Defining Properly Collected Urine: Thresholds to Improve the Accuracy of Urinalysis for Microscopic Hematuria Evaluation in Women.

PURPOSE: Microscopic hematuria is one of the most common office consults for urologists. While revised guidelines have risk-stratified patients to reduce unnecessary screening, they do not provide guidance concerning specimen quality. We sought to define "properly collected" specimens using catheterized urine samples as a reference to improve the utility of hematuria screening in women. MATERIALS AND METHODS: We prospectively acquired same-visit voided and catheterized urine samples from 46 women referred for microscopic hematuria from September 2016 to March 2020. Characteristics of pre-referral urinalysis were compared to the matched specimens. True microscopic hematuria was defined as ≥3 red blood cells per high power field on catheterization. RESULTS: Catheterized urinalyses had significantly fewer red blood and squamous epithelial cells in comparison to both referral urinalyses (p=0.006, p=0.001, respectively) and same-day void urinalyses (p=0.02, p=0.04, respectively). As no catheterized sample had >2 squamous epithelial cells, we applied this squamous epithelial cell threshold to referral urinalyses for analysis. Addition of this criterion for "properly collected specimen" increased the positive predictive value of referral urinalyses from 46.1% to 68.8% for true microscopic hematuria. Fewer than 2 squamous epithelial cells with elevated RBC was a significant predictor for true microscopic hematuria (p=0.003). CONCLUSIONS: Voided specimens in the urology clinic had significantly lower red blood cells than referral samples, indicating improved collection technique may reduce false positive urinalyses. Matched collection suggested that repeat collection by catheterization in women who present with >2 squamous epithelial cells per high power field on referral urinalysis may prevent unnecessary future work-up.

A Randomized Controlled Trial of Enhanced Recovery After Surgery Versus Standard of Care Recovery for Emergency Cesarean Deliveries at Mbarara Hospital, Uganda.

BACKGROUND: Enhanced recovery after surgery (ERAS) expedites return to patient baseline and functional status by reducing surgical trauma, stress, and organ dysfunction. Despite the potential benefits of enhanced recovery protocols, limited research has been done in low-resource settings, where 95% of cesarean deliveries are emergent and could possibly benefit from the application of ERAS protocols. METHODS: In a prospective, randomized, single-blind, controlled trial, mothers delivering by emergency cesarean delivery were randomly assigned to either an ERAS or a standard of care (SOC) recovery arm. Patients in the ERAS arm were treated with a modified ERAS protocol that included modified counseling and education, prophylactic antibiotics, antiemetics, normothermia, restrictive fluid administration, and multimodal analgesia. They also received early initiation of mobilization, feeding, and urethral catheter removal. The primary end point was length of hospital stay. The secondary end points were complications and readmission rates. Mean length of stay in the intervention and control arms were compared using t tests. Statistical analyses were performed using STATA version 13 (College Station, TX). RESULTS: A total of 160 patients were enrolled in the study, with 80 randomized to each arm. There was a statistically significant shorter length of stay for the ERAS arm compared to SOC, with a difference of -18.5 hours (P < .001, 95% confidence interval [CI], -23.67, -13.34). The incidence of complications of severe pain and headache was lower in the ERAS arm compared to SOC (P = .001 for both complications). However, pruritus was more common in the ERAS arm compared to SOC (P = .023). CONCLUSIONS: Use of an ERAS protocol for women undergoing emergency cesarean delivery in a low-income setting is feasible and reduces length of hospital stay without generally increasing the complication rate.

Withholding Urinary Catheters in Children Receiving Patient-Controlled Analgesia for Appendicitis.

BACKGROUND: In some institutions, urinary catheters (UCs) have been placed in all patients receiving opioid patient-controlled analgesia (PCA) because of the increased incidence of urinary retention. Our institutional data demonstrated no UC replacements in 48 children who had PCA for perforated appendicitis who had their catheters removed before discontinuation of the PCA. As part of a quality improvement initiative, we discontinued the practice of requiring UC with PCA for perforated appendicitis. MATERIALS AND METHODS: A prospective list of patients with perforated appendicitis was maintained. Data were gathered regarding 60 consecutive patients. UC placement was allowed for specific indications including urinary retention and surgeon discretion. RESULTS: Sixteen patients (27%) received a UC with 14 of these being placed in the operating room (OR). Two UCs were placed outside the OR for urinary retention. Patients who underwent UC placement in the OR weighed significantly more than those who did not (33 versus 42 kg, P = 0.05). No patients required replacement of the catheter once removed. There were no postoperative urinary tract infections. Median PCA duration was 68 h (50, 98) for patients with UC placed in the OR compared with 60 h (47, 78) (P = 0.42). Median postoperative length of stay for patients with UC placed in the OR was 95 h (76, 140) compared with 90 h (70, 113) (P = 0.09). CONCLUSIONS: UC can be withheld from patients with perforated appendicitis who are placed on PCA with a very low placement rate. UC placement at time of operation did not lengthen time receiving PCA or length of stay.

Accuracy of postvoid residual volumes after vaginal delivery: a prospective equivalence study to compare an automatic scanning device with transurethral catheterization.

INTRODUCTION AND HYPOTHESIS: Abnormal postvoid residual volumes (PVRV) after delivery are common in daily clinical practice. By using an automatic scanning device, unnecessary catheterizations can be prevented. The aim of this study was to determine the accuracy of PVRV after vaginal delivery measured by an automatic scanning device through a comparison with transurethral catheterization. MATERIALS AND METHODS: This prospective observational equivalence study was performed in patients who delivered vaginally between June 2012 and May 2017 in three teaching hospitals in The Netherlands. After the first spontaneous void after delivery, postvoid residual volume (PVRV) was measured with a portable automatic scanning device (BladderScan® BVI 9400). Directly afterward, it was measured by catheterization. Correlation between measurements was calculated using Spearman's correlation coefficient and agreement plot. The primary outcome was to validate the correlation between the BladderScan® compared with the gold standard of transurethral catheterization. RESULTS: Data of 407 patients was used for final analysis. Median PVRV as measured by BladderScan® was 380 ml (± 261-0-999 ml) and by catheterization was 375 ml (± 315-1800 ml). Mean difference between measurements was -12.9 ml (± 178 ml). There was a very good correlation between methods (Spearman's rho = 0.82, p < 0.001). Using a cut-ff value of >500 ml, specificity and sensitivity were 85.4 and 85.6%, respectively. CONCLUSIONS: The BladderScan® (BVI 9400) measures PVRV precisely and reliably after vaginal delivery and should be preferred over catheterization.

Strategy to reduce E. coli bacteraemia based on cohort data from a London teaching hospital.

BACKGROUND AND AIM: In 2017, National Health Service Improvement set a 10% reduction target for Escherichia coli bacteraemia by 2018, followed by a 50% reduction in healthcare-associated Gram-negative bacteraemias by 2022. We analysed consecutive cases of E. coli bacteraemia and devised a strategy to achieve these targets. METHODS: From December 2012 to November 2013, demographic, clinical and microbiological data were prospectively collected on all patients with bacteraemia at the Royal London Hospital in East London, UK. RESULTS: There were 594 significant bacteraemic episodes and 207 (34.8%) were E. coli. Twenty-four (11.6%) of the E. coli isolates were extended spectrum beta-lactamase producers, 22 (10.6%) gentamicin resistant and 2 (1.0%) amikacin resistant. The three most common sites of infection were pyelonephritis 105 (56.7%), catheter-associated urinary tract infection 22 (10.6%), and other medical devices and procedures that cause bacteraemia 32 (15.5%). In the pyelonephritis group, trimethoprim resistance in urinary isolates was 16/47 (34.0%) compared with 3/47 (6.4%) for nitrofurantoin. Twelve months postbacteraemia, recurrent bacteraemia rates were 10/105 (9.5%). There were 44 medical device-associated E. coli bacteraemias, and 22 (50%) were urinary catheter associated. There were 10 patients with E. coli bacteraemia caused by procedures, seven genitourinary or biliary tract instrumentation and three postgastrointestinal surgery. CONCLUSION: E. coli bacteraemias related to urosepsis could have been prevented by better empirical treatment and targeted prophylaxis. Urinary catheter quality improvement programmes should contribute to a further reduction. For patients undergoing high-risk urinary or biliary tract procedures or device manipulation, we advocate single-dose amikacin prophylaxis.

Urinary catheterisation management after laparoscopic hysterectomy: a national overview and a nurse preference survey.

The aim of this study was to evaluate the catheterisation regimes after a laparoscopic hysterectomy (LH) in Dutch hospitals and to assess the nurses' opinion on this topic. This was particularly relevant as no consensus exists on the best moment to remove a urinary catheter after an LH. All 89 Dutch hospitals were successfully contacted and provided information on their catheterisation regime after LH: 69 (77.5%) hospitals reported removing the catheter the next morning after the LH, while nine hospitals (10.1%) removed it directly at the end of the procedure. The other 11 hospitals had different policies (four hours, up to two days). Additionally, all nurses working in the gynaecology departments of the hospitals affiliated to Leiden University were asked to fill in a self-developed questionnaire. Of the 111 nurses who completed the questionnaire (response rate 81%), 90% was convinced that a direct removal was feasible and 78% would recommend it to a family member or friend. Impact Statement What is already known on this subject? Although an indwelling catheter is routinely placed during a hysterectomy, it is unclear what the best moment is to remove it after an LH specifically. To fully benefit from the advantages associated with this minimally invasive approach, postoperative catheter management, should be, amongst others, optimal and LH-specific. A few studies have demonstrated that the direct removal of urinary catheter after an uncomplicated LH is feasible, but the evidence is limited. What the results of this study add? While waiting for the results of the randomised trials, this present study provides insight into the nationwide catheterisation management after an LH. Despite the lack of consensus on the topic, catheterisation management was quite uniform in the Netherlands: most Dutch hospitals removed the urinary catheter one day after an LH. Yet, this was not in line with the opinion of the surveyed nurses, as the majority would recommend a direct removal. This is interesting as nurses are closely involved in the patients' postoperative care. What are the implications of these findings for clinical practice and/or further research? Although randomised trials are necessary to determine an optimal catheterisation management, the findings of this present study are valuable if a new urinary catheter regime has to be implemented.

Factors Associated With Healthcare-Acquired Catheter-Associated Urinary Tract Infections: Analysis Using Multiple Data Sources and Data Mining Techniques.

PURPOSE: The purpose of this study was to identify factors associated with healthcare-acquired catheter-associated urinary tract infections (HA-CAUTIs) using multiple data sources and data mining techniques. SUBJECTS AND SETTING: Three data sets were integrated for analysis: electronic health record data from a university hospital in the Midwestern United States was combined with staffing and environmental data from the hospital's National Database of Nursing Quality Indicators and a list of patients with HA-CAUTIs. METHODS: Three data mining techniques were used for identification of factors associated with HA-CAUTI: decision trees, logistic regression, and support vector machines. RESULTS: Fewer total nursing hours per patient-day, lower percentage of direct care RNs with specialty nursing certification, higher percentage of direct care RNs with associate's degree in nursing, and higher percentage of direct care RNs with BSN, MSN, or doctoral degree are associated with HA-CAUTI occurrence. The results also support the association of the following factors with HA-CAUTI identified by previous studies: female gender; older age (>50 years); longer length of stay; severe underlying disease; glucose lab results (>200 mg/dL); longer use of the catheter; and RN staffing. CONCLUSIONS: Additional findings from this study demonstrated that the presence of more nurses with specialty nursing certifications can reduce HA-CAUTI occurrence. While there may be valid reasons for leaving in a urinary catheter, findings show that having a catheter in for more than 48 hours contributes to HA-CAUTI occurrence. Finally, the findings suggest that more nursing hours per patient-day are related to better patient outcomes.

Reducing catheter-associated urinary tract infections: standardising practice.

Inspired by innovations in catheter practice from the USA, in 2014 Nottingham University Hospitals NHS Trust introduced catheterisation standardisation across the Trust's two acute sites. Standardisation was achieved by the introduction of an all-in one catheterisation tray (Bard® Tray), which included all the necessary equipment required for catheterisation, coupled with a training programme. The introduction of the tray was followed by a clinically significant 80% reduction in the CAUTI rate from 2014 to 2016. This reduction in CAUTI rate provided the Trust with a considerable reduction on annual expenditure (nearly £160 000 less in 2016 compared with 2014). The introduction of the tray has additionally improved practice with nursing staff now less likely to forget the necessary equipment before commencing catheterisation as all the components are provided in one place.

Study comparing 3 hour and 24 hour post-operative removal of bladder catheter and vaginal pack following vaginal surgery: a randomised controlled trial.

BACKGROUND: Traditional practice after vaginal hysterectomy was to keep the vaginal pack and urinary catheter for 24 hours post operatively. But there were studies that prolonged cathterisation was associated with urinary infection. So this study was conducted to compare the post operative outcome when the urinary catheter and vaginal pack were removed after 3 hours and after 24 hours after surgery. METHODS: The study was done in the Department of Obstetrics and Gynecology, in a tertiary teaching institute of South India from September 2008 to March 2010. It was a randomised controlled trial involving 200 women undergoing vaginal surgery, who were randomly assigned to 2 groups - catheter and vaginal pack were removed either in 3 h in study group or were removed in 24 h in control group. The outcome of the study were vaginal bleeding, urinary retention, febrile morbidity, and urinary infection. RESULTS: There was no significant difference between the study and control groups with respect to vaginal bleeding (0 and 1%, p = 1), urinary retention (9 and 4%, p = 0.15), febrile morbidity (7 and 4%, p = 0.35), and urinary infection (26% in each group, p = 1.0). CONCLUSION: Keeping the urinary catheter and vaginal pack for 24 h following vaginal surgery does not offer any additional benefit against removing them after 3 h.

Suprapubic Catheter Change Methods: A Crossover Comparison Cohort Trial.

PURPOSE: The purpose of this study was to compare 2 methods of suprapubic catheter (SPC) change, instillation and observation. The instillation method requires instillation of saline to the bladder prior to SPC removal; the observation method is completed taking note of the angle and length at which the indwelling SPC is withdrawn and observation of urine from the newer catheter when inserted. DESIGN: Nonrandomized crossover trial. SUBJECTS AND SETTING: Fifty-nine community-dwelling adults who were long-term SPC users participated in the study. There were 38 males and 21 females, with a mean age of 68.5 years. Most had chronic, progressive, or complex comorbidity. The mean duration of SPC use was 3.5 years. METHODS: Participants underwent 4 SPC changes using the instillation method, followed by 4 changes using the observation method. Data were collected using a 3-part survey document; it queried demographic and catheter-related clinical information, the number of symptomatic catheter-associated urinary tract infections (CAUTIs) requiring antibiotic treatment, the number of catheter blockages that occurred during data collection, and nurses' experiences during catheter changes (including narrative feedback-related problems, concerns, or comments in relation to each catheter change). The comparative CAUTI and blockage outcomes were analyzed using McNemar's test for 2 paired samples. Narrative data were analyzed using thematic analysis. RESULTS: There were 231 SPC changes using the observation method. No episodes of catheter displacement occurred. Analysis of nurses' narrative revealed concerns regarding "slowness" of urine drainage from the newly inserted catheter. This concern was addressed by promotion of adequate hydration prior to catheter change. There were 120 paired useable surveys included in the CAUTI and blockage incidence comparison; no statistically significant differences in CAUTI occurrences were found based on catheter change method (11 vs 11, P = .7728). No differences in the catheter blockage episodes were found based on catheter change method (8 vs 6, P = .7237). CONCLUSION: The observation method of SPC change was as effective as the instillation method.

Urology study day: Leeds 2016.

Last year, urology nurses and continence nurse specialists took part in the second of two study days on urology. The events were delivered by the British Journal of Nursing with programme support in association with the British Association of Urology Nurses and Hollister Inc. Below are reports of some of the presentations.

[Urinary catheter : comply with guidelines to avoid infections]. / Sonde urinaire : respecter les indications pour éviter les infections.

Catheter-associated urinary tract infection (CAUTI) is the most frequent hospital acquired infection, associated with significant morbidity, mortality and health care costs. Up to 50 % of urinary catheter use in hospital are for incontinence or convenience without proper indication. In addition, urinary catheters are not removed when no longer necessary, due to a lack of vigilance of the health care team. The duration of catheterization is the most important risk factor for the development of CAUTI. Simple measures to prevent CAUTI include appropriate use, maintaining awareness of catheters in place and use of different alternatives. These measures can reduce the number of CAUTI over 50 % along with positive impact on the quality of care and costs.

Les infections liées aux sondes urinaires sont les infections nosocomiales les plus fréquentes avec un impact majeur sur la morbi-mortalité et les coûts de la santé. Près de la moitié des patients sondés le sont sans indication formelle. De plus, les sondes urinaires sont laissées en place plus longtemps que nécessaire, souvent en raison d'un manque de vigilance des soignants. Or, le risque de développer une infection est étroitement lié à la durée du sondage. Des mesures simples pour améliorer la sécurité des patients consistent à respecter les indications, penser aux différentes alternatives et réévaluer quotidiennement la nécessité des sondes. Ces mesures permettent de diminuer le nombre d'infections urinaires liées aux sondes de plus de 50 % avec un impact positif sur la qualité de la prise en charge et une diminution des coûts.

Resident performance in complex simulated urinary catheter scenarios.

BACKGROUND: Urinary catheter insertion is a common procedure performed in hospitals. Improper catheterization can lead to unnecessary catheter-associated urinary tract infections and urethral trauma, increasing patient morbidity. To prevent such complications, guidelines were created on how to insert and troubleshoot urinary catheters. As nurses have an increasing responsibility for catheter placement, resident responsibility has shifted to more complex scenarios. This study examines the clinical decision-making skills of surgical residents during simulated urinary catheter scenarios. We hypothesize that during urinary catheterization, residents will make inconsistent decisions relating to catheter choices and clinical presentations. METHODS: Forty-five general surgery residents (postgraduate year 2-4) in Midwest training programs were presented with three of four urinary catheter scenarios of varying difficulty. Residents were allowed 15 min to complete the scenarios with five different urinary catheter choices. A chi-square test was performed to examine the relation between initial and subsequent catheter choices and to evaluate for consistency of decision-making for each scenario. RESULTS: Eighty-two percent of residents performed scenario A; 49% performed scenario B; 64% performed scenario C, and 82% performed scenario D. For initial attempt for scenario A-C, the 16 French Foley catheter was the most common choice (38%, 54%, 50%, P's < 0.001), whereas for scenario D, the 16 French Coude was the most common choice (37%, P < 0.01). Residents were most likely to be successful in achieving urine output in the initial catheterization attempt (P < 0.001). Chi-square analyses showed no relationship between residents' first and subsequent catheter choices for each scenario (P's > 0.05). CONCLUSIONS: Evaluation of clinical decision-making shows that initial catheter choice may have been deliberate based on patient background, as evidenced by the most popular choice in scenario D. Analyses of subsequent choices in each of the catheterization models reveal inconsistency. These findings suggest a possible lack of competence or training in clinical decision-making with regard to urinary catheter choices in residents.

Errors in bladder catheterization: are residents ready for complex scenarios?

BACKGROUND: The aim of this study was to investigate whether junior surgical residents had successfully mastered bladder catheterization. Our hypothesis was that surgical residents would be overly confident in their abilities and underestimate the potential for case complexity. MATERIALS AND METHODS: PGY 2-4 surgery residents (n = 44) were given 15 min. to complete three of four bladder catheterization simulations. Participants reported their mastery by rating confidence using a 5-point Likert scale. Multiple linear regression analysis was used to test predictors of procedure performance. RESULTS: Participants made a total of 228 errors with an average of 5.1 errors (standard deviation = 2.6) per participant. The most common errors included not maintaining the sterile field (52.0%), failure to get urine return (20.3%), and inflating the catheter balloon before urine return (8.4%). Some residents committed the same error more than once. Presimulation confidence ratings ranged from "1" being not confident to "5" being extremely confident. Average presimulation confidence was 4.42 (range 1-5, standard deviation = 0.85). Sixteen (36%) residents ranked their presimulation confidence in problem-solving abilities as "moderately confident" or below, whereas 28 (64%) were "very confident" or above. The lower the resident's presimulation confidence in problem-solving, the more errors they committed during the simulation (beta = -0.33, t = -2.15, P = 0.04). CONCLUSIONS: The residents did not perform as well as they anticipated when presented with more complicated bladder catheterization scenarios. Simulation can be used to identify and expose potential errors that may occur during complex presentations of basic procedures. This type of training and assessment may facilitate mastery.

Policies for replacing long-term indwelling urinary catheters in adults.

BACKGROUND: Long-term indwelling catheters are used commonly in people with lower urinary tract problems in home, hospital and specialised health-care settings. There are many potential complications and adverse effects associated with long-term catheter use. The effect of health-care policies related to the replacement of long-term urinary catheters on patient outcomes is unclear. OBJECTIVES: To determine the effectiveness of different policies for replacing long-term indwelling urinary catheters in adults. SEARCH METHODS: We searched the Cochrane Incontinence Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 19 May 2016), and the reference lists of relevant articles. SELECTION CRITERIA: All randomised controlled trials investigating policies for replacing long-term indwelling urinary catheters in adults were included. DATA COLLECTION AND ANALYSIS: At least two review authors independently performed data extraction and assessed risk of bias of all the included trials. Quality of evidence was assessed by adopting the GRADE approach. Any discrepancies were resolved by discussion between the review authors or an independent arbitrator. We contacted the authors of included trials to seek clarification where required. MAIN RESULTS: Three trials met the inclusion criteria, with a total of 107 participants in three different health-care settings: A USA veterans administration nursing home; a geriatric centre in Israel; and a community nursing service in Hong Kong. Data were available for three of the pre-stated comparisons. Priefer and colleagues evaluated different time intervals between catheter replacement (n = 17); Firestein and colleagues evaluated the use of antibiotic prophylaxis at the time of replacement (n = 70); and Cheung and colleagues compared two different types of cleaning solutions (n = 20).All the included trials were small and under-powered. The reporting of the trials was inadequate and as a result, risk of bias assessment was judged to be unclear for the majority of the domains in two out of the three trials. There was insufficient evidence to indicate that (i) there was a lower incidence of symptomatic UTI in people whose catheter was changed both monthly and when clinically indicated (risk ratio (RR) 0.35, 95% confidence interval (CI) 0.13 to 0.95; very low quality evidence) compared to only when clinically indicated, (ii) there was not enough evidence to assess the effect of antibiotic prophylaxis on reducing: positive urine cultures at 7 days (RR 0.91, 95% CI 0.79 to 1.04); infection (RR 1.41, 95% CI 0.55 to 3.65); or death (RR 2.12, 95% CI 0.20 to 22.30; very low quality evidence), (iii) there was no statistically significant difference in the incidence of asymptomatic bacteruria at 7 days (RR 0.80, 95% CI 0.42 to 1.52) between people receiving water or chlorhexidine solution for periurethral cleansing at the time of catheter replacement. However, none of the 16 participants developed a symptomatic catheter-associated urinary tract infection (CAUTI) at day 14.The following outcomes were considered critical for decision-making and were also selected for the 'Summary of findings' table: (i) participant satisfaction, (ii) condition-specific quality of life, (iii) urinary tract trauma, and (iv) formal economic analysis. However, none of the trials reported these outcomes.None of the trials compared the following comparisons: (i) replacing catheter versus other policy e.g. washouts, (ii) replacing in the home environment versus clinical environment, (iii) clean versus aseptic technique for replacing catheter, (iv) lubricant A versus lubricant B or no lubricant, and (v) catheter user versus carer versus health professional performing the catheter replacement procedure. AUTHORS' CONCLUSIONS: There is currently insufficient evidence to assess the value of different policies for replacing long-term urinary catheters on patient outcomes. In particular, there are a number of policies for which there are currently no trial data; and a number of important outcomes which have not been assessed, including patient satisfaction, quality of life, urinary tract trauma, and economic outcomes. There is an immediate need for rigorous, adequately powered randomised controlled trials which assess important clinical outcomes and abide by the principles and recommendations of the CONSORT statement.

Improving the quality of obstetric care for women with obstructed labour in the national referral hospital in Uganda: lessons learnt from criteria based audit.

BACKGROUND: Obstructed labour remains a major cause of maternal morbidity and mortality whose complications can be reduced with improved quality of obstetric care. The objective was to assess whether criteria-based audit improves quality of obstetric care provided to women with obstructed labour in Mulago hospital, Uganda. METHODS: Using criteria-based audit, management of obstructed labour was analyzed prospectively in two audits. Six standards of care were compared. An initial audit of 180 patients was conducted in September/October 2013. The Audit results were shared with key stakeholders. Gaps in patient management were identified and recommendations for improving obstetric care initiated. Six standards of care (intravenous fluids, intravenous antibiotics, monitoring of maternal vital signs, bladder catheterization, delivery within two hours, and blood grouping and cross matching) were implemented. A re-audit of 180 patients with obstructed labour was conducted four months later to evaluate the impact of these recommendations. The results of the two audits were compared. In-depth interviews and focus group discussions were conducted among healthcare providers to identify factors that could have influenced the audit results. RESULTS: There was improvement in two standards of care (intravenous fluids and intravenous antibiotic administration) 58.9 % vs. 86.1 %; p < 0.001 and 21.7 % vs. 50.5 %; P < 0.001 respectively after the second audit. There was no improvement in vital sign monitoring, delivery within two hours or blood grouping and cross matching. There was a decline in bladder catheterization (94 % vs. 68.9 %; p < 0.001. The overall mean care score in the first and second audits was 55.1 and 48.2 % respectively, p = 0.19. Healthcare factors (negative attitude, low numbers, poor team work, low motivation), facility factors (poor supervision, stock-outs of essential supplies, absence of protocols) and patient factors (high patient load, poor compliance to instructions) contributed to poor quality of care. CONCLUSION: Introduction of criteria based audit in the management of obstructed labour led to measurable improvements in only two out of six standards of care. The extent to which criteria based audit may improve quality of obstetric care depends on having basic effective healthcare systems in place.

Urinary Catheterization: a Paradigm Shift in Difficult Urinary Catheterization.

BACKGROUND: The urinary catheter is an ancient device for urinary drainage in patients. Placement of a urethral catheter is a common medical procedure that may have led to morbidity and mortality. Urethral catheterization is commonly performed by a nurse. Difficult catheter placement generates urology consultation. Difficult catheterization with a vision-guided urinary catheter may provide expedited and successful catheter placement by nursing personnel. METHODS: A PubMed.gov and Ovid Medline search for articles on history of urinary catheter, difficult urinary catheterization, iatrogenic urethral injury, iatrogenic urethral injury and CAUTI, management of iatrogenic urethral injury, and techniques for urinary catheter placement was performed. RESULTS: The history of urinary catheters is reviewed. Technical advances in the last century are discussed. Indications for catheter placement are included. Outcomes and cost of complications of urinary catheters are discussed relative to present practice quality standards. Review of difficult urinary catheterization management algorithms developed with urological catheter improvements during the last decade is analyzed. Educational and technological advances to improve outcomes of urinary catheter use are addressed. CONCLUSIONS: Provider attention to issues of urinary catheterization is enhanced by education and additional skills for catheterization. Physician and nurse providers can use current technology with preparation to improve the catheterization care of patients.

The effect of a short educational intervention on the use of urinary catheters: a prospective cohort study.

OBJECTIVE: To assess the effectiveness of implementation of evidence-based recommendations to reduce catheter-associated urinary tract infections (CAUTIs). DESIGN: Prospective cohort study, conducted in 2010-12, with a before and after design. SETTING: A major referral university hospital. PARTICIPANTS: Data were collected before (n = 244) and 1 year after (n = 255) the intervention for patients who received urinary catheters. INTERVENTION: The intervention comprised two elements: (i) aligning doctors' and nurses' knowledge of indications for the use of catheters and (ii) an educational effort consisting of three 30- to 45-minute sessions on evidence-based practice regarding catheter usage for nursing personnel on 17 medical and surgical wards. MAIN OUTCOME MEASURES: The main outcome measures were the proportion of (i) admitted patients receiving urinary catheters during hospitalization, (ii) catheters inserted without indication, (iii) inpatient days with catheter and (iv) the incidence of CAUTIs per 1000 catheter days. Secondary outcome measures were the proportion of (i) catheter days without appropriate indication and (ii) patients discharged with a catheter. RESULTS: There was a reduction in the proportion of inpatient days with a catheter, from 44% to 41% (P = 0.006). There was also a reduction in the proportion of catheter days without appropriate indication (P < 0.001) and patients discharged with a catheter (P = 0.029). The majority of catheters were inserted outside the study wards. CONCLUSIONS: A short educational intervention was feasible and resulted in significant practice improvements in catheter usage but no reduction of CAUTIs. Other measures than CAUTI may be more sensitive to detecting important practice changes.

Accuracy of Post-Void Residual Urine Volume Measurement Using an Ultrasound Bladder Scanner among Postoperative Radical Hysterectomy Patients.

Background: Postoperative urinary retention occurs in 17 to 42% of Radical hysterectomy (RH) cases. The gold standard assessment of post-void residual urine volume (PVR) is bladder catheterization. The use of the 3D portable ultrasound device (VerathonBladderScan BVI 9400) to evaluate PVR is quick, safe, non-invasive, painless, and comfortable for patients as well as being easy to use. Objective: To compare the accuracy of ultrasound bladder scanner with that of urethral catheterization in the assessment of post-void residual urine volume (PVR). Material and Method: This was a prospective study. After removal of Foley's catheter in postoperative radical hysterectomy(RH) patients, the voiding care schedule consisted of voids after six hours or earlier if the patient had the urge. Promptly after voiding, PVR was measured using the BladderScan (Scan volume). Immediately after the procedure, urethral catheterization was performed to obtain the actual PVR (Catheter volume). The process was repeated in subsequent voids, and correlations between scan volume and catheter volume were analyzed. Results: Seventy patients (140 measurements) were included. A high correlation was found between the scan volume and the catheter volume (r = 0.89, p<0.001). A 91.0% specificity and 93.1% negative predictive value(NPV) were obtained using the scan volume in predicting a catheter volume of <100 ml. The difference in measurements between the two methods was not related to age, body mass index, parity, co-existing illness, type of surgical incision or duration of indwelling catheter. When catheter volume >100 ml was the cutoff for determining the need for re-catheterization, the scan volume returned 90.0% accuracy. Repetition of ultrasound scan in patients who had a first scan volume of <100 ml yielded a 97.2% specificity and 100% NPV in predicting catheter volume of <100 ml. Conclusion: The Bladder Scan provides good correlation together with high rates of specificity and NPV, and it could be an alternative modality to catheterization for the measurement of PVR in postoperative RH patients.