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Welcome to the Right Decision Service (RDS) newsletter for August 2024.

  1. Contingency planning for RDS outages

Following the recent RDS outages, Tactuum and the RDS team have been reviewing the learning from these incidents. We are committed to doing all we can to ensure a positive outcome by strengthening the RDS to make it fully robust and clinically resilient for the future.

We would like to invite you to a webinar on 26th September 3-4 pm on national and local contingency planning for future RDS outages.  Tactuum and the RDS team will speak about our business continuity plans and the national contingency arrangements we are putting in place. This will also be a space to share local contingency plans, ideas and existing good practice. We would also like to gather your views on who we should send communications to in the event of future outages.

I have sent a meeting request for this date to all editors – please accept or decline to indicate attendance, and please forward on to relevant contacts. You can also contact Olivia.graham@nhs.scot directly to register your interest in participating.

 

2.National  IV fluid prescribing  calculator

This UK CA marked calculator is now live at https://righdecisions.scot.nhs.uk/ivfluids  . It has been developed by a multiprofessional steering group of leads in IV fluids management, as part of the wider Modernising Patient Pathways Programme within the Centre for Sustainable Delivery.  It aims to address a known cause of clinical error in hospital settings, and we hope it will be especially useful to the new junior doctors who started in August.

Please do spread the word about this new calculator and get in touch with any questions.

 

  1. New toolkits

The following toolkits are now live;

  1. Updated guidance on current and future Medical Device Regulations

We have updated and simplified this guidance within our standard operating procedures. We have clarified the guidance on how to determine whether an RDS tool is a medical device, and have provided an interactive powerpoint slideset to steer you through the process.

 

  1. Guide to six stages of RDS toolkit development

We have developed a guide to support editors and toolkit leads through the process of scoping, designing, delivering, quality assuring and implementing a new RDS toolkit.  We hope this will help in project planning and in building shared understanding of responsibilities throughout the full development process.  The guide emphasises that the project does not end with launch of the new toolkit. Implementation, communication and evaluation are ongoing activities throughout the lifetime of the toolkit.

 

  1. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:
  • Thursday 5 September 1-2 pm
  • Wednesday 24 September 4-5 pm
  • Friday 27 September 12-1 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

7 Evaluation projects

Dr Stephen Biggart from NHS Lothian has kindly shared with us the results of a recent survey of use of the Edinburgh Royal Infirmary of Edinburgh Anaesthesia toolkit. This shows that the majority of consultants are using it weekly or monthly, mainly to access clinical protocols, with a secondary purpose being education and training purposes. They tend to find information by navigating by specialty rather than keyword searching, and had some useful recommendations for future development, such as access to quick reference guidance.

We’d really appreciate you sharing any other local evaluations of RDS in this way – it all helps to build the evidence base for impact.

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

 

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

Postoperative bladder care (688)

Objectives

  • To standardise the practice for management of bladder care after uncomplicated gynaecological procedures
  • To diagnose and manage postoperative voiding problems
  • This guideline applies to those patients admitted to Day surgery, 23 hour beds and inpatient beds

Please report any inaccuracies or issues with this guideline using our online form

Background

One in 10 women in the immediate postoperative period following gynaecological surgery will have urinary retention. Indwelling catheters are associated with increased risks of urinary tract infection (UTI) and the longer they are in situ, the higher the risk of UTI.

Postoperative bladder voiding issues may be due to:

  • Pre-existing voiding problems
  • Bruising /swelling around bladder/urethra e.g. after anterior colporrhaphy
  • Over-distension of the bladder by delayed trial of voiding (TOV) can cause bladder atony
  • Physical obstruction - stress urinary incontinence procedures eg mid-urethral sling, colposuspension, autologous fascial sling (AFS)
  • Clot retention e.g. bladder injury during surgery

Removal of Catheter After Surgery

  • The planned date for catheter removal should be clearly documented in the postoperative care plan
  • All urethral catheters should be removed at 06.00 the next morning as per ERAS unless otherwise stated in the operation notes or there are clinical concerns
  • Patients who have had colposuspension (open/laparoscopic) or AFS usually have indwelling catheter for at least 48 hours
  • Women who do not have an indwelling catheter (this includes midurethral sling and bladder neck injection) should have a trial of void 4 hours after surgery
  • For the trial of void, women should be encouraged to drink normally and aim to pass urine at around 4 hrs.
  • All urogynaecological procedures, ie those for incontinence and prolapse repair, should have a bladder scan after the first two voids. The residuals should be recorded in the ‘bladder diary’ (see Appendix 1).

Trial without catheter (TWOC)

  • Measure the urine volume after each void, no later than 6 hours from catheter removal
  • Residual volume should be measured immediately after the patient passes urine
  • If uncomfortable and unable to pass urine 4 hours after catheter removal, check bladder residual by scan and follow protocol as below (Table 1).

Women undergoing AFS

  • These women are very likely to have initial short term voiding dysfunction (approximately 67% based on local data) and are taught Clean Intermittent Self Catheterisation (CISC) pre-operatively. They should be encouraged and supported to do CISC if required post-operatively. Patients who are unable to perform CISC should be discharged with an indwelling catheter. They must also be referred to Urogynaecology nurses at the Victoria ACH for ongoing care.  This is done via the following referral form: Clean Intermittent Catheterisation referral form.

Assessment and Management of Post-void Residual

Table 1: Assessment and Management of Post-void Residual 

Volume voided

Diagnosis

Action

2 voids each >200 ml

USS residual <50% of voided volume

Normal

Nil required

Small volume (<200mL) voided

Frequency of micturition (1-2 hourly)

Likely incomplete bladder emptying

Bladder scan residual after second void. 

If voided volumes increase (>50% of residuals) and residual volume decrease, continue trial of void.

If voided volumes are not increasing and residuals ≥ voided volume see below

Unable to pass urine or residuals 

> 50% of voided volumes 4– 6 hours post operatively

Urinary retention

Inform medical staff

Perform vaginal examination to assess for haematoma/bruising

Insert indwelling catheter – short Female size 12

  • If the patient is discharged with an indwelling catheter following a midurethral sling procedure, inform the surgeon who performed the operation as early division of the tape may be required
  • Patients with voiding concerns following bladder neck injection should have CISC performed by nursing staff. If voiding fails to improve over 48 hours, offer to teach patient CISC and refer to urogynaecology nurses. Discuss with the urogynaecology team if patient is unable to perform CISC and continues to have voiding difficulties. Do not insert an indwelling catheter as this may compromise the outcome of the procedure.
  • Women who have a successful TWOC but remain as an inpatient should continue to have their bladder/voiding assessed by monitoring input/output. Ensure patient is voiding 3-4 times/day and has no sensation of incomplete bladder emptying

Guidelines for women sent home with an indwelling catheter

  • Ensure woman understands catheter care and a follow-up appointment for TWOC in the gynaecology ward is in place. She should have an emergency contact number for the ward.
  • Prophylactic antibiotics are not routinely required unless symptomatic of infection.
  • A Foley catheter size 12 with a flip-flo valve and leg bag should be used. The valve should be released every 4 hours during the day and the leg bag should be left on free drainage overnight.

First TWOC after an episode of retention

Table 2: First TWOC after an episode of retention

2 voids, each >200mL

USS residual <50% of voided volume

No further intervention

2 voids where residual volumes are >50% of voiding volume despite trying double void technique

Teach CISC

Contact the Urogynaecology specialist nurse team for follow up 
  • If TWOC unsuccessful after 1 week, please inform the responsible clinician

Appendix 1: POSTOPERATIVE BLADDER DIARY

Postoperative Bladder Diary (Word doc)

Contacts for further assistance

QEUH
Karen Nicolson        
Senior Charge Nurse, Urogynaecology
Karen.Nicolson@ggc.scot.nhs.uk
01412012264

PRM
Julie Graham        
Senior Charge Nurse, Gynaecology
Ward 56 
Julie.Graham@ggc.scot.nhs.uk
01412114433

RAH
Ward 32
01418879111

Editorial Information

Last reviewed: 14/08/2024

Next review date: 14/08/2029

Author(s): Veenu Tyagi.

Version: 2

Approved By: Gynaecology Clinical Governance Group

Document Id: 688

References
  1. Bodker B, Lose G. Postoperative urinary retention in gynaecological patients. Int Urogynecol J (2003) 14: 94–97
  2. Hakvoort R, Thijs S, Bouwmeester F, Broekman A, Ruhe I, Vernooij M, Burger M, Emanuel M, Roovers J. Comparing clean intermittent catheterisation and transurethral indwelling catheterisation for incomplete voiding after vaginal Prolapse surgery: a multicentre randomised trial. BJOG 2011; 118:1055–1060