Portable Bladder Ultrasound. OHTAC Recommendation. Portable Bladder Ultrasound

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Bethanie Lang
5 years ago
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1 OHTAC Recommendation Portable Bladder Ultrasound April 18,

2 The Ontario Health Technology Advisory Committee (OHTAC) met on April 18, 2006 to review the utility of portable bladder ultrasound for the measurement of bladder volume in Ontario patients based on a health technology policy review prepared by the Medical Advisory Secretariat, Ontario Ministry of Health and Long-Term Care. Bladder ultrasound products are portable ultrasound devices that use automated technology to digitally register bladder volume, including post-void residual (PVR) urine volume, and provide 3-D images of the bladder. The predominant clinical use of portable bladder ultrasound is diagnostic, where health professionals (predominantly nurses) administer the device to obtain PVR in order to determine if urinary retention is present to prevent unnecessary catheterization and subsequent urinary tract infections (UTI). The device s adjunctive functions can be utilized in order to visualize the placement and removal of catheters. In addition to measuring PVR, portable bladder ultrasound products may also be used in continence care in diagnosis and differentiation of urological problems, management and treatment in establishing voiding schedules and bladder biofeedback, reduction of UTI, and in post-operative and trauma monitoring of potential UI. PVR urine volume is the amount of urine in the bladder immediately after urination. PVR urine volume is an important component of continence assessment and bladder management in order to provide quantitative feedback to both the patient and continence care team regarding the effectiveness of the voiding technique. Urinary retention (UR) has been associated with poor outcomes including urinary tract infections, bladder overdistension, and higher hospital fatalities. Overdistension following surgery under general anesthesia is probably the most common cause of acute urinary retention. In neurogenic populations, UR may occur due to the loss of function in muscles and nerves in the urinary system. UR can be silent and lower abdominal symptoms of acute UR may be masked in the elderly by analgesics or may not be perceived due to cognitive impairment. In the elderly, UR has an estimated PVR of 9-11%, in neurogenic bladder patients in CCC settings UR prevalence is 17%, and in post-surgical UR is estimated at 11% and up depending on patients characteristics type of surgery, and type of anesthetic. Alternative methods of PVR assessment include clinical examination which is notoriously unreliable, using stationary ultrasound or X-rays which require machine availability, transportation of the patients from the bedside, highly trained staff to use the technology, a radiologist to interpret results, require complex calculations to determine bladder volume, and may expose the patient to radiation or invasive contrast dye. Urinary catheterization, a soft thin flexible tube which is inserted through the urethra to remove urine build-up in the bladder, remains the gold 2

3 standard for precise measurement of PVR volumes. However, patients report that catheterization is uncomfortable and humiliating. Common problems associated with catheter use include; introducing bacteria into the urethra and bladder, resulting in urinary tract infections and causing fever and inflammation to the urinary tract; injury to the urethra caused by rough insertion of the catheter; narrowing of the urethra due to scar tissue caused by catheter insertion ; injury to the bladder caused by incorrect insertion of the catheter; discomfort in the urethra; bladder spasm; leakage around the catheter; interruption of sexual activity; and bladder stones after years of catheterization. Furthermore, costs are increased because each catheter is an expense, the demand on nursing time, and most commonly UTI. The most common complication of catheter care is infection. Urinary tract infections account for about 40% of hospital-acquired (nosocomial) infections, and about 80% of these are associated with urinary catheters. The first step in reducing catheter-associated urinary tract infections and other complications is to avoid unnecessary catheterization. Portable bladder ultrasound offers a non invasive painless method of estimating the post void residual urine and eliminates the risk of introducing urinary infection or causing urethral trauma by catheterization. Using a portable bladder ultrasound device also eliminates the need to calculate bladder volume formulas. Additionally non-invasive biofeedback, toileting trials and self-continence programs may be implemented based on the portable bladder ultrasound measurements of urine volume and PVR. Lastly, as portable bladder ultrasound is a portable and noninvasive device it allows the patient to stay in their area, increases patient comfort, and patient dignity. The costs associated with implementing portable bladder ultrasound include savings in nurse time, catheterization equipment savings, saving in laundering, and savings in medical imaging. OHTAC Findings: From the literature search, 17 observational studies were relevant to the MAS review. Articles were found with regards to the clinical utility of portable bladder ultrasound in elderly, urology, rehabilitation, post-surgical, and neurogenic bladder patients as well as episodes of catheterizations avoided and reduction in catheterizations and subsequent UTI with implementation of portable bladder ultrasound. Based on the MAS review, it was found that the portable bladder ultrasound has acceptable levels of clinical utility, however is not as accurate as catheterization. All but one study considered portable bladder ultrasound to be an acceptable alternative 3

4 to catheterization. In the study by Alnaif and Drutz, the authors concluded that because of misaimed scanheads there were missed bladder and partial bladder volume measurements where lateral borders were missing, producing underestimated PVR measurements; that caution should be used in interpreting PVR from portable bladder ultrasound machines; and that, if an accurate PVR measurement is necessary, catheterization may be the preferred assessment modality. Nonetheless, portable bladder ultrasound use was found to significantly decrease unnecessary catheterizations by 20-47% and UTIs were decreased by 38-50%. There were no studies addressing the application of portable bladder ultrasound to prompted voiding. The cost of the portable bladder ultrasound devices ranges from $17, to $19, total purchase price per unit as quoted by the device manufacturer, Diagnostic Ultrasound Corporation. There was insufficient data on catheterization rates in acute care and home care settings, and evidence with application to prompted voiding to provide a valid economic analysis estimates. In long-term care homes, on average there are approximately 3 patients per institution receiving catheter care, and hence an insufficient number of LTC patients per site to justify the purchase and use of portable bladder ultrasound. Portable bladder ultrasound was found to be cost-effective in Complex Continuing Care settings. The economic analysis showed that $234,000 in cost savings would result due to the decrease in the number of catheterizations performed (including cost of catheters and nursing time) and costs avoided due to a decrease in UTI (approximately $6,300 for oral antibiotic treatment). Across all CCC facilities in Ontario, budget impact analysis indicated that net costs savings would be 2.9M for the first year of portable bladder ultrasound implementation. However, cost-savings may not be realized as they are based on a reduction of nursing human resources associated with the fewer catheterizations needed after portable bladder ultrasound implementation. Due to the lack of literature on the effectiveness of portable bladder ultrasound in prompted voiding and assisted toileting, and the low catheterization rates in LTC residents, no recommendations were made regarding portable bladder ultrasound use in LTC care settings. Incontinence is a serious issue, and is particularly salient in LTC settings. Incontinence is one of the sleeping giants that prompts admittance into LTC institution. Over 80.5% of LTC residents report constant incontinence, and another 8.9% of residents report occasional incontinence. Patients requiring catheter 4

5 care are often not admitted to LTC facilities. There is only a 2.8% catheterization rate among Ontario long-term care residents, however UR prevalence is estimated to be between 9-11% in elderly patients. In LTC facilities, diapering is preferred to catheterization due to convenience. This suggests that there is room for improvement in the management of incontinence. Additionally, given that there are 64,350 LTC residents, over 42,213 residents may benefit from bladder retraining and prompted voiding from portable bladder ultrasound use. Incontinence affects over 90% of LTC residents and therefore should be prioritized and incorporated into policy agendas for continence care. OHTAC Recommendations: Based on the above findings, OHTAC recommends: Portable bladder ultrasound for use in Complex Continuing Care and rehabilitation facilities for neurogenic bladder populations and in urology settings for urinary incontinence and urinary retention assessment. Hospitals should explore the utility of portable bladder ultrasound for acute and post-surgical care settings based on their population needs. Providers should be formally trained in the use of portable bladder ultrasound to ensure accurate measurements. 5

Scottish Health Technologies Group

Scottish Health Technologies Group Advice Statement Portable bladder ultrasound scanners 8 March 2011 Advice Statement 002/11 Question: Can the use of a portable 3D ultrasound bladder scanner to measure