In the world of critical care, accurate monitoring of urine output (UO) may seem like a routine task, but its importance cannot be overstated. Measuring urine output in an accurate and timely manner guides treatment choices, offers critical insights into a patient’s hemodynamic status and can alert clinicians to impending septic shock or acute kidney injury (AKI).
Despite advances in technology, manual urine output measurement remains the standard in many intensive care units. However, this approach carries hidden costs – not only financial, but also clinical and operational. As healthcare systems strive for better outcomes and efficiency, it’s time to re-examine the true cost of manual urine measurement in critical care.
Human Error in Urine Measurement and Its Clinical Consequences
Manual urine measurement introduces multiple opportunities for human error, despite best intentions and practices. In an era of significant nurse staffing shortages, burnout only further increases the risk of errors. As a result, incorrect volumes, inconsistent documentation and delayed reporting can all affect patient outcomes.
In a 2021 prospective study, records were missing a manual recording 39% of the time, and nurses overestimated hourly urine output by an average of nearly 20 ml and documented urine output an average of 47 minutes late – with some delays up to six hours. These delays can have a serious impact – in one study, 41% of severe oliguric events lasting more than 3 hours were missed by nursing staff using manual methods.
The consequences can be far-reaching. Low urine output is not only predictive of septic shock, but it has also been linked to a significant increase in mortality for patients with the diagnosis. UO is also an important predictor of AKI, which occurs in as much as 57% of the ICU patient population. Patients with AKI that progresses to later stages also experience increased mortality risks. Early detection of these conditions is therefore paramount.
Infection Risks and Manual Urine Measurement
Even with optimal accuracy and timeliness, manual urine measurement increases the risk of catheter-associated urinary tract infections (CAUTIs), bringing with it additional hidden costs. Each manual manipulation of the catheter carries with it risk of introducing bacteria, with the annual cost of CAUTI to healthcare systems in the U.S. as high as $450 million. In one study, the rate of manual manipulation was noted to be twice per hour – exposing not only the patient to risk of infection, but also the nurse to potential contamination from body fluids. It is also worth noting that the costs of hospital-acquired CAUTI are not reimbursable by CMS.
Along with increased costs, CAUTIs result in extended lengths of stay, higher mortality risk, increased antibiotic use and discomfort for patients. Morbidity risk includes sepsis and AKI, with one study describing that 12% of patients with UTI develop AKI, and 60% of those with septic shock develop AKI.
Workflow Inefficiencies and Staff Burden
A recent survey by the American Nurses Association found that 96% of ICU nurses reported 4:1 nurse-patient ratios, twice the recommended number. In a busy, high-stress environment, frequent manual urine output monitoring is time-consuming, inefficient and at times impossible.
For example, intensive urine monitoring, necessary to proactively detect changes that indicate developing AKI, involves hourly recordings and no gaps in recording greater than three hours during the first 48 hours of an ICU admission.
All of this adds up to an average of two minutes per patient per nurse per hour, or 20 minutes per hour and eight hours per day of time in an ICU with 10 patients. This risks taking critical time away from other tasks and only further exacerbates nurse burnout, contributing to high staffing turnover, elevated staffing costs and dangerous and costly errors in care delivery.
Manual vs. Digital Measurement: A Compliance Perspective
When comparing manual urine output measure with automated electronic monitoring, there are clear advantages to digital measurement. As previously discussed, manual measurement often results in inaccurate, missing or delayed UO recording. With digital measurement, we see improved accuracy (2.9 ml variance from study personnel measurements), fewer missed recordings (8.6%) and consistent real-time measurement (out of 187 hourly measurements, 6 were partial).
With real-time data integration and automated alerts, digital measurement and monitoring allows nurses to focus on other imperative care, while still benefiting from insights that allow rapid, proactive intervention if a patient experiences a decrease in urine output.
Improved decision-making, enhanced care management and reduced infection risk via automated urine output measurements means that organizations are also poised to improve regulatory compliance, boost financial performance and protect their reputation. Outcomes related to UO and UTI have a direct impact on several measures, including:
- The CMS AKI eCQM— Within the framework of value-based care delivery, this quality measure assesses the incidence of Stage 2 acute kidney injury (AKI) and higher as a hospital harm, directly impacting reimbursement.
- The Hospital-Acquired Condition (HAC) Reduction Program— CMS tracks events including CAUTI and reduces payments to hospitals that perform poorly.
- The CMS Hospital Readmissions Reduction Program (HRRP)— Missed events and poor outcomes equal higher readmissions, and this program levies financial penalties for institutions who have excessive readmissions.
Adopting Digital Urine Output Measurement is Essential
By adopting automated electronic urine measurement and monitoring, healthcare organizations can reduce excess costs, improve care outcomes, and lower the risk of complications such as CAUTI, sepsis and AKI. This technology also helps prevent avoidable readmissions and eliminates the hidden costs and inefficiencies of manual measurement. For leaders focused on boosting operational efficiency, supporting staff, and achieving stronger clinical and financial results, exploring advanced urine measurement solutions is a practical next step toward better care.
References
- https://www.nature.com/articles/s41598-021-97026-8.pdf
- https://link.springer.com/article/10.1007/s10877-023-00991-w
- https://pubmed.ncbi.nlm.nih.gov/34869431/
- https://www.nature.com/articles/s41598-024-79533-6
- https://psmf.org/aebp-publications/catheter-associated-urinary-tract-infections/
- https://www.nature.com/articles/s41598-021-97026-8.pdf
- https://pmc.ncbi.nlm.nih.gov/articles/PMC4516244/
- https://www.nursingworld.org/content-hub/resources/nursing-leadership/why-nurses-quit/
- https://pubmed.ncbi.nlm.nih.gov/28527880/
- https://pmc.ncbi.nlm.nih.gov/articles/PMC3925530/
- https://www.nature.com/articles/s41598-021-97026-8.pdf
