Trial of Void

* No clinical indications for catheter to remain present

* No documented reason for catheter to remain in situ

* Patient is not constipated

* Between 0000 and 0600hours, no later than 1000 (St Vincent's Policy)

Assess patient history prior to catheter removal for:

- medications that affect ability to void (eg. anticholinergics, beta3-adrenergic agonists, alpha blocker, opioid agents.

- any clinical conditions that may affect catheter removal

eg. - bleeding tenancy, UTI, congestive cardiac failure, sacral of perineal wound, falls risk).

Discuss with senior clinicians on required precautions.

* Recommended time for urethral catheter removal is from 0000hrs (at the earliest) to 1000hrs (at the latest), commonly MOs order removal at 0600hrs. Removal after 1000hrs is not recommended to enable adequate time to manage urinary retention later in the day.

- The evidence is inconsistent that midnight, rather than early morning, catheter removal

leads to shorter hospital stays. However midnight catheter removals do have consequential

resource savings. (Joanna Briggs, 2016).

* Encourage the patient to drink water in order to void.

* Ask the patient to notify the nurse prior to first void, so that this volume can be recorded.

* Give the patient a urine bottle or bed pan so the volume can be measured and recorded on the fluid balance chart.

- It was recommended in the literature that patients are educated regarding the procedure.

This education can include what the procedure involves, measuring and documenting urine output, importance of regular fluid intake, and importance of reporting discomfort.

Accurate fluid intake and output reporting is required. As a guide, output and input should be approximately equal. (Joanna Briggs, 2016).

* The MO may consider re-insertion of the urethral catheter or use of intermittent catheterisation.

* Ensure the patient is not constipated at the time of catheter removal as constipation can contribute to urinary retention and may result in a failed trial of void.

- Very little evidence is available regarding the management of urinary retention following

indwelling urinary catheter removal. Intermittent catheterization and re-catheterization are common adjunct methods used until bladder function is restored. (Joanna Briggs, 2016).

* Explain the procedure to the patient

* Remove the drainage bag and attach the SPC to a catheter valve.

* Advise the patient to maintain a fluid intake of 250 - 500mls/hour when awake (unless contraindicated) and record on the fluid balance chart.

* Advise the patient to void urethrally using a bedpan or urinal when they have the desire to void.

* Measure each individual voided volume and record on a fluid balance chart.

* Following each void, drain any residual urine via the SPC into a measuring jug and record on the fluid balance chart as the post void residual. Do not use a bladder scanner due to infection risk to SPC site and decreased accuracy.

* If the patient is unable to void urethrally (after 6 - 8 hours) or they experience discomfort, then release the valve and document the volume drained.

* If the volume drained exceeds 300mls then the TOV is considered to have failed and free drainage or timed emptying via the valve should be resumed.

* Advise medical staff or experienced nursing staff of outcome (see educational notes)

* Document outcome in patient record.

Trial of Void

When is considered safe for a TOV to occur?

What is a Trial of Void (TOV)?

NSW Health. (2015). Adult urethral catheterisation for acute settings. Retrieved from http://www1.health.nsw.gov.au/pds/Pages/doc.aspx?dn=GL2015_016

TOV is undertaken to determine the patient's

ability to urinate/empty their bladder successfully

once their indwelling catheter has been removed

It has been found that urinary catheters often remain inserted for longer than necessary. It is therefore recommended that a TOV should occur as soon as possible or when safe.

Natalia Miller

When is considered as safe for a TOV to occur?

Dao Le, Long Khanh. (2016) Urinary catheter: trial of void. Evidence Summaries. Retrieved from Joanna Briggs Institute Database.

Key Points:

* Always refer to St Vincent's Hospital policy

* Ensure conditions are safe to perform TOV

* Dicuss with senior clinicians if in doubt

* Usual time for TOV is 0600hrs, no later than 1000hrs

* Educate patient, encourage oral intake and record fluid balance

* Bladder scanner to determine residual urine - if more than 600mls inform MO

* Urinary retention is a serious condition that can lead to renal failure

Urinary Retention

What is the St Vincent's

Policy on TOV?

Clinical Practice Manual - Urethral Catheterisation Protocol - Trial of void

Failure of TOV is an indicator of urinary retention.

Signs and symptoms include:

- palpable bladder which is dull on percussion

- pain/discomfort

- poor urine output

- urge to void but unable to void sufficiently enough to satisfy this need

Who is at risk of urinary retention?

* Acute urinary retention (AUR) can happen in men or women and results from a variety of causes, although it most commonly occurs in men with benign prostatic hyperplasia (BPH)

* older patient (plus 75 years)

* large prostate prior to resection

* patients with constipation

What are the risks of untreated urinary retention?

If the urinary retention has lasted several days (often accompanied by overflow incontinence), patients may develop acute renal failure

* It is advisable to monitor post void residual via bladder scanner on at least 3 subsequent voids if urinary retention is suspected

* If the patient has not voided 8 hours after the catheter removal, a bladder scan should be performed

* Notify the MO of the need to review the patient if the bladder scan reveals a volume greater than 600mls

- Bladder scanning with a portal bladder ultrasound can be used to assess residual volume during the procedure. This relies on competent use and analysis of the ultrasound equipment.

In the literature it was stated that a trial of void is successful if the patient can empty the bladder without residual urine (300ml). This may take several attempts. (Joanna Briggs, 2016).

TOV with SPC

Chamie K, Rochelle J, Shuch B, Belldegrun AS. Urology. In: Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE. eds. Schwartz's Principles of Surgery, 10e New York, NY: McGraw-Hill; 2015. http://accessmedicine.mhmedical.com.acs.hcn.com.au/content.aspx?bookid=980&sectionid=59610882. Accessed July 06, 2017.

NSW Agency for Clinical Innovation (2010). Trial of void, hospital clinical guideline. Retrieved from https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0007/191068/ACI_TOV_Hospital_Jan13.pdf

Thank You!