Jennifer Ann Meddings, MD, explains urinary retention evaluation and catheterization algorithm

In this video, Jennifer Ann Meddings, MD, discusses the implementation of a urinary retention evaluation and catheterization algorithm that is described in the JAMA Network Open paper “Urinary Retention Evaluation and Catheterization Algorithm for Adult Inpatients.” Meddings is an associate professor at the University of Michigan in Ann Arbor. The algorithm can be accessed at: https://msqc.org/wp-content/uploads/2024/01/Urinary-retention-and-safe-catheter-insertion_2024-version.pdf

Transcription:

How do you anticipate the implementation of this algorithm will affect patient outcomes, such as reduced catheter-associated urinary tract infections and improved patient comfort? Are there plans to evaluate the algorithm's effectiveness in a larger, prospective study?

Our goal is that people would not be getting catheterized when they actually do not have sufficient urinary retention. When we did interviews, we would find out sometimes nurses were catheterizing for 100, sometimes they were catheterizing for 450, and so particularly those patients who have lower volumes, particularly when they were simply scanning a certain number of hours after a surgery, when they hadn't voided and they didn't have symptoms, we give guidance regarding that, and particularly if they have a really low volume, maybe they actually need fluids. Maybe they're dehydrated. And so we actually give feedback on that when we've implemented the algorithm so that you're simply not catheterizing for low volumes because they haven't urinated. And so we're hoping it will reduce unnecessary catheterization.

The other thing that you'll see in the middle of the algorithm, which is also novel, is really identifying not only like once you've decided that the patient needs to be catheterized, it has them do a very simple risk assessment. Is this patient at high risk for injury? Because 1 of our most common risk factors for catheter-associated UTI is repeated attempts at catheterization before the successful catheterization. Unfortunately, a lot of those patients have enlarged prostates and have some other anatomic challenges. And so we're trying to really identify those higher risk patients first, so that you can do a couple of things. You can either, first, make sure that for the person who's going to catheterize them that it's not their first catheter; it really is someone who's more experienced...We've worked with our urology teams to identify patients who really have a red flag and that, based upon their medical history, like recent surgery, recent urethral trauma, GU reconstructive surgery, artificial sphincter, they really should be chatting with urology before they even attempt catheterization, because often urology needs to assist with that.

That was another thing that we had found, that nurses did not have a set of red flags, and sometimes these patients were only identified after they had trauma or after they had a complication. And so we're hoping that it will reduce trauma, because hopefully these patients will be catheterized by more experienced proceduralists when they're getting their catheter placed. The other thing we've also suggested in the algorithm is particularly, for example, those patients with enlarged prostates to consider a coudé catheter instead of a regular catheter. And that was the other thing—nurses did not have guidelines about this, and when we did our interviews regarding coudé catheter use, we found that particularly in the pandemic, there was a lot of change in nursing staff, and that sometimes there were a lot of float nurses or nurses who were coming from different units, and some of these nurses, it had been a very long time since they had been trained to use a coudé. It was all part of their standard training, but they needed some refresher training regarding that, and really even just to know, when do you use a coudé. And so we're hoping that also, if they're more comfortable using coudés, then we'll also get a little bit less trauma, and less trauma also leads to less infections in these patients. Regarding the evaluating the effectiveness in larger studies, there's actually one ongoing right now. We are collaborating with the Michigan Surgical Quality Collaborative, and we've been doing this now for a few years. But we had to first develop our tools; we also had to develop measures regarding trauma and catheter use and appropriateness in this collaborative. Our project focuses on elective appendectomies, cholecystectomies, colorectal procedures, and hernia procedures, and at least regarding the urinary retention, we had developed measures of urinary retention because there also wasn't a routine measure of how to look at this in the chart. So we had to first train the abstractors to do this. And then this is actually one of the tools that was implemented in 2023 and so it's currently in the evaluation phase right now.

And then I was actually going to show you the tool as it's being implemented in that collaborative. Our project within this MSQC collaborative is called SUCCESS, which is surgical urinary catheter care enhancement study. And so this is the prospective study looking at not only the effectiveness of this algorithm, but also some other tools that we developed. This is the same algorithm, except it's more stylized. We worked with a graphic artist, and really worked with a lot of clinicians going back and forth, trying to make sure it was very easy to read and of course, it has more color and more icons, because we weren't restricted by what the journal wanted.

And so you'll see it really starts with icons that talk about symptoms. We actually use some icons that sort of get their attention about making sure they're using the bladder scanner. The algorithm that we're using in the collaborative has a little bit more detail because of some specific patient populations they deal with, like same-day discharge. And so we've addressed that. And then we've also used this caution tape to really bring people's attention to doing that high-risk assessment. And then we also have, if they've failed the first attempt, we actually have additional resources in this collaborative. They have more to do with safe insertion, rather than retention. But this is actually in our collaborative what gets laminated and put on the bladder scanner. Because one of the things that we realized, particularly in that this project was funded right after the pandemic started, and there was lots of change in staff. Nurses were working in units they weren't normally working in; there were floats, new hires. We had to make it very easy to use so that they wouldn't have to go hunt, say, on a website to get it. It was 1 page. They could easily see it. And we specifically worked with the nurses to figure out what format they wanted. They did not prefer the sort of boxes and arrows that journals tend to prefer. They preferred the color formats and really decision from top to bottom. They always worked from top to bottom. That's what their usual protocols were, and so that's how it is getting tested currently.

This transcription was edited for clarity.