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Compliance with Removal of Urinary Catheter Guideline Recommendations Leads to Improved Outcome in Enhanced Recovery after Surgery (ERAS) Patients
Allan Okrainec*1,4, Mary-Anne Aarts1, Emily A. Pearsall1,3, J. Charles Victor2, Marg McKenzie3, Anand Govindarajan3,1, Ori Rotstein1, Stuart McCluskey4, Lesley Gotlib Conn5, Robin McLeod1
1Surgery, University of Toronto, Toronto, ON, Canada; 2Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; 3Mount Sinai Hospital, Toronto, ON, Canada; 4University Health Network, Toronto, ON, Canada; 5Sunnybrook Health Sciences Centre, Toronto, ON, Canada
Background
Although Enhanced Recovery after Surgery (ERAS) pathways have been shown to improve outcome in patients undergoing colorectal surgery, there is uncertainty about the benefit of individual ERAS recommendations. The objective of this study was to determine whether compliance with urinary catheter recommendations leads to decreased length of stay (LOS) and decreased urinary tract infections (UTIs) and urinary retention.
Methods
An ERAS guideline with 18 recommendations based on best evidence and contextualized to the local culture was developed and implemented at 15 academic hospitals in Ontario. With respect to urinary catheters, we recommend their removal at 24 hours after colonic and 72 hours after rectal operations. During implementation, all patient, preoperative, intraoperative, postoperative, and outcome data were collected prospectively in all patients having colonic and rectal operations.
Results
Between September 2012 and April 2015, 2,927 patients (1,395 females; mean age 62 years) were enrolled. 1897 (64.8%) patients had colonic resections while 1030 (35.2%) had rectal resections. Overall, 53.2% of patients had their catheter removed in compliance with the guideline (44.3% after colonic resections and 69.5% after rectal resections). Following colonic operations, 1% of patients who were guideline compliant had a UTI compared to 4.1% in noncompliant patients (RR 0.20, 95% CI 0.07 to 0.58, p = 0.003). Following rectal operations, 3.5% of patients who were guideline compliant had a UTI compared to 9.6% of patients who were noncompliant (RR 0.37, 95% CI 0.20 to 0.68, p = 0.001). The median LOS in compliant patients who had colonic operations was 4 days compared to 5 days in noncompliant patients (RR 0.73, 95% CI 0.66 to 0.82, p<0.001). Compliant patients undergoing rectal operations also had a statistically significant reduced median LOS of 5 compared to 8 days (RR 0.54, 95%CI 0.49 to 0.59, p<0.001). Urinary retention was not significantly increased in compliant patients (p=0.25 for both colonic and rectal groups).
Conclusion: Early removal of urinary catheters is associated with decreased UTIs and LOS without a significant increase in urinary retention and therefore should be an integral part of an ERAS pathway.
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