The aim of this study was to test the feasibility and acceptance of a urinary diary to assist with bladder self-management (SM) for long-term urinary catheter users prior to discharge from post-acute care. The greater risk of urinary tract infection (UTI) associated with urinary catheterization has been well documented and individuals dependent on long-term urinary catheterization are at high risk for UTI’s. Education and catheter training for this population is often initiated while in post-acute care. Because hospitalization time is often brief, it is important that patients develop strategies to prevent chronic complications such as UTI’s prior to discharge. The use of a urinary diary has been reported as an effective intervention for individuals to reduce UTI’s for persons within the community setting. These reported findings help to support diary use in the post-acute care setting.

This descriptive feasibility study was conducted at a rehabilitation center. Subjects requiring long-term catheterization for bladder management were recruited from a post-acute care unit.  Following informed consent, demographic and clinical data were collected via medical chart review and face to face interview. Subjects were then asked to complete a urinary diary and urinary journal for three consecutive days. Each participant received the urinary diary in two formats: paper and online. The urinary diary prompted the participants to document fluid intake, urine output, color of urine and to complete the urinary journal. Participants used the urinary journal to document more details about “what was noticed” and “what was going on or done about it”.  Staff and/or family caregivers could assist in diary completion. At the end of the 3 days, subjects completed a feasibility assessment and data were collected from the urinary diaries related to completeness.  Demographic, clinical, and urinary diary data were analyzed using descriptive statistics. Differences between the paper format of the urinary diary and the online format were examined for amount of recorded data. Comment data from the feasibility assessment were analyzed using simple coding by the principal investigator and faculty advisor.

Six subjects completed the feasibility study.  The sample included 3 men (50%) and 3 women (50%), mean age 43.7 years (range 23-66). Participants primary diagnoses were spinal cord injury (n=4), Multiple Sclerosis (n=1), and other (n=1). The spinal cord injured participants included cervical injuries (n=2) and thoracic injuries (n=2). Fifty percent of the participants (n=3) had no bladder sensation, one participant had partial sensation and two had full sensation. All participants plan of care for discharge included continued use of long-term urinary catheterization. Current bladder management methods included urethral urinary catheter (n=3), clean intermittent catheter (n=2) and a combination of clean intermittent and condom catheter (n=1).  
Comparing the amount of data from the online and paper formats of the urinary diary, we found that all participants (n=6) had complete entries in the paper format while only one participant had complete entries in the online format for the three consecutive days. Missing data for the online format were noted to increase for diary day two and three. One participant did not access the online diary after completing orientation. 
We found in the feasibility assessment that all participants agreed (n=3) or strongly agreed (n=3) that the urinary diary documentation was useful. Participants satisfaction with the urinary diary ranged from strongly agree (n=4), agree (n=1) and neutral (n=1). Fifty percent of the participants (n=3) were not able to enter any data online. Three participants reported to PI that they needed assistance from caregivers to enter data online and that caregivers were more likely to help with the urinary diary in the paper format. In the comments section participants reported that the paper format was “easily available,” “easier to use” and “easier and faster” to complete. A common theme identified within the comments section was that all participants reported increased awareness related to: fluid intake and types of fluid (n=5); urine and urine output (n=3); increased caregiver awareness (n=2); adjusting fluid intake based on diary information (n=4). Two participants reported being diagnosed with a UTI after completing day one of the urinary diary, and these participants reported being more aware of their own urine and the changes that occurred with a UTI. Many of the participants identified that the nursing staff had monitored their fluid intake and urinary output but did not consistently share that information with them.

Comparing the use of the online urinary diary and paper urinary diary revealed that subjects completed the paper format diary more accurately with less missing data due to ease of use. Participants who were not able to independently document online were able to complete the paper format of the urinary diary with assistance from healthcare staff and family caregivers. All the participants reported a decrease or lack of involvement in monitoring their own fluid intake and urinary output before beginning the study. Importantly participants commented that they had increased communication with hospital staff related to fluid intake and urine output during the time of the study. This was particularly true for individuals with lower levels of independence and using a urethral catheter who needed help with the urinary diary documentation.

To our knowledge, this is the first study assessing the feasibility of a self-management intervention in the post-acute care setting for long-term urinary catheter users. This study supports post-acute care use of a urinary diary as a self-management strategy to increase patient awareness and active participation in their bladder management. The use of the urinary diary in the paper format was identified as the preferred method based on findings related to the amount of recorded data and participants’ comments. Further research is needed to validate the use of a urinary diary during the patient transition time before and after discharging from post-acute care. It is possible that the use of a urinary diary may have a positive impact on patient knowledge, bladder management, and confidence leading to a conceivable decrease in complications.