Point-of-Care Ultrasonography in Nursing Care
As frontline careproviders, nurses are always under pressure to provide more efficient and cost-effective healthcare. Technological advances have led to rapid growth in point-of-care ultrasonography. Appropriate use of this technology coupled with robust training solutions will empower nurses and extend the scope of practice of advanced-practice nurses. This broader responsibility and added skill set will radically improve frontline healthcare delivery and efficiency. The list of topics relevant to nurse training is long and will continue to evolve and expand. Several “low-hanging fruit” examples are listed below:
Case Study: Iatrogenic Hospital-Acquired Urinary Tract Infection
Urinary tract infections are the most common type of hospital-acquired infection, accounting for greater than 30 percent of infections reported by acute care hospitals. (Klevens) The catheter-related urinary tract infection rate is 3.1 to 7.5 infections per 1000 hospital catheter days. An estimated 15 to 25 percent of patients get catheters. (Warren, Weinstein 1999) Catheter-associated urinary tract infections are the most common source of secondary nosocomial bloodstream infections. Seventeen percent of hospital-acquired bacteremias are from a urinary source, with a mortality rate of 10 percent. (Weinstein 1997) Approximately 17 to 69 percent of catheter-associated urinary tract infections are preventable with recommended infection control measures, which means 380,000 infections and 9,000 deaths related to catheter-associated infections per year could be avoided. (Umscheid) Bladder ultrasonography with subsequent selective bladder catheterization has decreased the incidence of nosocomial urinary tract infections by 30 to 50 percent. A recent meta-analysis documented that selective bladder catheterization based on bladder ultrasonography resulted in an OR of .27 in favor of reducing nosocomial urinary tract infection rates. (Palese)
Case Study: Infant Fever Evaluation
The presentation of a febrile infant to an emergency department (ED) is a frequent occurrence. Given the frequency of a urinary tract infection as a cause of an infant’s fever, urinalysis and culture is a critical part of the patient’s evaluation. Suprapubic bladder aspiration has been replaced by urethral catheterization as the preferred method of obtaining a urine sample. Voided urine samples are considered suboptimal due to contamination risks and length of time required for obtaining a sample. A very frequent occurrence is a “dry catheterization”. A nurse often attempts a urethral catheterization; however, the infant has recently voided or may be dehydrated and no urine is obtained. Parents frequently refuse subsequent attempts due to the perceived and real discomfort associated with the procedure by the patients. This results in inefficient, prolonged, and suboptimal care. Careproviders are forced to either keep the patient in the ED and await a voided urine sample (increased length of stay and potentially contaminated urine sample), empirically treat with antibiotics, or the patient and family leave the ED without an adequate evaluation that excludes a life-threatening gram-negative urinary tract infection.
Suboptimal care could be avoided by simply having nurses screen patients for a full bladder prior to attempted urethral catheterization, which would negate “dry catheterizations”. (Baumann 2007 & 2008, Chen 2004, Chen 2005) First-attempt success rates are improved from 67 to 92 percent with ultrasound assistance. (Baumann 2008) In addition, both careproviders and caregivers of young children expressed greater satisfaction following the use of ultrasound to determine bladder volume prior to urethral catheterization. (Baumann 2007)
Baumann B, McCans K, Stahmer S, et al. Volumetric bladder ultrasound performed by trained nurses increases catheterization success in pediatric patients. Am J Emerg Med 2008 Jan;26(1):18-23.
Baumann BM, McCans K, Stahmer SA, et al. Caregiver and health care provider satisfaction with volumetric bladder ultrasound. Acad Emerg Med 2007 Oct;14(10):903-907.
Chen L, Hsiao A, Moore C, Santucci K. Utility of bedside bladder ultrasound prior to urethral catheterization in infants. Acad Emerg Med 2004 May;11(5):598 Abstract.
Chen L, Hsiao AL, Moore CL, et al. Utility of bedside ultrasound before urethral catherization in young children. Pediatrics 2005 Jan;115(1):108-111.
Palese A, Buchini S, Deroma L, et al. The effectiveness of the ultrasound bladder scanner in reducing urinary tract infections. a meta-analysis. J Clin Nurs 2010 Nov;19(21-22):2970-2979.
Umscheid C, Mitchell M, Agarwal R, Williams K, Brennan P. Mortality from reasonably-preventable hospital acquired infections. included in written testimony by the society of healthcare epidemiology of america for the committee on oversight and government reform hearing on healthcare-associated infections: A preventable epidemic, chaired by henry A. waxman, april 16, 2008, washington, DC. [congressional testimony].
Warren JW. Catheter-associated urinary tract infections. Int J Antimicrob Agents 2001 Apr;17(4):299-303.
Weinstein MP, Towns ML, Quartey SM, et al. The clinical significance of positive blood cultures in the 1990s: a prospective comprehensive evaluation of the microbiology, epidemiology, and outcome of bacteremia and fungemia in adults. Clin Infect Dis 1997 Apr;24(4):584-602.
Weinstein JW, Mazon D, Pantelick E, et al. A decade of prevalence surveys in a tertiary-care center: trends in nosocomial infection rates, device utilization, and patient acuity. Infect Control Hosp Epidemiol 1999 Aug;20(8):543-548.