Michaela MB Kelleher conducted clinical research on the effects of removal of indwelling urinary catheter (IDCs) at different timings on the early normal micturition patterns in patients, and on their length of date of discharge. The research was published in the British journal of nursing in 2002. The research is titled “Removal of urinary catheters: midnight vs. 0600hours.” (Kelleher, MB, 2002). The title is short and self-explanatory. The article is about the links between IDCs removal at 2 different timings i.e. midnight and 0600 hours and comparing which time is better and will lead to normal voiding of the patient and early discharge. The study which was conducted encompassed patients admitted for urological problems and were about to undergo surgery.
The author notes in the introduction that even though there is a lot of literature about the time appropriate timing for removal of a urinary catheter is at midnight, the current practice still follows their removal at 0600hours. The Joanna Brigg institute in 2006 published a list of guidelines concerning the Best practices pertaining to urinary catheters it stated that 6 out of 7 trials conducted to observe which timing is better for urinary catheters, found that midnight removal of catheters leads to a reduced length of hospital stay. It recommends catheter removal at midnight timings. 4 of the trials conducted noted a delay in discharge, in patients in whom the catheters were removed in the morning timings.
In the abstract of this paper, Kelleher, MB produces a well-structured summary of the whole issue at hand and takes us through the study and its results briefly. According to her, there is not enough clinical evidence to support the practice of removal of catheters at 0600hours. The aim of this study according to the author is to observe the time it takes for patients to return to their normal voiding patterns after urinary catheters at different times of the day.
The abstract informs us that 160 people were conveniently selected and randomly placed in two groups, one whose catheters were removed at midnight and the other group in whom the urinary catheters were removed at 0600 hours in the morning. The abstract summarizes the result component of the study and states that the group in whom the urinary catheters were removed at midnight voided a larger volume of urine in both, first and the second time they micturated after catheter removal with a P value less than 0.0001.
Finally, in the abstract, the author links this result to the early discharges of patients from a hospital in which the catheter removal occurred at midnight and recommends that the tradition of removing the IDCs at 0600 hours in the morning must be changed keeping in mind the benefits of removing them at night time. (Kelleher, MB, 2002).
The author’s rationale for conducting this research was to “determine whether patients who had their IDCs removed at midnight resumed normal voiding patterns earlier than the patients who had their IDCs removed at 0600 hours and whether this had any impact on when the patient was discharged from the hospital.” (Kelleher, MB, 2002). The main complications that can occur from the placement of urinary catheters include urinary tract infections and urinary retention after the urinary catheter is removed. The logic behind questioning the traditional methods of catheter removals in the early hours of the morning, according to the author is that infection usually occurs sometime after the catheter removal.
And if the catheter is removed in the morning time, the infection will only be detected late in the evening when the senior medical staffs are not on duty. This leads to delays in the patient’s treatment and overall delay in the discharge of the patient. The author further inquires whether it would be better if the catheters were removed in the nighttime for the reason that whatever complications that can arise, from its presence or removal can be dealt with, by the senior staff as to any complication if present would be detected while they are still on duty. The Kelleher MB (2002) further argues that late-night catheter removals provide the patients with reduced anxiety and enable quicker recovery and discharge.
Kelleher MB (2002) put this question to the test by conducting a prospective clinical trial on patients who had urological problems and needed placement of urinary catheters after their surgeries. Patients were requested to participate in the study, and those who agreed were randomly assigned numbers by a computer. Patients who received odd numbers were placed in one group and the patients receiving even numbers, in another. When the respective times came for the catheter removal, the patients were instructed to ask for containers every time they had to void for the first two times. The first two timings of the micturation and the quantity of urine excreted by each patient were documented.
The research design is appropriate in many ways. The research was designed to observe the timing of resumption of normal voiding patterns after catheter removal and it was designed in such a way that the dependant variables of the study i.e. quantity of urine produced and the time it took for a patient to urinate for the first two times was recorded by the clinical staff. The independent variables included the timing at which the urinary catheters were removed from the patients i.e. midnight or at 0600 hours. Randomization was done when selecting the patients for placement into two groups to avoid bias.
Some potential sources for extraneous variables are present in the experiment. The research does not describe whether or not fluid intake was monitored during the experiment. It could be that some of the patients were very well hydrated and consumed much more fluids while others did not. This could have directly interfered with the quantity of urine being produced and could have skewed the results. Another source of potential extraneous variables comes from the absence of exclusion of any patient having renal problems. If the patients had renal problems, they could have been oliguric. This also could have skewed the results.
Lastly, no gender criterion or age boundaries were set. Randomization was used in an attempt to avoid bias. Age could have had a significant impact on the results and a better option would have been to select or match the patients of the two groups to eliminate any sort of bias from this front.
A query comes to mind when looking at the description of data collection methods that were used. The author states that patients requested containers in which to void and that they recorded the time at which they passed urine and the quantity of urine that was passed, but the author fails to describe whether the nurses were there for the observation and the collection of urine or whether the patients themselves measured the urine quantity and the time and later informed the nursing staff. If the latter were true, then, a certain amount of error can be expected from the patients, as there could have been delays in the recording of time.
The study participants were urology patients who were selected through convenient sampling. Patients who had suprapubic catheters or had to undergo open prostate or vesicular surgery were excluded from the study. People who had dementia and other psychological problems were also excluded from the study. (Kelleher, MB, 2002)
Even though convenience was the appropriate method to use in the study, it failed to exclude patients with other illnesses which could affect the voiding frequency and quantity. This includes patients with diabetes, which can lead to patients having increased frequency of urination etc.
The study which was conducted constituted of 160 participants in total, 80 people in each of the two groups. They were selected through convenient sampling methods. The sample size was large enough to provide statistically significant results. “Four of the participants from each group developed urinary retention and had to be catheterized and therefore had to be removed from the study completely.”(Kelleher MB, 2002).
The results of the study showed that all of the patients who had their catheters removed at midnight had at least voided once, before 0600 hours. The results were highly significant in terms of the quantity of urine produced in the first as well as the second time the patients had to void. It showed that the quantity of urine produced the significantly larger than that which was produced by the 0600-hour group. The results also significantly show that the patients in whom the catheters were removed at midnight, got discharged earlier than those patients in whom the catheters were removed early morning. The study was only conducted on a narrow spectrum of patients’ i.e. urological patients. Patients with problems other than urological, in whom the catheters were placed were not included. Still, we can interpret these results in general and say that catheter removals at midnight significantly increase the chances in urological patients of returning to normal voiding patterns.
The results of the outcome variables are reliable and valid. All of the patients who had had their catheters removed and had voided sufficiently got discharged on the day.
The article does not specifically mention if blinding was done to ensure that the results were not skewed. This leads us to believe that no blinding of outcome measures was done. This could have impacted the end results. According to the author, the patients have first explained what the research study was about, and only then did the participants agree to be part of the study. Nursing staff who were appointed with the job of collecting the data were also part of the investigative team.
The doctors who decided the patients in whom the catheter needed to be pulled out were also had a research investigator amongst them. Therefore we come to the conclusion that no blinding was done. This may have given rise to a skewed result. Doctors in charge of determining the date of catheter removal and also the date of discharge could have influenced the results by keeping the patients who had their catheters removed at 0600 hours longer etc.
For the analysis of the data, a simple Students t-test was used. This is an appropriate test for the study as a t-test is applicable in studies in which the samples are normally distributed. The samples, in this case, were independent and normally distributed.
Since there was a need to compare the mean volumes of the urine voided by the patients in the first and second instance, it is logical that a t-test was used for analysis.
In the management of patients who have undergone catheterization, one needs to highlight the importance of each action, every step of the way. Paying attention to each and every step in the management with the use of evidence-based actions can improve the overall outcomes and recovery of the patients. A study conducted by Dingwall L, (2006) highlighted this fact. According to him, the nurses that decision-making was not sufficiently supported by “evidence-based assessment”. (Dingwall L, 2006). Removal of catheters in the morning can lead to delay in discharges and since the anxiety levels are greater in the morning time, the removal of catheters in the morning can lead to problems like urinary retention and delay in patients returning to their normal voiding patterns.
Lack of awareness about appropriate catheter management has been increasing amongst nurses. Urinary catheters placed in patients lead to risk factors which include urinary tract infection (Hassan, WD 2004) & (Danchaivijitr S, 2005). In order to ensure that the patients, in whom urinary catheters are placed, can remain infection free and can get discharged earlier, Hassan, WD (2004) recommends that prophylactic antibiotics should be used, whereas Afshar, Z (2007) proposes the use of double voiding techniques to reduce UTI incidence.
Kelleher in this study concludes that even though no significant differences were seen in the volumes of urine passed, but that there was a significant change in the length of stay after catheter removal. This conclusion is supported by another study conducted by Griffiths RD, (2004) who stated that there are considerable “benefits in terms of patient outcomes and reduction in the length of hospitalization after midnight removal of the ICUs”. The Joanna Briggs institute in the publication titled removal of indwelling catheters also supported and recommended the practice of catheter removal at midnight hours. (JBI, 2006) Kelleher conducted the study on patients with urological problems only.
There is a need to further expand this study and to observe if similar results are seen in patients with illnesses. Gross JC (2007) who conducted a similar study on stroke patients found no evidence which supports the hypothesis that midnight catheter removal has beneficial effects on the volume of urine and early discharge. Even though it is imperative that research is put into practice. (Schneider, 2007).
Most of the researches conducted on this front all points to the recommendation that the practices of catheter removal should be changed to allow their removal at might night hours. It is therefore recommended on the basis of results of Kelleher’s research and that of others, that the current practice be modified to ascertain that the patient’s discharge timing is optimized and so that the patients can return to their regular voiding patterns as early as possible in their post-operative period.
References:
Afshar, Z., & Abulfasel, A. (2007). Double Urinary Bladder Voiding Technique Post Removal of Urethral Catheter in Renal Allograft Recipients. Saudi journal of kidney diseases and transplantation.18, 532-535.
Dingwall L, McLafferty E. (2007). Nurses’ perceptions of indwelling urinary catheters in older people. Nursing standard. 21, 35-42.
Danchaivijitr S, Dhiraputra C, Cherdrungsi R, Jintanothaitavorn D, Srihapol N. 2005. Catheter-associated urinary tract infection. Journal of medical association of Thailand. 88, S26-30.
Griffiths RD, Fernandez RS, Murie P. (2004). Removal of short-term indwelling urethral catheters: the evidence. Journal of wound, ostomy and continence nursing. 31, 299-308: official journal of American urological association allied.3, 326-238.
Gross JC, Hardin-Fanning F, Kain M, Faulkner EA, Goodrich S. (2007). Effect of time of day for urinary catheter removal on voiding behaviors in stroke patients. Urological nursing, 3, 231-235.
JBI, (2006), Removal of short term indwelling urethral catheters. Best Practice. Web.
Kelleher, MB, (2002). Removal of urinary catheters: midnight Vs 0600 hours. British Journal of nursing.
Schneider, Whitehead, Elliott, LoBiondo-Wood & Haber (2007). Nursing and Midwifery Research, Elsevier Australia.