H.29 A project aiming to maximize urinary output volume monitoring in hospitalized patients with incontinence

A project aiming to maximize urinary output volume monitoring in hospitalized patients with incontinence

Nearly 6.5 million Americans over the age of 20 have heart failure. In addition, it is estimated that there are 960,000 new heart failure cases annually. Heart failure directly accounts for about 8.5% of all heart disease deaths in the United States. In addition, heart failure is one of the leading cause of hospitalizations. In fact, it remains the number one cause of hospitalizations in our Medicare population, leading to a huge burden to our healthcare system. 

When a patient is hospitalized for a heart failure exacerbation, main goal of therapy is optimization of the patient’s home medications, accurate evaluation of their current fluid status and aggressive/advanced diuresis with intravenous diuretics.

Currently there are two major concerns that require improvement in this setting:

1. Optimizing the accuracy of non-invasive fluid status assessment of the patient who is admitted for heart failure exacerbation.
2. Optimizing the measurement of volume of urinary output. Unmeasured urinary output volume is common, especially in patients with incontinence or on the medicine floors where nursing to patient ratios is extremely high, leading to high workload. 

Currently, the way we address the above problems in the clinical setting are:

1. Fluid status assessment: Currently, assessing the fluid status of a patient (overloaded or dry) is done by measuring jugular venous distention on our physical exam and estimating central venous pressure based on the above findings, biomarkers which are associated with myocardial stretch (B- natriuretic peptide) or assessing peripheral lower extremity edema. Sometimes, point of care ultrasound can be used to assess inferior vena cava (IVC) dilation, however this sometimes is affected/confounded by other parameters such as right heart failure, valvular disease, liver disease or invasive ventilation. Overall, the fluid status of a patient has always been a challenging clinical exam process when a patient is on the general floors. The gold standard to assess volume is invasively through catheterization, however this usually happens in the catheterization laboratory or the critical care units. There is a need for a more standardized, objective approach of assessing fluid status. An ideal approach would include a noninvasive device that objectively estimates JVD followed by a creation of a patient specific multivariate model that would include patient specific information such as their baseline weight, prior IVC measurements etc. A scoring system would be later created to map the patient on the specific encounter based on their overall fluid curve.

1. Measurement of urinary output: Currently, for conscious and cooperative patients, urinary output is measured by having the patient urinate in a urinal, and then the volume is subsequently measured and logged in the patient’s chart by nursing staff. Sometimes, urinary catheters are used, however they can be associated with urinary tract infections and are uncomfortable for most patients. In the case of a patient with incontinence monitoring urinary output is even more challenging. Absorbent pads are used on almost every patient who is hospitalized. These pads are mostly for sanitary purposes. However, additional properties can be added to these pads (color change based on volume absorbed) so we can gather one additional datapoint of estimated volume (with some standard error). This is of crucial importance as unmeasured volume output can lead to additional diuresis, since we are underestimating the diuresis effect, leading to kidney injuries and prolonged hospitalizations and thus increased costs to our healthcare system. 

The overall impact of the solutions addressing the above problem will lead to improved patient care of the hospitalized patient with acute exacerbation of heart failure, shorted hospital stays leading to less financial burden to our healthcare system and less hospitalization complications for patients since these are usually associated with prolonged stays.