Accurate urine output monitoring is crucial for early detection and management of acute kidney injury.
In this episode, Tom Calabro, Assistant Vice President of Cardiac Service Line for Atrium Health, discusses the importance of automated urine collection systems in today's fast-paced, data-driven healthcare environment, particularly concerning AKI. He explains AKI, its causes, and how it is categorized into pre-renal, intrinsic, and post-renal phases. Tom highlights the significance of urine output as an early indicator of AKI, emphasizing its role in timely intervention and improved patient outcomes, even amidst nursing shortages. He also shares his experience with the Akron automated urine collection system, praising its accuracy, EMR integration, ability to predict AKI onset up to 30 hours earlier, and overall contribution to enhanced patient care.
Tune in and learn how automated urine output monitoring can empower nurses, improve patient safety, and ultimately save lives!
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[00:00:02] Hey everyone, welcome back to the Outcomes Rocket. I'm thrilled to have Tom Calabro with us. He's an experienced Senior Director of Patient Care Services with over two decades of diverse nursing experience across multiple clinical settings, including pediatric critical care, adult critical care, cardiothoracic surgery, and emergency medicine.
[00:00:25] He's a graduate of Loyola University in New Orleans, and Tom's highly skilled in advanced cardiac life support, healthcare management, patient safety, medical surgical care, and public speaking. I'm excited to have him here on the podcast from Atrium to talk to us about some interesting conditions and ways to take a look at them. So Tom, thanks for joining us.
[00:00:48] Saul, thanks so much. It's great to be with you and with everyone. We'll be having a great day.
[00:00:52] Yeah, no, thank you. It's for sure. It's a lot greater now that you're with us. We're going to be talking about AKI, acute kidney injury, why it's important, and options for folks out there. So talk to us about, in particular, automated urine collection. It seems urine collection would be straightforward. Are these systems necessary as it relates to AKI? Talk to us about that. Orient us.
[00:01:20] Yeah, it really is. In today's rapid pace, data-driven, accuracy-demanding, consumer-savvy, quality-thirsty world in healthcare. Yeah, without question, it's necessary, it's needed. Today, more than ever before, patients are more complex, and everything we see from diabetes to heart disease to acute kidney injury. So yeah, we've got to have accurate data as quickly as possible.
[00:01:42] Thanks for that, Tom. And so let's dive in, because I feel like a lot of people may not know what acute kidney injury is. What is it? Why is it important? What causes it?
[00:01:53] A lot of times we cause it. So I mean, it's really one of those things. Acute kidney injury used to be called the curenal failure. You remember from high school biology, the kidney, the functional units of nephron, and basically the way it works is this.
[00:02:05] You have blood delivers it to the kidneys, and under pressure, ions and water are filtered out. And then as they filter out, what happens is we see that the urine is created.
[00:02:16] Here's the deal. Acute kidney injury is basically a decrease in the ability of the kidney to filter waste products.
[00:02:22] And so if you don't have good blood pressure, and you don't have good blood flow, and you don't have good nephrons, you're not going to make any urine. So when I taught at the College of Nursing, I used to tell the students, no BP, no PP. That's just basically how it works.
[00:02:37] I love it. That's a good way to remember it for sure. No BP, no PP. All right. How do you know when your patient's developing AKI, acute kidney injury?
[00:02:50] It's interesting. So AKI falls into a few categories. There's a pre-renal phase, and that's the one that really is the one that we want to be concerned about.
[00:02:59] And that pre-renal phase, what we see is a decrease in blood flow to the kidneys. It's usually due to trauma or bad cardiac output, infections, sepsis, medications a lot of times, bleeding, those types of situations.
[00:03:12] And so what happens is your blood pressure goes down, and as a result, what we start to see is you're not making any urine.
[00:03:19] Again, it goes back to that whole idea of no BP, no PP. Other things are intrinsic intrarenal things where you have a low blood pressure again, or you have bad organ perfusion, or basically some medications, and then the post-renal phase.
[00:03:33] So what we start to see is this. How do we know that they're getting sicker? We start to see a decrease in urine output. So what we look for as clinicians is a certain amount, 0.5 mls per kilo per hour.
[00:03:46] And if it's below that for a period of 6 to 12 hours, we know the patient is starting to get into trouble.
[00:03:52] Wow. Interesting. And because you're measuring their fluid intake as well, right? So it's all part of the calculation.
[00:03:59] Yeah, it's all part of the calculation. And we see what's going in, and we know what should be coming out.
[00:04:04] And unfortunately, what happens today, you know, and we see this more and more.
[00:04:08] Our patients have never been sicker in the ICUs and in the hospitals.
[00:04:12] And if you think about it, people we used to send home, we now send home, we used to keep for days on end.
[00:04:19] What happens in reality is this, and this is why this electronic measurement is really important.
[00:04:25] And it's because what happens is the nurse is busy. She has two patients in the ICU.
[00:04:30] She gets tied up in a room for a few hours. She comes out, and in that traditional urine collection system,
[00:04:37] all of a sudden she looks in the bag. It's been four hours, and there's 600 mls of urine in there.
[00:04:44] So what does she do? A lot of times what they'll do is go 150, 150, 150, 150, and call it a day.
[00:04:50] But what happens in acute kidney injury is we start to see that trend over time,
[00:04:55] and that urine starts to dwindle off. And when that happens,
[00:04:58] that's how we start to know that our patients get in trouble.
[00:05:01] Yeah, interesting. And so urine output monitoring, is it controversial?
[00:05:06] Are we focusing on urine output monitoring too much?
[00:05:11] In recent years, the controversy has been eliminated somewhat with respect to urine output
[00:05:15] because it's a good marker of acute kidney injury.
[00:05:17] A lot of peer-reviewed articles point to the importance of accurate urine output monitoring.
[00:05:23] You know, sure, there are biomarkers that we can collect like serum creatinine and things,
[00:05:27] but really the quickest and earliest indicator, that leading indicator that we know
[00:05:32] that tells us that the patient is developing an acute kidney injury is that urine output.
[00:05:37] So we have to think about that.
[00:05:39] So in an industry where we have to have new and creative ideas to care for our patients,
[00:05:44] we have to be on the front side of this.
[00:05:46] And so those leading indicators are really important for us.
[00:05:49] You think about it, why do people come to the hospital?
[00:05:52] You know, we're sending people home after surgery every day,
[00:05:55] but why do they stay in the hospital now?
[00:05:57] And the one reason is expert nursing care.
[00:05:59] If we give the nurses the tools they need to do the work,
[00:06:02] they're able to get great information and collaborate with our physicians
[00:06:05] in order to drive better outcomes.
[00:06:08] Thanks, Tom.
[00:06:09] And so, you know, we all know nurse patient ratios, they're struggling.
[00:06:15] Like there's not enough nurses, there's not enough physicians.
[00:06:18] What role does automation play in all this?
[00:06:21] You know, automation plays a huge role because what we have to think about as leaders,
[00:06:25] particularly in healthcare, is we have to think about the trade-off.
[00:06:29] Nursing burden is a big component of our care factors.
[00:06:34] And so when we think about how do we decrease harm,
[00:06:38] how do we have zero harm and move toward eliminating never events,
[00:06:43] one of the things we have to do is we have to look at what's the nursing ratio,
[00:06:47] and then how do we make it easier for them?
[00:06:49] You know, many, many, many years ago,
[00:06:51] before you and I were walking around this planet,
[00:06:53] nurses used to have to collect blood pressures every 15 minutes manually.
[00:06:57] We move to an automated system.
[00:07:00] Same with heart rate and everything else.
[00:07:02] We can look at that and we collect that data electronically.
[00:07:05] Really, we started to look at urine output as essentially another vital sign.
[00:07:10] So that's really important for us.
[00:07:12] Well, yeah, I think that's very interesting.
[00:07:14] And so how are you guys doing it?
[00:07:16] Do you guys have this urine output technology?
[00:07:19] What brand do you use?
[00:07:20] Why do you choose it?
[00:07:21] Tell us more about that.
[00:07:22] We do have this technology.
[00:07:24] And we, after a lot of review, a lot of back and forth,
[00:07:29] we went with Accurant.
[00:07:30] In our organization, we're committed to zero harm.
[00:07:34] We're on an HRO journey of excellence, high reliability organization,
[00:07:38] much like that coming to us out of the airline industry.
[00:07:41] And so as leaders, we started to look at this urine collection system.
[00:07:45] We looked at a lot of different technologies.
[00:07:46] And essentially what we did is we started to say,
[00:07:49] okay, what is going to make this the best type of product for us?
[00:07:54] So we went to the experts, those folks who are going to use it every single day.
[00:07:59] And we asked the question, hey, tell us what your needs are.
[00:08:02] Tell us what you like.
[00:08:04] What is it that would make your job easier?
[00:08:06] And so we started to look at that technology.
[00:08:08] We tried a number of them.
[00:08:10] And we found that the Accurant device was the best one for us.
[00:08:14] And so some of the reasons for that is we know that the Accurant device,
[00:08:19] not only does it accurately collect the urine output,
[00:08:23] it uploads the data to the EMR.
[00:08:26] That is a game changer for nurses.
[00:08:28] Because the other nice thing about this is we can go back
[00:08:31] and we can see in increments how much went out in this hour,
[00:08:34] how much went out in 15 minutes,
[00:08:36] how much was put out in 30 minutes.
[00:08:37] So when we give medications, we can tell,
[00:08:40] are the medications being effective or are they not being effective?
[00:08:44] Then we considered another aspect.
[00:08:46] And we are a trauma center,
[00:08:47] as well as the fact that we do a lot of complex surgeries.
[00:08:51] And one of the things that we're able to do is
[00:08:54] we want to measure the pressure inside the abdomen a lot of times.
[00:08:57] And the way we do that is by putting a Foley catheter,
[00:09:01] the pressure sensor inside the bladder.
[00:09:04] It tells us what that pressure is.
[00:09:06] And as that pressure goes up,
[00:09:08] it tells us are you starting to get into trouble with other organs in the body.
[00:09:12] So Accurant has figured out how to take care of that.
[00:09:15] And we don't have to do some crazy setup like we normally have had to do in the past.
[00:09:20] Another reason that we chose to go with Accurant
[00:09:24] is the device passed what I call the nurse test.
[00:09:27] Essentially, it's nurse proof.
[00:09:29] We see a lot of products come through
[00:09:31] and we hand it over to these very jemure, very beautiful, slight people.
[00:09:36] And they can break something quicker than anybody in the whole universe.
[00:09:39] And because they are using it effectively,
[00:09:43] but we found that this device has a very rugged, rugged stand.
[00:09:48] And so we went with this as well.
[00:09:50] In addition to that, it measures the temperature in the bladder.
[00:09:53] So we know what the temperature is of the patient and their body.
[00:09:57] And so that's a very important thing to us.
[00:09:59] So we can manage the patient effectively.
[00:10:01] But here's the other thing.
[00:10:03] And this is a game changer for us,
[00:10:04] is that the Accurant device is able to predict the onset of AKI
[00:10:10] up to 30 hours before clinical changes are noted by the care team oftentimes.
[00:10:15] So being on the front side of this care concern helps to save lives.
[00:10:20] So not only can it predict the onset of AKI,
[00:10:23] but it also provides an alert to the team
[00:10:25] so that they're able to see in a display
[00:10:28] that your patient's getting into trouble.
[00:10:30] So to sum it up, as a clinician,
[00:10:33] better data leads to better decisions and better outcomes.
[00:10:36] And that's why we chose Accurant.
[00:10:38] That's great, Tom.
[00:10:39] Really appreciate the summary there
[00:10:41] and the review of this acute kidney injury and urine collection.
[00:10:47] It's something that we need to talk about more.
[00:10:50] And it's one of those, as you called it,
[00:10:52] one of our new vital signs that we really need to be thinking about.
[00:10:55] Thanks for sharing your thoughts on your choice with Accurant
[00:10:58] and really the clinical experience that you've had with this product.
[00:11:02] What call to action would you leave our listeners with
[00:11:04] and Merkin, they reach out to you to learn more?
[00:11:06] I think from a call to action, I think as leaders,
[00:11:09] we need to look at how we manage our teams.
[00:11:12] We need to look at this and maybe reconsider the paradigm
[00:11:15] and shift it a little bit to look at what can we do more for nursing
[00:11:18] to make sure that they can provide the care
[00:11:21] that we want to deliver to our patients
[00:11:23] because everyone goes into healthcare with that focus.
[00:11:26] If they want more information,
[00:11:27] they can certainly reach out to us on the Accurant website
[00:11:30] and that would be the easiest way to get any information.
[00:11:34] The sales teams will be able to help you out.
[00:11:36] I'm just a nurse, so I'm just letting you know.
[00:11:39] That's what my experience is.
[00:11:41] I love it.
[00:11:41] Well, there you have it, folks.
[00:11:42] Tom Calabro, just an incredible discussion around this topic.
[00:11:47] In the show notes, we're going to leave all the ways
[00:11:49] to get in touch with him, the Accurant team,
[00:11:52] and for you to learn more.
[00:11:53] So, Tom, thanks for doing this.
[00:11:54] This was a lot of fun.
[00:11:55] Thanks, Saul.
[00:11:56] It's great to see you.
[00:11:56] Have a great day.
[00:11:57] You too.
[00:11:58] Thank you.
[00:11:58] You