Documenting urine output for pediatric urology patients in the post-anesthesia care unit: A quality improvement initiative

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Close monitoring and documentation of urine output (UOP) after urologic surgery is a nursing standard of care in the post-anesthesia care unit (PACU). UOP is a critical piece of information for surgeons and anesthesiologists to provide safe quality patient care. The electronic medical record (EMR) is used to communicate this information between members of the care team. Initial review at our institution confirmed only 31.3% of children recovering in the PACU after urologic surgery had a numerical value for UOP documented in the EMR. The aim of this project was to improve compliance of UOP documentation in the EMR for pediatric urologic patients in the PACU from 31.3% to 80% by August 2021, using quality improvement methodology. Patients undergoing urologic surgery with planned post-operative hospital admission were identified in the EMR by admission status and Current Procedural Terminology (CPT) code. UOP documentation data during the patients' PACU stay was retrieved from the EMR. Traditional QI methods were used to develop a key driver diagram, identify barriers, and implement targeted interventions. Statistical process control charts tracked the outcome measure (percentage of patients with UOP documented in the PACU) and balancing measure (average PACU length of stay). The project began in July 2019, and four interventions started between July and October 2019. These interventions resulted in a centerline shift of our outcome measure, UOP documentation rate, from 31.3% to 76.2% (p<0.001). Patient volumes were stable with the exception of March, April, and May 2020 during the Covid-19 pandemic. An X-bar chart tracked PACU LOS, the balancing measure, in average minutes per patient without any trends. This quality improvement initiative sought to improve urine output (UOP) documentation for pediatric urologic patients during the immediate post-operative period. Targeted interventions leading to this improvement included educating nursing staff, establishing direct communication expectations for the surgical team, and improving the availability of UOP measurement tools. Limitations include reliance on education and behavioral change, only including urologic surgery patients, and our institution's robust focus on quality improvement work. This performance improvement initiative successfully increased the rate of UOP documentation by PACU nurses for pediatric urology patients through a combination of interventions. The next phase is to expand these interventions throughout the hospital to improve UOP documentation for all post-operative patients.