Background: Hip surgery, a common healthcare procedure in Sweden and worldwide, is like other surgical procedures associated with risks of complications, such as urinary retention. Urinary retention is prompted by several factors experienced by the orthopaedic patient, such as pain, bed rest, medication (opioids, anaesthesia) and intravenous treatment with fluids. To prevent urinary retention or other voiding complications, there are evidence-based guidelines, supporting safe clinical care and averting unnecessary care injuries. Prior studies indicate that these guidelines are neither fully known nor used by orthopaedic staff, but bladder distension is still one of the most common adverse events in Swedish orthopaedic care. This licentiate thesis represents two studies, constituted by baseline data from 17 orthopaedic units in the Onset PrevenTIon of urinary retention in Orthopaedic Nursing and rehabilitation (OPTION) trial.   

Aim: The overall aim was to explore patients’ experiences of bladder care and voiding issues due to hip surgery and to evaluate staffs’ adherence to risk assessment for urinary retention according to evidence-based guide-lines.  

Design and method: Study I had a descriptive design and data was analysed using inductive content analysis. Study II was an observational study analysed with descriptive and comparative statistics, and logistic regressions.  

Findings: Patients experienced that bladder care and monitoring seemed important, although the reason was not fully explained to them, nor the related risk between hip surgery and urinary retention. Those experiencing bladder issues postoperatively managed and sought care on their own, not associating such events with their hip surgery. The bladder issues were described as negatively affecting daily life.  

Documentation in medical records (n=1382) indicated low adherence to recommended risk assessment for urinary retention (23.4%), and performed assessment was significantly associated with acute surgery or being treated at an academic hospital. Acute patients experienced urinary retention or other bladder issues more frequently, and among those patients completing a survey (n=447), 11.9% reported increased bladder issues after surgery.  

Conclusions: With a lack of communication with patients about bladder care, and limited adherence to risk assessment for urinary retention, further efforts to reinforce guideline implementation are needed. This should include a more patient-centred approach in the attempts to provide better, safer and more equal care. 

Background: Hip surgery procedures is common both in Sweden and worldwide. Much like other surgical procedures, hip surgery is associated with risks of complications, such as urinary retention (UR). UR is prompted by several factors, such as pain, bed rest, certain medication (like opioids and anaesthesia) and intravenous fluid therapy. UR can cause bladder distention and short- and long-term complications. Therefore, evidence-based practice (EBP) guidelines are available to support clinical care, and to avert adverse bladder events. Prior studies indicate that these guidelines are neither fully known nor used by orthopaedic staff, but bladder distension is one of the most common adverse events in Swedish orthopaedic care. This thesis represents four sub-studies, constituted by data from 17 Swedish orthopaedic units in the Onset PrevenTIon of urinary retention in Orthopaedic Nursing and rehabilitation (OPTION) trial, a cluster-randomised hybrid implementation effectiveness study.

Aim: The overall aim of the thesis was to investigate evidence-based practice in the orthopaedic care context, focusing bladder care—prior to and following a team-based implementation intervention.

Design and method: Study I had a qualitative descriptive design where patient interviews and survey data were analysed using inductive content analysis. Study II was a quantitative observational study where medical records, patient survey data and an extract from a quality registry were analysed with descriptive and comparative statistics, and logistic regressions. Study III applied a mixed methods approach, using convergent parallel design to analyse patient and staff interviews and survey data. Lastly, study IV was a cluster-randomised RCT meant to analyse the effects of an implementation intervention using descriptive and comparative statistics, and Poisson regression to analyse differences between intervention and control groups.

Results: Patients experienced that bladder care and monitoring seemed important, although the reason behind staff’s focus on bladder care were not fully explained to them, nor was the related risk between hip surgery and UR, due to a lack of communication. If patients experienced bladder issues postoperatively, they managed and sought care on their own, and did not associate such events with having hip surgery. Bladder issues were described as negatively affecting their daily life. 

Documentation in medical records (n =1382) revealed low adherence to recommended risk assessment for UR (23%), as prescribed in the evidence-based guidelines. When conducted, the risk assessment was significantly associated with acute surgery or with being treated at an academic hospital. Patients who had had acute hip surgery experienced UR or other bladder issues more frequently than elective patients, and among those patients who completed the self-reported patient survey (n =447), 12% reported increased bladder issues after surgery. Few bladder-related incidents were reported via the perioperative quality registry SPOR (n =11).

The orthopaedic care context was characterised as overall enabling for EBP, although it was challenged by fast-track processes and time and resource constraints. Feedback on EBP adherence, evaluation of EBP efforts, and managerial support were voiced as important context elements to consider in the implementation process in healthcare. Moreover, future implementation efforts also require patients’ perspectives, to increase understanding of EBP actions and outcomes.

The implementation intervention in OPTION did not render any statistically significant effects on the adherence to risk assessment documentation nor on patients’ ability to empty their bladders postoperatively. Significant differences were found between groups at baseline, with higher adherence to risk assessment in the intervention group, and more patients contacting healthcare services due to voiding issues in the control group. The prevalence of documented UR was low at all timepoints, with no significant differences between the groups, and there were few reports on bladder-related incidents from the perioperative quality registry SPOR.

Conclusions: With a lack of communication with patients about bladder care, and a prevailing limited documented adherence to UR risk assessment in line with EBP guidelines, further efforts are needed to reinforce guideline adherence. Further implementation efforts should target the initial risk assessment for UR, bladder-related documentation in the patient’s medical record, and person-centred care— with sensitivity to contextual factors that may hinder or facilitate evidence-based practice in orthopaedic settings. This together can provide for high-quality, safe and equitable bladder care for patients having hip surgery.  

Bakgrund: Höftkirurgi är vanligt förekommande i Sverige och internationellt. Precis som andra kirurgiska procedurer är höftkirurgiska ingrepp förknippade med en ökad risk för komplikationer, exempelvis urinretention (UR). Att patienter som genomgår höftkirurgi drabbas av UR kan förklaras av flertalet faktorer, så som smärta, sängläge, medicinering (opioider, anestesi) och intravenös infusion av vätska. Då UR kan orsaka blåsöverfyllnad med kort- och långsiktiga komplikationer, så har evidensbaserade riktlinjer tagits fram i syfte att stödja det kliniska arbetet och för att förhindra blåsskador. Trots detta indikerar tidigare studier att riktlinjerna inte är fullt implementerade. Riktlinjerna används inte fullt ut och är inte heller helt kända av vårdpersonal, och blåsöverfyllnad är fortfarande en av de vanligaste vårdkomplikationerna inom svensk ortopedisk vård idag. Denna avhandling innefattar fyra delstudier, vilka bygger på data från 17 svenska ortopediska enheter inkluderade i Onset PrevenTIon of urinary retention in Orthopaedic Nursing and rehabilitation (OPTION), en kluster-randomiserad implementeringsstudie med hybrid-design.

Syfte: Det övergripande syftet med avhandlingen var att undersöka evidensbaserad praktik inom ortopedisk vårdkontext, med fokus på blåsvård - före och efter en teambaserad implementeringsintervention.

Design och metod: Studie I hade en kvalitativ deskriptiv design där patientintervjuer och enkätdata analyserades med induktiv innehållsanalys. Studie II var en observationsstudie där journaldata, enkätdata och ett registerutdrag från ett kvalitetsregister analyserades med deskriptiv och jämförande statistik samt logistisk regressionsanalys. I studie III användes en mixad metod med konvergent parallell design för att analysera intervjuer med patienter och personal, samt enkätdata. Avslutningsvis, studie IV var en kluster-randomiserad RCT för att analysera effekterna av en implementeringsintervention, med hjälp av beskrivande och jämförande statistik, samt Poisson regression för att analysera skillnaderna mellan interventions- och kontrollgrupp.

Resultat: Patienterna upplevde att blåsvård- och övervakning verkade viktigt men de hade inte fått veta anledningen till personalens fokus på detta, och hade inte heller vetskap om den ökade risken för UR i samband med höftkirurgi, pga. bristande kommunikation. De som erfor blåsbesvär postoperativt hanterade och sökte hjälp på egen hand, och associerade inte besvären till den höftoperation de genomgått. Blåsbesvären beskrevs ha en negativ påverkan på deras dagliga liv.

Dokumentation i granskade patientjournaler (n =1382) påvisade låg följsamhet till riskbedömning för urinretention (23%) enligt evidensbaserade riktlinjer. Utförd bedömning var signifikant associerad till akut kirurgi eller att ha blivit behandlad vid ett universitetssjukhus. Patienter som genomgått akut höftkirurgi upplevde oftare UR eller andra blåsbesvär jämfört med elektiva patienter, och bland de patienter som besvarade den själv-rapporterade enkäten (n =447), rapporterade 12% ökade blåsbesvär efter sin höftoperation. Få blåsrelaterade incidenter rapporterades via det perioperativa kvalitetsregistret SPOR (n =11).

Den ortopediska vårdkontexten kännetecknades av en i huvudsak underlättande organisatorisk kontext för evidensbaserad praktik (EBP), dock utmanad av snabba vårdprocesser och tids- och resursbrist i verksamheterna. Både feedback kring följsamhet till EBP, utvärdering av EBP insatser och chefsstöd uttrycktes som viktiga faktorer att ta hänsyn till vid implementering i hälso- och sjukvård. Förutom detta, så behöver framtida implementeringsinsatser av EBP även innehålla patienternas perspektiv för en ökad förståelse gällande EBP-interventioner och utfall.

Implementeringsinterventionen i OPTION hade ingen statistiskt signifikant effekt på följsamheten till dokumenterad riskbedömning, eller på patienters förmåga att tömma sin blåsa postoperativt. Signifikanta skillnader noterades mellan grupperna vid baslinjen, med högre följsamhet till riskbedömningen i interventionsgruppen, och fler patienter som kontaktade sjukvården pga. blåsrelaterade besvär i kontrollgruppen. Prevalensen av dokumenterad UR var låg vid alla tre mätpunkter, utan signifikanta skillnader mellan grupperna, och få blåsrelaterade incidenter var rapporterade i det perioperativa kvalitetsregistret SPOR.

Slutsatser: Med en brist på kommunikation med patienter om blåsvård och en fortsatt låg dokumenterad följsamhet till riskbedömning för UR enligt evidensbaserade riktlinjer, krävs ytterligare ansträngningar för att implementera riktlinjerna. Fortsatta implementeringsinsatser bör inriktas på den initiala riskbedömningen för UR, blåsrelaterad dokumentation i patientens journal samt personcentrering—med en lyhördhet till hindrande/underlättande kontextuella faktorer i ortopedisk vård. Detta för att kunna ge en högkvalitativ, säker och jämlik blåsvård till patienter som genomgår höftkirurgi.