There are worse things that a surgical nurse can do than wait and wait and wait for a post-operative patient who doesn't have to go to the bathroom to go to the bathroom, but it's a pretty short list.

There was many a night here at the Surgery Center at Virginia Baptist Hospital in Lynchburg, Va., when a couple of us outpatient surgery nurses would stay hours past our unit's 7 p.m. closing time waiting for patients to void before we'd discharge them. There were also lots of after-hours phone calls to physicians — "This patient hasn't voided. Do we need to admit him overnight?" — as well as unnecessary catheterizations and overtime. Patients were frustrated, too. Once post-op patients are awake, tolerating liquids and in minimal discomfort, they expect to be discharged without any delays. Waiting for patients to urinate was really starting to wear on us. And for what? That was the question.

A couple years ago, 5 of us nurses began to wonder why we couldn't safely discharge patients who met all other discharge criteria except voiding. Take a healthy 50-year-old gallbladder patient, for example. If he didn't have the urge to void, we could send him home after a short recovery, right? Same goes for a patient on whom we could non-invasively measure how much urine was in his bladder. So we decided to put our facility's longstanding "need-to-void" policy to the test, embarking on an evidence-based research project and investing $13,600 in a portable bladder scanner.

We've since changed our discharge criteria and now send many patients home after routine surgery without voiding, either because we determined that there's no need to void after the particular surgery that they had or because we used the bladder scanner to measure the volume of urine in their bladder. Some patients, of course, need to void before we'll discharge them (we'll call their physicians if they're unable to void) and not all of our surgeons are comfortable discharging patients who can't void. Beyond the satisfied surgeons, staff and patients, perhaps the greatest measure of success from our new discharge policy is this: Patients are spending an average of 3 hours less in our facility.

What the literature tells us
A review of the current literature told us 4 things:

• Post-operative voiding is no longer a definitive requirement for discharge. Research supports discharge without voiding for patients who have no urge to void, have no bladder distention and aren't at high risk for urinary retention — defined as the inability to void at a bladder of 600ml.
• The incidence of urinary retention in low-risk ambulatory surgical patients is less than 1%. These patients will usually void without intervention within 3 hours after surgery. Patients who have a higher risk for post-op urinary retention are those who've undergone surgical procedures involving the genitourinary, anorectal and urological systems, as well as hernia repairs and those who had perioperative catheterization.
• Monitoring bladder volume by ultrasound helps determine the need for catheterization in post-operative patients. Intermittent catheterization was the gold standard for measuring urine volume; but researchers found that you could obtain accurate results using an easily accessible bladder scanner. Researchers describe the bladder scanner as an "effective, non-invasive intervention to assess the bladder volume with minimal discomfort to the patient."
• You need a discharge protocol if you're going to send patients home without voiding. Changing practices based on the most current literature has decreased the need for unnecessary urinary catheterizations and delays in patient discharge (Sparks and Boyer, et al., 2004). If patients aren't required to void before discharge, written discharge instructions should be given to ensure that they seek medical help if unable to void within 6 to 8 hours from the time of discharge (Awad and Chung, 2006). It's necessary to have a clearly defined discharge protocol to ensure the safest and most appropriate care of post-operative patients (Awad and Chung, 2006).

Shorter stays, fewer catheterizations
Our team of 5 nurses reviewed the current discharge criteria for ambulatory surgical patients. Using the Iowa Model of Evidence-Based Practice to promote quality care, we developed a pilot program to look at our discharge criteria and decrease the length of stay for post-surgical patients.

We wanted to use the bladder scanner to decrease unnecessary urinary catheterizations. Our surgical unit purchased a bladder scanner for $13,600. There's no charge to the patient for the use of the scanner. After consultation with our anesthesiologists and surgeons, we developed a bladder scanner protocol for staff to use as a guideline for post-op urinary catheterization (above). We classify patients into 1 of 3 categories:

• No need to void after surgery. We give these patients a printed "Urinating After Surgery" instruction sheet to take home.
• Need to void after surgery. We use the bladder scanner protocol.
• Need to void. We call the physician if these patients are unable to void.

We added a physician order set to the doctor's discharge orders, giving them the option to discharge their patients without voiding, receive a call if there is inability to void or enact the bladder scanner protocol.

Voiding at home
Using our new order set and protocol, we've found that many of the physicians let their patients be discharged home without voiding. We send these patients home with "Urinating After Surgery" instructions. In follow-up phone calls, these patients reported satisfaction with their discharge processes and the benefit of being able to void at home.

I'd say 4 out of 5 catheterizations we did before were unnecessary. We wouldn't know how much urine was in the bladder, so we had to catheterize to find out. As you know, it often takes time for the bladder to "wake up" after anesthesia; patients simply won't have the urge to void. With the use of the bladder scanner, we've been able to decrease unnecessary catheterizations. We can quickly scan patients and know exactly how much urine is in the bladder rather than catheterizing them.

We decreased our length of stay by more than 33%. In the 3 months before the trial, the length of stay was 9.15 hours. During the 6-month trial, the average length of stay was 6.05 hours.

Thanks to our new policy for post-operative voiding criteria, we're discharging patients in a more timely manner. We've also been able to decrease the number of phone calls to physicians regarding post-operative voiding issues. This in turn has given our nurses more autonomy in caring for our patients.