Nurse-led Voiding Algorithm Improves POUR Rates

Feb 01, 2022

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Article in Critical Care Nurse details how Yale New Haven Hospital customized its nurse-led voiding algorithm to quickly reduce rates of postoperative urinary retention among thoracic surgery patients

ALISO VIEJO, Calif. — Feb. 1, 2022 — A Connecticut hospital reduced its rates of postoperative urinary retention (POUR) among thoracic surgery patients recovering from a lobectomy from 21% to 3%, after implementing a nurse-led voiding algorithm customized to the patient population.

POUR is a common complication for patients recovering from surgery, in which they are unable to empty their bladder, often due to clinical characteristics, surgery-related factors or adverse effects from medication. Treating POUR requires urinary catheterization, which then heightens the risk for undesirable catheter-associated consequences, longer hospital stays and more care needs after hospital discharge.

Progressive care nurses in the 14-bed thoracic stepdown unit at the Heart and Vascular Center, Yale New Haven Hospital, New Haven, Connecticut, were the first to observe a troubling trend: an increased occurrence of POUR among patients recovering from thoracic surgery. They noticed that more patients were getting an indwelling urinary catheter when nurses followed the hospital’s newly implemented general urinary catheterization protocol. The protocol included specific criteria pertaining to voiding, within a defined time period after catheter removal that seemed too brief for their thoracic surgical patients. Interdisciplinary discussions with thoracic surgeons revealed a further concern that the use of a continuous medication delivery system for pain relief, often called the “pain buster,” was also contributing to POUR.

Working with thoracic surgeons and other members of the clinical team, the nursing staff developed a quality initiative project to identify the root cause of the increase and implement a voiding algorithm tailored to the needs of their patient population.

A Nurse-led Voiding Algorithm for Managing Urinary Retention After General Thoracic Surgery” details how the unit rapidly decreased the overall POUR rate to 8%, with an especially significant reduction among patients who had a lobectomy. The article is published in the February issue of Critical Care Nurse (CCN).

Co-author Mary Pierson, MSN, APRN, ACNS-BC, CNML, was the unit’s assistant nurse manager during the study period. She is now the assistant nurse manager of the hospital’s medical intensive care stepdown unit.

“Clinicians often struggle to find the balance between optimizing pain control while minimizing complications such as POUR and its associated risks,” she said. “Bedside nurses provided valuable insight into our problem with POUR, and they were a crucial part of the project’s success.”

The hospital participates in the Society of Thoracic Surgeons (STS) voluntary clinical registry, and a report from its database confirmed that the hospital’s rate of POUR after lobectomy had risen to 21% for two quarters, a rate more than double that from previous quarters and far exceeding the STS national benchmark of 6.4%.

In response, an interdisciplinary team developed an evidence-based nurse-led voiding algorithm to guide clinical practice during the first 10 hours of postoperative recovery. The hospital’s standard protocol specified a four-hour time period, and the team recognized that their patients would need more time after surgery to accumulate an adequate bladder volume that triggers the urge to void.

The algorithm involved nurses quickly assessing patients’ bladder volume with a portable ultrasound bladder scanner to determine urine volume and postvoid residual volume (PVR), a routine nursing practice in the unit. The results are objective measures of POUR status and help determine the emptiness of the bladder or the risk for bladder distention.

Nurses performed these assessments when a patient was first admitted to the unit, after the first void and then at a routine frequency based on PVR volume and time since last void. The results determined the need for continued assessment over the 10-hour period.

Patients were considered POUR-negative with a voided volume of 200 mL or more and a PVR less than 400 mL within the 10-hour assessment window. If a urinary catheter was required during the 10-hour time frame or bladder scans indicated urinary retention, the patient was considered POUR-positive. Most of the 167 patients (86%) included in the study were POUR-negative, while 8% were POUR-positive. (POUR status was indeterminate in 6% of the patients because their voided volumes or PVR volumes did not meet the criteria.) In the POUR-positive cohort, 10 of the 13 patients had had a lobectomy, the only factor significantly associated with POUR.

In addition to confirming the validity of nurses’ initial concerns about overuse of urinary catheterization, the study found no association between use of the pain buster and POUR, which dispelled concerns about a potential negative effect from the pain management strategy.

“Our results demonstrate that our algorithm, tailored to the needs of this patient population, is safe and more effective than a generic protocol designed for use with all hospitalized adult patients,” Pierson said.

The next step is to recommend a change in practice through the nursing professional governance structure to expand use of the voiding algorithm to other units. Adoption of the algorithm as the standard of care would ensure project sustainability, thereby minimizing the injudicious use of urinary catheterization in patients who are at risk for POUR.

As the American Association of Critical-Care Nurses’ bimonthly clinical practice journal for acute and critical care nurses, CCN is a trusted source of information related to the bedside care of critically and acutely ill patients.

Access the article abstract and full-text PDF by visiting the CCN website at

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