By Aaron Smith
Easing Patient Discomfort When measuring postvoid residual urine volume, bladder ultrasound screening is an efficacious and less painful option. Using ultrasound scanning of the bladder can reduce discomfort and infection risk, while saving staff time and money over the long run. For rehabilitation patients with bladder management needs, urethral catheterization is commonly used to measure postvoid residual urine volume. Perhaps too common, according to two experienced rehabilitation nurses, Pat Auston, CRRN, and Regina G. Cox, RN, CRRN, considering the discomfort it causes patients and the fact that many catheterizations only serve to show that the patient's bladder volume is fine and the discomfort is unnecessary. COMFORT VS RISK "The overall benefit of the ultrasound is that it's a noninvasive way to determine urinary retention," says Auston, clinician/educator at St John's Health System in Springfield, Mo. The 33-bed, hospital-based acute rehabilitation facility uses a portable bladder scanner. "In the past, the only way we could measure [postvoid residuals] would be to in-and-out catheterize the patient, and when you do that, you're risking a urinary tract infection (UTI)," Auston says. Southeastern Regional Rehabilitation Center in Fayetteville, NC, also utilizes a portable bladder scanner, which education coordinator Cox believes is a vast improvement over catheterization. "There is no such thing as a 100% sterile catheterization-you're putting something in the patient," Cox says. "But until we got the bladder scanner, it was the only way to know that the bladder was empty. We had to do three caths on almost every patient who had a stroke or brain injury that could affect the bladder. Each patient has to have a postvoid residual of around 100 cc." Now, say Auston and Cox, through ultrasound scanning, rehab professionals at facilities can determine residual volume in a kinder, gentler manner that provides immediate advantages to the patient as well as long-term benefits to the facility. THE COST ISSUE In a 3-year study published by the American Journal of Nursing on the reduction of UTIs, the use of a bladder scanner was cited as a "critical factor."1 A separate study of long-term care patients showed that catheterization carried a urinary infection rate risk of 5%.2 The study recommended that catheterization be limited to clinically appropriate indications. Still, despite the documented medical benefits, a great many institutions do not have a bladder ultrasound program in place. Auston and Cox agree that there are several reasons, starting with the most obvious: the acquisition cost of an ultrasound scanner can run more than $10,000. "I think the initial cost for the machine is an issue for many institutions, particularly the smaller institutions, but it can be offset easily with the advantages to the patient," Auston says. "When you consider over time the cost of the catheter kits, it's only a one-time cost for the scanner." Factoring in staff time, reimbursement issues, and catheter charges, Cox agrees: "On average, the scan takes about 10 minutes. With a catheter, you have to do all the cleaning. And it's a charge each time. With a scan, you're ahead of the game. Between staff time and fewer UTIs, the scanner saves money, especially with Medicaid patients where the daily charges add up." TRAINING MATTERS In addition to price sticker shock, a general fear of the unknown is another stumbling block to implementing a bladder ultrasound program, including a misplaced intimidation regarding the level of training required to operate the machine. In fact, Cox notes that learning how to operate and care for a bladder ultrasound scanner is actually not as complicated as the sophisticated technology might suggest. She says the scanner "involves minimal training." Manufacturers often offer an in-facility training program as well as a manual and video as part of the purchase price of the scanner. Training covers basic procedures and proper care for the equipment. Once a few members of a rehab facility's staff are up to speed, they can help train others, according to Cox. "It's good to have one or two designated trainers to make sure that the staff uses the right procedures," she says. As with most sophisticated pieces of equipment, care must be taken when handling the scanner, which sits on a cart for better mobility. "It's fragile and you can't drop the [flat probe scan] head and expect it to work," Cox says. "You have to respect the machine and take care of it. According to Cox, in instances where a problem does arise with the scanner, the manufacturer ships a loaner-often the same day-to be used while the unit is repaired. And as with any other procedure, practice makes perfect. At St John's, Auston says she demonstrates the machine to other nurses and then observes them perform demonstrations until they are confident and comfortable with its operation. PROCEDURES To perform a bladder ultrasound scan, a nurse or other rehab professional lays the patient down supine and adjusts clothing to place the unit's flat probe scan head on the lower bladder right above the pubic bone, Cox explains. To get an accurate reading of postvoid residual urine, the ultrasound scan must be performed on the patient within 15 to 20 minutes after the void. "If not, the kidneys have already deposited more urine in the bladder and you're going to get a bad number," Cox says. To further ensure an accurate picture of bladder volume, more than one reading must almost always be taken to rule out human error. "The most important thing is that you get two or three readings," Auston says. "The bladder comes in different shapes and sizes, so you can not rely on the first reading." "You can't be afraid to do as many scans as needed until you feel you have the most accurate picture of the bladder," Cox adds. "If it takes four tries, that's what it takes." The scanner, which is not used on pregnant patients, shows an outline of the bladder and displays, in cubic centimeters (ccs), how much urine is contained in the bladder. Of multiple readings, the largest one will be the most accurate, according to Cox and Auston. The machine can then print a picture of the bladder outline to put in the patient's medical chart. According to a 1995 study of a bladder ultrasound program implemented at one rehabilitation facility, 79% of postvoid residuals done by bladder ultrasound found volumes of 100 cc or less, and catheterization was avoided for these patients.3 In cases where a reading shows a large postvoid residual volume, different facilities have different parameters to determine if they are going to catheterize the patients, Cox says. "One hospital may say that ‘if they have 150 cc in their bladder, cath them.' Another may say, ‘That's OK.'" By and large, the ultrasound scans are handled by nursing staff, Cox says. "In my facility, it's covered under the Rehab Nurses Bladder Protocol, so nurses are automatically allowed to do it and it's covered on their admission orders. It's noninvasive." Both St John's and Southeastern do not charge for the bladder ultrasound scans; other facilities do. "It's a service for our patients," Auston says. "And the only thing we need to order on an ongoing basis is a gel [for the scanning procedure]." Auston's only lament is that her facility does not have more than one scanner on-site. "If you're using it for a large floor with many patients, and you have only one machine, it's not always available at the exact time you need it," she says. "Many times, you'll have three or four patients that you need to scan at the same time. You really need to get them postvoid immediately to be as accurate as possible, and if someone has to wait 30 minutes, it will not be as accurate." Multiple units aside, Auston says she hopes the bladder ultrasound scanner is "discovered" by more rehab facilities. "It is a wonderful machine," Cox adds. "Patients do not like to be catheterized. It's not fun, let alone the chances of introducing bacteria into the bladder. This increases their comfort and self-esteem." Aaron Smith is a contributing writer for Rehab Management. References 1. Study establishes ‘best practice' for prevention of urinary tract infections. Am J Nurs. 2000;100:3-12. Available at: http://nurses.medscape.com/MedscapeWire/2000/0400/medwire.0425.Study.html. Accessed November 12, 2001. 2. Nicolle LE. Urinary tract infections in long-term care facilities. Infect Control Hosp Epidemiol. 1993;14(4):220-225. 3. Lewis N. Implementing a bladder ultrasound program. Rehabilitation Nursing. 1995;20(4):215-217.
