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Protocol for Bladder Management

Post-operative urinary retention (POUR) is common after joint replacement surgery and often requires several episodes of intermittent bladder catheterization. This procedure is invasive, uncomfortable, and may result in harm to the patient. It also leads to higher costs and a longer length of stay for the patient.

The Goal:
The Medical University of South Carolina (MUSC) sought to reform how it manages incidents of POUR by implementing a standardized approach to post-Foley bladder management protocol for joint replacement patients.

Method & Implementation:
MUSC Joint Replacement Protocol was created using all available research to determine the best approach to reducing POUR. The resulting care plan requires careful attention following the removal of the Foley. Patients are expected to void within three hours of the removal and receive hourly monitoring until spontaneous voiding has returned. Providers should encourage the consumption of fluids and natural positioning to assist in emptying the bladder. Bladder scans that result in more than 400cc of urine require a straight catheter be inserted. Over 700cc, nurses should insert a Foley catheter and leave it in to rest the bladder. The Foley can be removed the first morning after the catheter has been placed. If the patient is unable to void a second time after the initial catheter and the scan is still above 400cc, a Foley should be inserted and can be removed the next morning as well.

Challenges & Barriers:
Limited success of past nurse-driven efforts to make hospital-wide changes
Lack of resources for void scanning and beside/bathroom assistance for patients
Proper bladder scanner calibration and settings
Interdisciplinary collaboration critical to success

MUSC saw a decreased rate of coded cases of urinary retention since protocol implementation, and the average number of times each patient was catheterized decreased. A survey of RNs revealed 42% fewer calls to residents about bladder management after the protocol was put in place.

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