideline implementation to approximately 70 providers (physician staff, residents, and certified nurse midwives) and 80 nursing staff. The provider staff met twice weekly for education and training purposes. As the prime opportunity for maximum attendance by all providers, unit leadership determined this to be the optimum forum for the Ward Medical Officer to educate and train providers. Staff members were provided a copy of the new guideline, given an opportunity for questions and answers, and trained to use ultrasound equipment in accordance with manufacturer protocol. Return demonstration was required to ensure understanding and compliance of the intervention. The training and education provided by the unit’s clinical nurse specialist to the nursing staff did not differ. Timely recognition of clinical signs and symptoms is critical to the management and development of urinary complications and/or permanent voiding difficulties. The guideline identifies bladder pain, dysuria, frequency and passing of small amounts of urine, inability or hesitancy to void, and a palpable distended bladder as clinical signs and symptoms of urinary retention. Suspicion of urinary retention is confirmed using a bladder scanner to assess residual volume. If a bladder scanner was not available, nursing staff members were advised
to insert a straight catheter and document the estimated residual volume in the electronic medical record (EMR). Data collection and analysis Data collection occurred in May through July 2012 and May through July 2013. The facility’s electronic birth log was used to identify project participants in accordance with inclusion and exclusion criteria. A Microsoft Excel spreadsheet was designed to capture the pre- and postintervention measurements from Essentris. Essentris is an electronic health record used in the inpatient setting across the Navy Medicine Enterprise. Preintervention measurements included mode of urine output, estimated urine volume(s) within 6 hours of vaginal delivery, and number of urinary catheters (indwelling and straight). Postintervention measurements included those measured during preintervention, as well as estimated residual volume(s) using the bladder scan or in-and-out catheter (if indicated), and staff compliance with guidelines. Run charts were used to display results. RESULTS A retrospective medical record review of 391 EMRs provided preintervention measurements and that of 301 EMRs provided postintervention measurements. The incidence of PUR preintervention ranged from 27.63% to 40.54% and that of PUR postintervention ranged from 17.30% to 35.00% (Figure). Implementation of the Clinical Practice 40.00 35.00 30.00 25.00 20.00 15.00 10.00 5.00 0.00 Jun-13
Jul-13
Aug-13
Figure. Postpartum urinary retention rates postintervention. Guideline implemented at project site in May 2013.
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Managing Postpartum Urinary Retention Guideline to address the management of PUR resulted in a decreased number of urinary catheterizations. Within 30 days of guideline implementation, the number of urinary catheterizations decreased by 4.19% (n = 1) when compared with the June 2012 data. However, within 60 and 90 days, the change in value was 0.76% (n = 9) and 11.05% (n = 10), respectively. On the basis of a review of 301 EMRs postintervention, guideline compliance was measured at 52.5% (June 2013), 62% (July 2013), and 57.69% (August 2013). Compliance was determined by the facility parameters: documentation of 2 spontaneous voids within 6 hours of vaginal delivery, utilization/documentation of a bladder scanner or straight catheter to determine estimated residual volume, and meeting minimal amount of spontaneous void (250 mL). DISCUSSION Decreased variance of clinical practice For the purpose of this project, staff compliance with the guideline was based on documentation in the EMR: if the woman was able to spontaneously void greater than 250 mL on 2 separate occasions and/or the documentation of the estimated residual volume using an ultrasound scan or passing a straight urinary catheter. Variance of compliance and/or clinical practice at the project site may be attributed to differing practices among physicians, inconsistency of nursing documentation, and utilization of the bladder scanner or straight catheter to determine estimated residual volume(s). The project site employs more than 150 health care providers, including physicians, certified nurse midwives, and nursing staff. The frequent clinical rotations of graduate medical education and allied health trainees lead to a greater chance that patient care may not be administered in full accordance with respective facility/unit policies and procedures. Poor documentation of urinary output leads to an assumption that nursing care was not in
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compliance with clinical recommendations. Seventy-nine of 182 records reflected 0 to 1 spontaneous void. The guideline specifies that a woman must spontaneously void 2 times within 6 hours of vaginal delivery or catheter removal. In addition to poor documentation, nursing staff did not demonstrate consistency regarding utilization of a bladder scanner versus straight catheter to estimate residual volume(s). Budget constraints and equipment malfunctions limited the availability of ultrasound equipment. This limitation prompted a shift to the alternate mode of verifying estimated residual volume using a straight catheter. Documentation in several records acknowledged a woman’s inability to void, however, did not reflect the estimated residual volume and mode of assessment. Decreased rate of PUR Implementation of a Clinical Practice Guideline to address postpartum bladder care resulted in a decreased rate of PUR. Of interest, the high preintervention rate of PUR at the project site relative to the incidence cited in the literature (1.7%- 17.9%) may be attributed to the high-risk obstetrical setting and/or the number of employed health care providers assigned to the unit.1 Decreased number of urinary catheterization(s) By decreasing the rate of PUR, implementation of a guideline also decreased the frequency of urinary catheterization. The number and frequency of urinary catheterizations were dependent upon clinical factors and accuracy of nursing documentation. A common clinical factor was provider practice using a straight catheter during repair of periurethral lacerations. Increased awareness regarding the medical condition Documented rates of compliance and anecdotal feedback further demonstrated the ability to recognize and manage this common condition that plagues obstetrical units. During
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the period of implementation, members of the nursing staff conducted literature reviews as an opportunity to self-educate, and potentially identify, national and/or international standards of practices or protocols for the medical condition. CONCLUSIONS There are no published national guidelines to address and/or manage PUR by our professional organizations that promote a standard
of quality care to women. Implementation of a uniform guideline to address PUR will significantly address the health and well-being of women’s health and the obstetrical population. This practice improvement project resulted in an increased awareness at the project site and decreased frequency of urinary catheterizations. The project’s success at implementing a guideline in a high-risk obstetrical unit in the United States demonstrates the need to replicate this project in a low-risk obstetrical setting.
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