Caregiver and Health Care Provider Satisfaction ... - Wiley Online Library

0 downloads 156 Views 97KB Size Report
Caregiver and Health Care Provider. Satisfaction with Volumetric Bladder. Ultrasound. Brigitte M. Baumann, MD, MSCE, Kat
Caregiver and Health Care Provider Satisfaction with Volumetric Bladder Ultrasound Brigitte M. Baumann, MD, MSCE, Kathryn McCans, MD, Sarah A. Stahmer, MD, Mary B. Leonard, MD, MSCE, Justine Shults, PhD, William C. Holmes, MD, MSCE

Abstract Objectives: Conventional (nonimaged) bladder catheterization has lower first-attempt success rates (67%– 72%) when compared with catheterization aided by volumetric bladder ultrasonography (US) (92%–100%), yet the total time to urine sample collection with US can be quite lengthy. Given the advantage and disadvantages, the authors assessed caregiver and health care provider satisfaction with these two methods. Methods: Caregivers and health care providers of children enrolled in a prospective, randomized, controlled trial examining the first-attempt urine collection success rates with these two methods completed standardized questionnaires. Each child’s caregiver, nurse, and physician noted their perceptions, satisfaction, and future preferences using Likert-scale assessments. Results: Of 93 caregivers, 45 had children randomized to the conventional arm and 48 to the US arm. Nine physicians and three nurses participated. Both caregiver groups had similar previous catheterization experience; none had children undergo volumetric bladder sonography. Caregivers in the conventional group rated their children’s discomfort higher (4.4 vs. 3.4; p = 0.02) and were less satisfied (4.5 vs. 6.4; p < 0.0001) than those in the US group. Nurses’ satisfaction with catheterization in the conventional group was lower than in the US group (3.0 vs. 5.5), as was physicians’ satisfaction (4.3 vs. 5.7; p < 0.0001). Both nurses and physicians indicated that they would be less likely to use conventional catheterization in future attempts. Conclusions: Caregivers in the conventional group rated their children’s discomfort higher than did caregivers in the US group. Both caregivers and health care providers expressed greater satisfaction with US and were more likely to prefer this imaging modality with future catheterization attempts. ACADEMIC EMERGENCY MEDICINE 2007; 14:903–907 ª 2007 by the Society for Academic Emergency Medicine Keywords: ultrasound, bladder, catheterization, pediatrics, nurse, emergency medicine, satisfaction

S

everal recent studies have demonstrated that use of ultrasonography (US) to aid in the timing of transurethral urine collection attempts improves first-attempt success rates, decreases the need for repeat catheterization attempts, and improves the adequacy and

From the Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School at Camden (BMB, KM, SAS), Camden, NJ; Department of Pediatrics, Children’s Hospital of Philadelphia (MBL), Department of Biostatistics, University of Pennsylvania School of Medicine (JS), Center for Health Equity Research and Promotion, Philadelphia VA Medical Center (WCH), Philadelphia, PA. Received April 20, 2007; revision received June 8, 2007; accepted June 25, 2007. Dr. Stahmer is currently with Department of Surgery, Division of Emergency Medicine, Duke University, Chapel Hill, NC. Contact for correspondence and reprints: Brigitte M. Baumann, MD, MSCE; e-mail: [email protected].

ª 2007 by the Society for Academic Emergency Medicine doi: 10.1197/j.aem.2007.06.041

quality of the final collected specimen.1,2 We have shown that nurses trained in bladder US for use in catheterizations of children aged 36 months or younger had firstattempt success rates of 67% in children assigned to the conventional (nonimaged) arm and 92% in children assigned to the US arm (p = 0.003).3 In all but one participant (conventional group), caregivers refused a second catheterization attempt, which led health care providers to utilize a perineal bag for further urine collection attempts. Children assigned to the conventional arm were also less likely to have both urinalysis and culture performed due to the inadequate specimen volume (91% vs. 100%, respectively; p = 0.04).3 Despite the improvements in urine collection provided by US, there was a real, albeit small, time delay in the US group when compared with standard, nonimaged urine collection. Time to obtain an adequate urine sample in the conventional group was less than half that of the US arm (12 vs. 28 minutes, respectively; p < 0.001).3 This was due to the time required to obtain and set

ISSN 1069-6563 PII ISSN 1069-6563583

903

904

Baumann et al.

up the US machine, as well as the time needed to perform the actual sonographic imaging and bladder measurements. Furthermore, in instances where the bladder was insufficiently filled, health care providers were required to return to the child’s bedside for repeat imaging until a sufficient urine volume was present. Our findings were similar to those of previous studies in which physicians, rather than nurses, performed the sonographic imaging.1–3 In all studies, screening bladder US improved the success of urine collection. Given the greater time and effort required of the health care provider using sonographic imaging, however, we were concerned that these additional demands on health care providers could outweigh clinical benefits experienced by patients, which, in turn, could limit acceptability and diffusion of this technology for use in collecting urine specimens. We anticipated these concerns before completing our study of nurses and, as a result, included assessment of caregivers’ and health care providers’ perceptions of and satisfaction with the procedures of each intervention arm.

Nurses who performed the catheterization, the on-duty attending physician, and caregivers were asked to rate their satisfaction with the modality used to obtain urine using a seven-point Likert scale (1 = ‘‘none,’’ 7 = ‘‘a great deal’’). All respondents were also asked to rate the amount of physical manipulation required to obtain urine and to rate the amount of time required to collect a urine specimen (using the previously noted Likert scale). Health care providers were also asked, ‘‘In your future practice, please rate the likelihood that you would use US-assisted catheterization to obtain urine from patients aged 0–36 months?’’ The same item was asked of conventional catheterization, with assessments provided using the Likert scale, with 1 = ‘‘never’’ and 7 = ‘‘all the time.’’ Caregivers were additionally asked to rate the amount of discomfort experienced by their child and to rate their preference for future catheterizations attempts, with 1 = ‘‘never use ultrasound,’’ 4 = ‘‘don’t care,’’ and 7 = ‘‘only use ultrasound.’’

METHODS Study Design and Population This was a substudy of a randomized controlled investigation examining the first-attempt success rates of pediatric emergency department (ED) nurses in obtaining adequate amounts of urine during transurethral bladder catheterization. Participants were queried regarding their satisfaction with the use of nonimaging or imaging (US)-assisted catheterization. This study was approved by the Cooper University Hospital Institutional Review Board, and written informed consent was obtained from all caregivers. Caregivers of children presenting to a tertiary center pediatric ED from July 2005 to June 2006 were approached for consent if their child was 36 months or younger and required urine catheterization as part of their medical evaluation. Caregivers of children who had a genital anatomic abnormality, had an indwelling catheter, or were toilet-trained were excluded from the study. The parent study has been described.3 Briefly, children were randomized to receive conventional (nonimaged, standard of care) catheterization or screening US before any catheterization attempt. Catheterization was performed by nurses trained in volumetric bladder US. Catheterization of those randomized to the US arm proceeded if the calculated bladder volume was R2.5 cm3, because this was the minimal acceptable volume for both a urinalysis and culture by our institution’s laboratory. Children randomized to the conventional catheterization arm underwent immediate catheterization unless there was evidence that they had recently voided. If this occurred, catheterization was typically postponed and this was at the discretion of the attending physician. Survey Content and Administration To assess perceptions and satisfaction with the two urine collection methods, standardized questionnaires were developed for the present study. Questionnaires were distributed to health care providers and to the children’s caregivers. All questionnaires were administered after the final catheterization attempt.



SATISFACTION WITH VOLUMETRIC BLADDER US

Data Analysis Sample size was determined by the primary study aim of an improvement in catheterization success rates, and this sample size was met. A post hoc sample size calculation for the perceptions and satisfaction aims indicated that we had 92% power to detect a mean difference of 1.0 on the seven-point Likert scale using a two-sided a of 0.05. All data analyses were performed using Stata 8 (Stata Corp., College Station, TX). Data are presented as proportions or means with 95% confidence intervals (CIs). Fisher exact test or chi-square analysis was used to compare baseline characteristics between the two groups. A two-tailed Student t-test was used to compare the mean scores of each item. Significance was set at p % 0.05. RESULTS Of the 95 caregivers whose children were enrolled in the parent study, all but two completed perception questionnaires. The first of these two caregivers was so distraught when her child was randomized to the conventional catheterization arm that she withdrew her child from the investigation. When she was informed that her child would still undergo conventional catheterization outside of the study, she continued to refuse, maintaining that all children should undergo sonographic screening before urine collection attempts. The second caregiver’s child was not able to participate in the study because there were technical difficulties with the US machine, and this was the group to which the child had been randomized. Of the remaining 93 caregivers, all (100%) completed questionnaires. Of the nine pediatric emergency physicians and three trained nurses who participated in study procedures, all (100%) completed questionnaires. Forty-five patients were randomized to the conventional catheterization arm, and 48 patients were randomized to the US arm. The two groups were similar with respect to previous caregiver’s experience with the catheterization procedure and the use of US in guiding catheterization attempts in their children (Table 1). Approximately one fifth of all patients had undergone a

ACAD EMERG MED



October 2007, Vol. 14, No. 10



www.aemj.org

Table 1 Previous Experience of Caregivers and Participants Characteristic, n (%) Caregiver has other children Previous experience with catheterization of other children Other child(ren) had US to aid with timing of catheterization Enrolled child has been previously catheterized Previous catheterization for enrolled child used US

905

Table 2 Perceptions and Satisfaction of Caregivers

Conventional Arm US Arm p(n = 45) (n = 48) value 18 (40)

24 (50)

0.4

4 (22)

5 (21)

1.0

0 (0)

2 (8)

0.4

10 (22)

9 (19)

0.7

0 (0)

0 (0)

1.0

US = ultrasonography.

previous catheterization, but none had ever had US utilized to guide the procedure. When responses to questions asked of the two groups of caregivers were compared, there was no difference in caregiver perception of the amount of physical manipulation or time needed for catheterization (Table 2). What caregivers did perceive to be different was the discomfort experienced by their children, with the caregivers in the conventional group noting a greater level of discomfort experienced by their children than did caregivers of the children assigned to the US arm. When asked to rate which method they would prefer for their child in the future using a Likert scale, both groups expressed a preference for US, albeit with the preference indicated by those caregivers whose children were randomized to the US arm being significantly higher. When the above items were reanalyzed using only the responses of caregivers whose children underwent successful first-attempt catheterizations, caregivers of children in the conventional catheterization group still noted a higher discomfort level (4.4 vs. 3.3; p = 0.03) and expressed a lower satisfaction when compared with caregivers of children assigned to the US arm (4.7 vs. 6.5; p < 0.0001). When caregivers of children with successful catheterization attempts were asked about future preferences, these too were maintained, with both groups preferring US and, again, the US group expressing a significantly higher preference (5.3 vs. 6.3; p = 0.003). The two full-time nurses participating in this study enrolled 35 children; a participating nurse with a two-thirds full-time equivalent position enrolled 23 children. Catheterization success rates did not differ among nurses.3 Unlike the caregivers, however, nurses’ perceptions of the amount of physical manipulation and time required to perform the catheterization were less in the conventional arm than in the US arm (Table 2). With every catheterization, nurses were also asked to rate how likely they were to use each modality, conventional catheterization and volumetric bladder US, with future attempts. Overall, nurses were less likely to prefer conventional catheterization (2.7; 95% CI = 2.4 to 3.1) than they were US-guided catheterization (5.5; 95% CI = 5.2 to 5.8) with future attempts (p < 0.0001). These differences were maintained even after adjustment for intervention arm assignment and when each nurse was individually assessed.

Caregivers Physical manipulation Time needed Child’s discomfort Satisfaction Future preference* Nurses Physical manipulation Time needed Satisfaction Likelihood of future use of conventional catheterization Likelihood of future use of volumetric bladder US Physicians Physical manipulation Time needed Satisfaction Likelihood of future use of conventional catheterization Likelihood of future use of volumetric bladder US

Conventional Arm (n = 45)

US Arm (n = 48)

3.5 (2.9, 4.1)

3.5 (2.9, 4.1)

2.9 4.4 4.5 5.3

2.9 3.4 6.4 6.2

(2.3, (3.7, (3.9, (4.8,

3.5) 5.0) 5.2) 5.8)

(2.3, (2.8, (6.1, (5.8,

p-value 0.9

3.4) 0.9 4.0) 0.02 6.8)