Pity the poor patient who can't pee after surgery. "You're going to put what ??? where?" his eyes scream as the nurse approaches carrying the red rubber catheter kit. What comes next is an invasive procedure that brings with it many adverse effects: anxiety, discomfort, risk of infection, increased costs, 30 minutes of a nurse's time and delayed discharge. In many cases, you can avoid them all.

Before the advent of ultrasound measurement of bladder volume, catheterization was thought to be a necessary evil of many surgeries. If a patient couldn't void in PACU after an hour or 2, you had no choice but to insert a catheter. Now there's a way for you and your patients to avoid unnecessary catheterizations — a portable ultrasound device that noninvasively measures patients' bladder volume, helps monitor post-operative urinary retention and determines whether catheterization is truly needed. With knowledge of a patient's bladder volume, you can determine if catheterization is really necessary, rather than simply catheterizing the patient after a standard amount of time has elapsed.

"It's like a crystal ball, like a window to the world that lets you see what's going on," says Ann Ward, RN, BSN, MBA, CAPA, the clinical operations coordinator at the Chestnut Surgical Center in Springfield, Mass. "Now that we have it, I would be kicking and screaming if they took it away. It'd be like not having a stethoscope."

A bladder scanner costs around $10,000 (excluding modest disposables: aquasonic gel and the cash-register-like receipt for the patient record); the scan takes 60 seconds to perform.

How it works in practice
Just as Chestnut Surgical Center's patients don't miss the unnecessary catheterizations, Ms. Ward and her staff don't miss trying to figure out whether 1 is needed.

"Instead of doing the math and trying to figure out how much urine a patient might have in his bladder," she says, "we now have the bladder scanner." Here's how it works in practice.

• A nurse scans appropriate patients as soon as they come out of the OR. She prints a receipt of each bladder scan and attaches it to the patient's chart. The scanner is simple to use: You know you have an accurate image when you get the body of urine in the center of the crosshairs of the readout display, says Ms. Ward. You clean the scanner between patients with a germicidal disposable wipe.
• Once a patient voids, the PACU nurse scans him again. "We scan a 2nd time, regardless of how much he voided," says Ms. Ward. "A patient can void 500cc and still have a liter in his system." If the patient has less than 100cc of urine on the bladder scan after his first urination, the patient can be discharged.

We know certain things about bladder volume. The body produces 30cc of urine an hour. The first urge to void is felt at a bladder volume of 150cc. The sense of fullness is felt at about 300cc. We also know that certain surgeries, especially colorectal and cystoscopy procedures, are more likely to produce post-op urinary retention (POUR) than others.

We also know that sometimes it will be necessary to catheterize patients. Ms. Ward shares this example. Let's say the first scan gives a reading of 300cc. A half-hour later, the patient still hasn't voided and the reading is now 600cc. "We explain what they're looking at. They know where they stand," she says. "There's a limit to how long you can let things go before you catheterize. As you're doing sequential scans, and you can see that volume is increasing and they can't void, they know."

• Generally, Ms. Ward says 500cc to 700cc is the limit before a patient is catheterized. "If you can't void at 500cc and you've had a couple of liters of fluid, chances are you're not going to void."

It's up to your facility to set discharge protocols to guide the decision to use catheterization (see "How We Decreased Bladder Retention Complications" on page 37). However you word your urinary discharge policy, Ms. Ward says you'll enjoy not having to play telephone tag with the surgeon. "He's been here 3 hours and he can't go ??? He doesn't feel he has to and his bladder doesn't look distended ??? What should we do?"

Chestnut Surgical Center has 18 post-op beds spread across 2 adjoining PACU suites. The lone bladder scanner, which is almost always in use, is stored in a supply area between each PACU.

"The greatest benefit is to the patient. It's always about the patient," says Ms. Ward. "This tool reduces the guessing game and the unnecessary catheterizations. Ambulatory surgery patients want to leave. From admission to recovery to out the door should be 2 to 21 ?2 hours. They know that they can't leave until they void."

171 patients spared
At nearby Baystate Medical Center in Springfield, Mass., the orthopedic nursing team eliminated routine post-surgical catheterization on patients recovering from total joint replacement surgery and adopted the bladder scanner as a standard part of post-operative care in its unit. Baystate nurses recently conducted a 6-week pilot study using a bladder scanner in place of routine catheterization. They prevented 171 patients from undergoing unnecessary catheterizations and reduced the cost of care — staff time, antibiotic medication and catheterization kits — by $15,000, says Jan Fitzgerald, MS, RN, CPHQ, Baystate's director of quality and medical management.

"The bladder scanner means we don't cath a patient unless we're really sure he needs it. This reduces potential infection and also the use of antibiotics," says Ms. Fitzgerald.

Before the study, not only were joint-replacement patients catheterized during surgery, they were also routinely catheterized afterward if they were unable to urinate within 6 hours of the removal of the catheter placed during surgery. The bladder scanner made the second, post-surgical catheterization rarely necessary. During Baystate's 6-week study, only 2 out of 45 patients required post-operative catheterization.

"If we can scan the bladder versus putting a catheter in, that's 1 less risk to have to give that patient," says Ms. Fitzgerald. "A nurse proficient in scanning the bladder can know the status of the bladder in 3 to 5 minutes."

Ms. Fitzgerald notes that infections in people recovering from total joint replacement surgeries can have particularly "devastating" consequences. An infection caused by catheterization can travel to the prosthesis; if the problem becomes severe enough, the patient's prosthesis must be removed.

One important note: If a patient says he feels like he has to void, you don't have to scan the bladder. "We don't want more scanning. We want more appropriate scanning," says Ms. Fitzgerald.