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Introducing a nurse-led urinary retention clinic Karen Wilkinson Abstract: acute urinary retention can be treated by an indwelling catheter, alpha-blocking medication and a later trial without the catheter. Two years of data were compared, before and after the introduction of such a protocol, for the A&E department and with a nurse-led urinary retention clinic to follow-up patients. Fourteen references. Contents Return to Nursing Progress contents list Introduction - treatments for acute urine retention Acute urine retention (AUR) is one of the most common urgent urological conditions. It is a condition characterised by a sudden inability to micturate that is usually, but not always, painful. AUR is both a significant public health issue and of consequence to the affected individual. [1] Over 10% of men in their sixties will experience AUR over a five-year period, with the risk increasing to one in three over 10 years. [2] The cause of AUR is usually benign prostatic hyperplasia (BIH). Traditionally, AUR was considered to be an absolute indication for prostatectomy however, [3] since the introduction of alpha-blockers, this concept has changed. It is becoming increasingly accepted that a trial of voiding should be part of the management of AUR. [1] The optimum period prior to a Trial Without Catheter (TWOC) has been reported as seven days. [4] Once the patient is catheterised, local practice usually dictates whether he is kept in hospital as an inpatient or sent home. Most institutions admit patients who present with AUR. In one UK survey, 65.5% of hospitals responding said they admitted their patients, with 19.3% admitting them only if renal function was deranged. [5] However, there is evidence that it is safe to send AUR patients home after they have been catheterised, provided they are not uraemic, septic, ill or dehydrated. [6] Setting up the urinary retention clinic at Barts and The London Traditionally at Barts and The London. patients were seen in the Accident and Emergency Department (A&E), catheterised and then admitted as inpatients to the urology ward. They then had a TWOC several days later. In May 2002, a new, nurse-led urinary retention clinic was set up by the Urology Nurse Specialist. As a result, patients who fulfilled set criteria were catheterised in A&E and then discharged home, to be seen the following week for a TWOC in the clinic. Urology was one of the first acute specialties to establish nurse specialist/ practitioner posts and has been at the forefront of this particular change in healthcare. [7] The benefits of nurse-led clinics in urology are well documented. [8 - 10] This development in nursing practice also has the support of the Nursing and Midwifery Council. [11] Material and methods The urinary retention clinic at Barts and The London was developed by the Urology Nurse Specialist, consultant urologists, A&E consultants and A&E senior nurses, supported by a protocol defining the criteria for appropriate patients and care. There were several reasons for the introduction and development of this clinic, along with associated benefits. Firstly, it had been demonstrated that patients who present with AUR and fulfill set criteria can be safely discharged home following catheterisation. [6] Secondly, the immediate discharge of patients in AUR with planned follow-up enable alternative use of inpatient urology resources. Inappropriate emergency admissions may lead to the disruption of planned operating lists due to the lack of available beds to admit patients for elective surgery. [12] Inclusion criteria for patients to be referred to the retention clinic Patients who attend A&E with AUR are catheterised and then discharged home if they fulfill the following criteria:
Exclusion criteria Patients with the following conditions are not suitable for discharge and referral to the urinary retention clinic:
Patients who meet the inclusion criteria are given an appointment to be seen the following week by the Urology Nurse Specialist in the retention clinic. They are also given contact details should they have any problems in the interim. At this time, they also are commenced on alpha-blocker therapy by the A&E doctor as appropriate. When the patients attend the nurse-led clinic, the catheter is removed after full discussion and explanation between the nurse and the patient. The patient's urine output and residual volumes are monitored over several hours during which the patient remains in the department. If, after that time, they still cannot pass urine or have a high residual volume, they are either recatheterised or taught intermittent self-catheterisation if they are able and willing to perform this. The patient is then given an appointment to see a consultant urologist the following week for discussion on further management and treatment. Patients who void successfully, are reviewed by a consultant urologist at a routine appointment. The Urology Nurse Specialist writes to both the patient's GP and the consultant urologist informing them about the course of events. Assessing the effectiveness of the urinary retention clinic A study was carried out one year prior to and one year following commencement of the clinic by a team comprising of a consultant urologist, a urology senior registrar and the urology nurse specialist. The aim of this audit was to examine the impact of the new retention clinic on the number of admissions, length of hospital stay and clinical outcome. In the study, we/the team compared patients who presented to A&E with AUR one year prior to the introduction of the retention clinic (year one) and one year after its introduction (year two). A study tool was constructed with the assistance of the Clinical Effectiveness Unit (CEU), enabling us to gather information on the following factors:
Through the study, information was gained retrospectively from medical notes and the records kept by the Urology Nurse Specialist. The study proformas were completed and analysed using SPSS (Statistical Package for Social Sciences) by the CEU. A total of 110 patients were studied. The average age of the patients was 73 years (range 18-9l years). In year one, 43 patients attended the A&E department (38 men and five women), while in year two, 67 patients attended (60 men and seven women). In total, 24 (22%) were commenced on alpha-blockers. Ten patients (10%) were already taking these. Of the men who were commenced on alpha-blockers or were already prescribed them, seven (32%) passed their TWOC and 15 (68%) failed. The table below shows the causes of acute urinary retention. Causes of AUR
Patient outcomes
The reasons for admission as an inpatient in year two included renal failure, inability to cope, haematuria and a residual volume greater than 1.5 litres. The operations performed included TURP, BNI and urethrotomy Additionally, 10 patients (9%) remain on a long-term catheter (either through patient choice or because they are unfit for surgery). Very few patients had a significant urological history, with three patients (3%) previously having a TURP and five patients (5%) having previous episodes of AUR. Back to Top DiscussionPrior to the opening of the urinary retention clinic, all patients presenting to A&E with AUR were admitted as inpatients to the urology ward. In the first year after the establishment of the clinic, 45 patients were catheterised and discharged home who would otherwise been admitted to hospital for several days as inpatients. A reduction in the number of patients admitted with AUR can benefit both the patients and the Trust, including considerable cost savings relating to the freeing up of inpatient hospital beds. However, one area of concern that emerged from the study was the relatively low number of patients who were commenced on alpha-blockers. This may have been caused by lack of education provided to A&E staff. One study found that 55% of patients had a successful TWOC after being commenced on alpha-blockers, compared with 29% who were given a placebo. [13] Now all patients who are suitable are commenced on alpha-blockade.The study also highlighted an interesting discrepancy in the number of patients attending the A&E department with AUR during the two years, with only 43 patients in year one and 67 patients in year two. It might be that some patients were overlooked prior to the commencement of the urinary retention clinic, and it is hoped that the clinic will also address this in the future. All patients attending the retention clinic are now entered onto a database to allow continuation of the audit process. In year one of our study 14 patients (33%) went on to undergo an operation, and in year two, 16 patients (24%) were operated on. This figure does not correlate with the findings that patients who had a successful TWOC were at high risk of having a transurethral resection of prostate (TURP) within a year. [14] It may be, however, that more patients will eventually require surgery. Nevertheless, it is worth attempting to free these men of their catheters even if they then go on to have elective surgery. This is because patients who have a TURP as a result of AUR are more at risk of intra-operative complications, blood transfusions, post-operative complications and hospital mortality. [1] Quality of life is also adversely affected by the presence of a catheter.There are as yet no guidelines for the management of AUR. Although we would agree with the findings of a recent UK survey by Manikandan et al, [5] that it is safe to discharge patients presenting with AUR, provided they fulfill defined inclusion criteria (as outlined above); that they should be commenced on alpha-blocker therapy; and that a TWOC is undertaken after one week. However, the overall management should be individualised to each patient.An occasional occurrence following the start of this clinic was that patients who presented to A&E with long-term catheters that had blocked were given appointments for the retention clinic. This has been communicated to the A&E department. The urology nurse specialist also checks through each referral prior to the clinic so that she can contact any patients who have been given appointments in error, saving them an unnecessary trip to hospital Next steps Further steps are needed to take this clinic forward, including the development of best practice guidelines between A&E and urology departments. In addition, any changes in the management guidelines for patients referred to the clinic should be communicated effectively with the A&E Department. It is important to have good links with both the A&E nursing and medical staff and therefore we have a dedicated link nurse in the A&E Department to facilitate two-way communication should any problems occur. We found this clinic is relatively easy to establish. There are potentially benefits for both patients and the urology service. On questioning, none of the patients seen in the retention clinic would have preferred to be admitted to hospital following catheterisation. Back to Top References1. Choong S, Emberton M. Acute Urinary Retention. British Journal of Urology International 2000; 85.2:186-201. 2. Jacobsen SJ, Jacobsen DJ, Girman J et al. Natural history of prostatism: risk factors of AUR. British Journal of Urology, 1997; 158: 481-7. 3. Blandy JP. Benign Enlargement of the Prostate Gland. In Blandy JP . Ed. Urology volume 2, chapter 33. Oxford, Blackwell Scientific, 1998. 4. Djvan B, Shariat S, Omar M. at al. Does prolonged catheter drainage improve the chance of recovering voluntary voiding after Acute Retention of Urine? European Urology, 1998; 33;110. 5. Manikandan R, Srirangam SJ, O'ReiIIy PH, Collins GN. Management of acute urinary retention secondary to benign prostatic hyperplasia in the UK: a national survey. British Journal of Urology International, 2004; 93.1:84-8. 6. Pickard R, Emberton M, Neal DE. The management of patients with acute urinary retention. British Journal of Urology, 1998;81: 712-20. 7. Gidlow A. Developing the Nurse Practitioner role in urology. Urology News, 2001; 5.4:12-18. 8. Booth C, Chaudry A, Smith K, Griffiths K. The benefits of a shared care prostate clinic. British Medical Journal, 1996; 77: 830-55. 9. Joyce J, Pope A. The nurse led prostate clinic. British Journal of Urology, 1996; 77 (supplement 1): 36. 10. Martell R. Trust's nurse led services improved patient care, says CHI-Commission for Health Improvement. Nursing Standard, 2001;16.2:8. 11. Nursing and Midwifery Council. Code of Professional Conduct. London, NMC, 2002. 12. Khoubehi B, Watkin NA, Mee AD, Ogden CW. Morbidity and the impact on daily activities associated with catheter drainage after AUR. British Journal of Urology International, 2000; 85.9: 1033-36. 13. McNeill SA, Hargreave TB. Alfuzosin once daily facilitates the return to voiding in patients in acute retention. Journal of Urology, 2004, June. 14. Klarskov P, Anderson JT, Asmussen CF, et al. Symptom and signs predictive of the voiding patterns after acute urinary retention in men. British Journal of Urology International, 1987;21:23-8. Progress in Practice: May 2005.Copyright: Progress in Practice 2005, |
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