Urinary Retention Evaluation and Catheterization Algorithm for Adult Inpatients

Abstract

Importance: Acute urinary retention (UR) is common, yet variations in diagnosis and management can lead to inappropriate catheterization and harm.

Objective: To develop an algorithm for screening and management of UR among adult inpatients.

Design, setting, and participants: In this mixed-methods study using the RAND/UCLA Appropriateness Method and qualitative interviews, an 11-member multidisciplinary expert panel of nurses and physicians from across the US used a formal multi-round process from March to May 2015 to rate 107 clinical scenarios involving diagnosis and management of adult UR in postoperative and medical inpatients. The panel ratings informed the first algorithm draft. Semistructured interviews were conducted from October 2020 to May 2021 with 33 frontline clinicians-nurses and surgeons from 5 Michigan hospitals-to gather feedback and inform algorithm refinements.

Main outcomes and measures: Panelists categorized scenarios assessing when to use bladder scanners, catheterization at various scanned bladder volumes, and choice of catheterization modalities as appropriate, inappropriate, or uncertain. Next, qualitative methods were used to understand the perceived need, usability, and potential algorithm uses.

Results: The 11-member expert panel (10 men and 1 woman) used the RAND/UCLA Appropriateness Method to develop a UR algorithm including the following: (1) bladder scanners were preferred over catheterization for UR diagnosis in symptomatic patients or starting as soon as 3 hours since last void if asymptomatic, (2) bladder scanner volumes appropriate to prompt catheterization were 300 mL or greater in symptomatic patients and 500 mL or greater in asymptomatic patients, and (3) intermittent was preferred to indwelling catheterization for managing lower bladder volumes. Interview findings were organized into 3 domains (perceived need, feedback on algorithm, and implementation suggestions). The 33 frontline clinicians (9 men and 24 women) who reviewed the algorithm reported that an evidence-based protocol (1) was needed and could be helpful to clinicians, (2) should be simple and graphically appealing to improve rapid clinician review, and (3) should be integrated within the electronic medical record and prominently displayed in hospital units to increase awareness. The draft algorithm was iteratively refined based on stakeholder feedback.

Conclusions and relevance: In this study using a systematic, multidisciplinary, evidence- and expert opinion-based approach, a UR evaluation and catheterization algorithm was developed to improve patient safety by increasing appropriate use of bladder scanners and catheterization. This algorithm addresses the need for practical guidance to manage UR among adult inpatients.

Figure.. Final Evaluation and Catheterization Algorithm to Manage Urinary Retention Among Inpatients

The algorithm is intended for the inpatient setting. Cutoffs were determined based on a combination of literature review, expert opinion, and local practice patterns. Of note, use of external catheters to treat urinary retention is inappropriate as external catheters only collect spontaneously voided urine. ISC indicates intermittent straight catheter. ^aConsider checking sooner if the patient is receiving high volumes of intravenous fluid or diuretics. ^bOther common causes of these urinary symptoms include urinary tract infection, overactive bladder, small bladder capacity, or recent catheterization. Consider contacting attending physician for further evaluation. ^cEvaluate the patient’s fluid intake and consider increasing fluids. Call attending physician if urine output is less than 35 mL per hour, raising concern for oliguria from hypovolemia or acute kidney injury.