Ashman

thanks, i am looking into this.

Of course not, we have our SOP's at q1h and q2h in general, but what I am saying is that the whole issue of UO is overloaded with problems whether it be the manual measurement, the time factor associated with it, the potential susceptibility to infection and sometimes the fact that the staff doesn't get to it. UO as a vital sign has been wholly ignored, and the problems that I mention are not just ours, but rampant. In my search for a solution (or at least a step in the right direction), I came across the following blurb: Postoperative retention of urine Following a nerve root decompression and L4-S1 posterior spinal fusion, Mr L experienced difficulty passing urine. His urinary output was nevertheless reasonable until the fourth postoperative day, when at midday nurses noted a distended abdomen and suspected urinary retention. They notified the house officer, but apparently no further action was taken. Mr L's fluid balance chart had been discontinued that morning, but it does not appear to have been re-instituted. Mr B, the consultant orthopaedic surgeon, was told about Mr L's distended abdomen on his ward round early that evening, and he asked that a urologist be brought in, but did not himself examine Mr L's abdomen. It seems that no further action was taken until the urologist came to see Mr L more than 24 hours later. He diagnosed urinary retention and Mr L was then catheterised. Unfortunately, by then the delay had already done its damage. When Mr L was examined three years later, he was still suffering from overflow incontinence despite self-catheterising several times a day. We settled Mr L's claim on the basis of expert opinion which concluded that he had suffered a permanent disability caused by the delay in recognising and treating urinary retention. In the opinion of an expert in orthopaedic surgery, it was not necessary to catheterise a patient prior to a spinal fusion, but 'it is necessary that the house staff and nursing staff should take early measures if acute retention of urine is suspected'. The consultant was also held to bear much of the reponsibility for his failure to examine Mr L during his ward round. Comment Postoperative ward rounds are not just courtesy calls. If the patient appears to be suffering a complication it is encumbent on all healthcare professionals involved to ensure the matter is investigated and action taken to correct the problem. Good communication between all members of the healthcare team is fundamental to the quality of a patient's care and this needs to be addressed by both the medical and nursing staff on the ward. International Casebook 16, February 2002 I do not exactly remember where I came across this, I think it was in a negligence/malpractice site that I ran into. The point is that today you would never consider taking a pulse in the following fashion: 1) you would use the watch on your wrist, 2) manually count heartbeats, 3) manually record the pulse rate and it would be a different person who took the heart rate every hour - in immediate post-op recovery, otherwise it could be 2 hours or more. It would be ludicrous in the 21st century. UO is a great indicator for so many conditions as well as a great indicator of a general problem, unfortunately there do not seem to be the tools available. Ideally studies would need to be conducted to prove the use of UO as a vital sign, but someone needs to invent the tool first.

What I am finding is that some of the mds after they are notified also take 24 hrs to get there. Who is the worse for it - the patient no?

Unfortunately what I am finding, in my research to find a solution, is that the problem is more rampant than anyone is willing to concede. We also have SOP's of q2h and definitely hourly in post-ops. However what I am saying is that UO has been the most ignored vital sign there is. Imagine today being in a position where you to monitor a pulse rate: 1) you would use the watch on your wrist, 2) manually count heartbeats, 3) manually record the pulse rate and it would be a different person who took the heart rate every hour - in immediate post-op recovery, otherwise it could be 2 hours or more. It would be ludicrous in the 21st century. Today however that is what we are doing with urine output - another vital sign. UO is such a great indicator of so many conditions, as well as a general indicator of a problem, but it has been wholly ignored as a vital sign!

You are by all means correct, these are our standard practices too. On the other hand, we are not talking about SOP's here and evidently we are not alone. In my effort to find an alternative method/procedure to ensure that what sometimes occurs, never happens again, I came across the following blurb (one of many): Postoperative retention of urine Following a nerve root decompression and L4-S1 posterior spinal fusion, Mr L experienced difficulty passing urine. His urinary output was nevertheless reasonable until the fourth postoperative day, when at midday nurses noted a distended abdomen and suspected urinary retention. They notified the house officer, but apparently no further action was taken. Mr L's fluid balance chart had been discontinued that morning, but it does not appear to have been re-instituted. Mr B, the consultant orthopaedic surgeon, was told about Mr L's distended abdomen on his ward round early that evening, and he asked that a urologist be brought in, but did not himself examine Mr L's abdomen. It seems that no further action was taken until the urologist came to see Mr L more than 24 hours later. He diagnosed urinary retention and Mr L was then catheterised. Unfortunately, by then the delay had already done its damage. When Mr L was examined three years later, he was still suffering from overflow incontinence despite self-catheterising several times a day. We settled Mr L's claim on the basis of expert opinion which concluded that he had suffered a permanent disability caused by the delay in recognising and treating urinary retention. In the opinion of an expert in orthopaedic surgery, it was not necessary to catheterise a patient prior to a spinal fusion, but 'it is necessary that the house staff and nursing staff should take early measures if acute retention of urine is suspected'. The consultant was also held to bear much of the reponsibility for his failure to examine Mr L during his ward round. Comment Postoperative ward rounds are not just courtesy calls. If the patient appears to be suffering a complication it is encumbent on all healthcare professionals involved to ensure the matter is investigated and action taken to correct the problem. Good communication between all members of the healthcare team is fundamental to the quality of a patient's care and this needs to be addressed by both the medical and nursing staff on the ward. International Casebook 16, February 2002 Unfortunately I do not remember exactly where I found this, but I think it was a malpractice/negligence site I ran into. As I mentioned previously I really feel that UO is a vital sign, but there are no tools (or studies for that matter) to prove it. Unfortunately the problem exists and we need to face it head on and solve it - for the good of our patients.

Using the Foley bag with a urimeter is the way we go. Unfortunately the urimeter that we use has a reservoir of only 250 ml. So, wouldn't you know it, when the staff finally got around to taking the measurement, the patient had maintained an average of more than 30 cc/hr for the shift, because there had been overflow (unmeasured of course). Such a situation is not particularly conducive for determining the patient's trend in urine output. This is one of the reasons that this whole subject has been thrust upon me. Personally I have a gut feeling that urine output is really a vital sign, but there are no real tools to measure it. Urine output is indicative of a all sorts of conditions: Renal function, perfusion or failure, Shock, Pre-operative/ Post-operative complications, Dehydration, hypervolemia, response to meds, urinary tract infection, pulmonary edema - as I think about it the list seems endless. In any case while doing my research for an alternative, the amount of literature which appears with "accurate" accounts of urine output (eg. "decreased urine output", "urine output was low", and my favorite "down to a trickle") is hurrendously the norm. While true continuous accurate accounts seem to be virtually only in research situations. In any case, I appreciate the help. If I ever find an alternative, I'll be in touch.

I agree completely. However could you imagine doing hemodynamic monitoring, manually, and crouched down under the bed? To do proper continuous urine output monitoring with a maybe less labor-intensive procedure for monitoring associated with it, we need to have a new way of effecting the measurement wouldn't you say?

I really do not think it was a lack of concern, but rather it is a clumsy, crude and cumbersome procedure for an estimated measuring urine output. Personally I have a gut feeling that urine output is really a vital sign, but there are no tools to measure it. Urine output is indicative of a all sorts of conditions: Renal function, perfusion or failure, Shock, Jaundice, Dehydration, hypervolemia, response to meds, pulmonary edema - as I think about it the list seems endless. Aren't we not reaching the level of care we could/should be by not monitoring urine output more closely?

You will have to pardon me, I have just been thrust into this urine output monitoring mess, in order to find a better way. We tend also to do only q8h I&O, even when they should be q1h. Personally I have this gut feeling that urine output really is a vital sign, but there are just no tools available to show it. The truth is that through my research I am finding that the time element is really crucial. For example if the reading was taken after 45 minutes instead of an hour, or 6.5 hours instead of 8. How are we supposed to determine if there is a trend in the urine output over time if we do not have continuous monitoring? Imagine what it would be like if there was an automatic reading? In addition, the business of getting down under the bed, attempting to take a reading - that's always fun.

We only have problems with the ambulatory onco patients and the majority of inpatients here are on I/O too. Unfortunately you have missed my point. Haven't you ever been in a situation where an attending physician left instructions for urine output to be monitored and if the level falls below say 30 cc/h, to contact them, but as the day goes it turns out that you never get the chance to measure the urine output on an hourly basis? In addition, the business of getting down under the bed, attempting to take a reading - that's no fun. I have just been thrust into this urine output monitoring mess, in order to find a better way. Personally I have this gut feeling that urine output really is a vital sign, but there are just no tools available to show it.

Recently we have been involved in a number of cases where had urine output been more thoroughly monitored, symptoms could have been more readily detected, more focused treatment would have been applied to the patient and therefore better care would have been given in the ER/ICU/OP/Trauma unit. Has anyone else had this experience?

Recently we have been involved in a number of cases where had urine output been more thoroughly monitored, symptoms could have been more readily detected, more focused treatment would have been applied to the patient and therefore better care would have been given in the ER/ICU/OP/Trauma unit. Has anyone else had this experience?