Asploro Journal of Biomedical and Clinical Case Reports

Asploro Journal of Biomedical and Clinical Case Reports

Riichi Ohfuru¹, Hiroshi Bando^1iD*, Nobuo Sakata^2,3
1Hakuai Memorial Hospital, Heisei Medical Welfare (HMW) Group, Tokushima, Japan
²Heisei Medical Welfare Research Group Institute, Tokyo, Japan
³Setagaya Memorial Hospital, Tokyo, Japan

Corresponding Author: Hiroshi Bando ^{ORCID iD}
Address: Hakuai Memorial Hospital, Heisei Medical Welfare (HMW) Group, Tokushima, Japan.
Received date: 30 November 2024; Accepted date: 23 December 2024; Published date: 30 December 2024

Citation: Ohfuru R, Bando H, Sakata N. Possible improvement of Urinary Tract Infection (UTI) by Gatch up positioning in Long-term Acute Care (LTAC). Asp Biomed Clin Case Rep. 2024 Dec 30;8(1):30-33.

Copyright © 2024 Ohfuru R, Bando H, Sakata N. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium provided the original work is properly cited.

Keywords: Long-Term Acute Care, Urinary Tract Infection, Gatch-Up 45-Degree Positioning, Post-Void Residual, Heisei Medical Welfare

Abbreviations: LTAC – Long-Term Acute Care; UTI – Urinary Tract Infection; PVR – Post-Void Residual; HMW – Heisei Medical Welfare

Abstract

Adequate medical practice has been emphasized for the increasing elderly population. The authors have long provided Long-Term Acute Care (LTAC). Concerning clinical problems related to urinary tract infection (UTI), we propose the Gatch-up 45-degree positioning as a preventive measure for UTI. The case involves a 68-year-old female who underwent the Gatch-up procedure for 1 hour, twice a day, over a period of 1 month. Post-void residual (PVR) urine volume was measured and compared between the previous month and the intervention period. The average PVR significantly decreased from 245 mL to 80 mL (p < 0.05), representing a 67.3% reduction. This suggests further indications and potential future development for this procedure.

Introduction

For several decades, global diseases have shifted from infectious diseases to lifestyle-related diseases [1]. This tendency has been prevalent in developed countries, and adequate treatment for chronic diseases has become an important issue [2]. In the medical practice of long-term care, the frequent occurrence of urinary tract infection (UTI) attributed to lifestyle-related diseases has been a significant clinical problem.

The main cause of these seems to be dysfunction related to urination. Concerning urinary symptoms, women are more likely to experience UTI than men [3]. Among these, the four most common problems are urinary incontinence, urinary retention, residual urine, and overactive bladder. Furthermore, post-void residual (PVR) volume has been involved in the problem, associated with functional decline with aging [4].

During our Long-term Acute Care (LTAC) services to elderly patients, UTI has been particularly problematic in patients with multiple comorbidities, including neurological disorders. The management of elevated PVR becomes more challenging in these patients, where traditional interventions may increase the risk of complications.

The authors considered the possibility of changing the patient’s position to improve urinary problems. While the effects of complete supine and standing positions have been investigated [5], there is limited research on intermediate positions that might be more practical for patients with mobility restrictions. We suggest that “Gatch-up 45-degree positioning” may improve clinical problems. The primary outcome of this study was to report the impact of Gatch-up 45-degree positioning on reducing PVR volume and preventing UTI in elderly patients undergoing LTAC.

Case Presentation and Methods

For history and physicals, the subject is a 68-year-old female. Medical problems include multiple system atrophy, type 2 diabetes (T2D), mild cognitive impairment (MCI), gastrostomy status, and urinary problems. She had been hospitalized for 5 years. At present, the patient has not shown apparent changes in the chest, lungs, heart, abdomen, or neurological findings.

As to some exams, chest X-ray showed no acute changes, and the electrocardiogram was within normal limits. Blood chemistry showed T-P 6.6 g/dL, Alb 3.6 g/dL, AST (GOT) 12 U/L, ALT (GPT) 10 U/L, BUN 19.3 mg/dL, Cre 0.77 mg/dL, T-Ch 127 mg/dL, LDL-C 58 mg/dL, Gluc 154 mg/dL, HbA1c 6.4 %, Hb 12.4 g/dL, WBC 7600 /μL, and CRP 0.06 mg/dL.

To evaluate the effect of Gatch-up positioning on PVR, we conducted a two-month observational study in February and March 2024. During the first month (control period), the patient received standard care with body positioning changed for left/right aside every 2 hours. In the second month (intervention period), we added Gatch-up positioning at 45 degrees for 60 minutes twice daily (9:00 and 15:00) to the standard care regimen (Fig-1A and Fig-1B).

Fig-1:

PVR volume was measured by catheterization at 10 a.m. twice weekly throughout the study period. Self-voiding volume was also recorded. The changes in PVR and self-voiding volumes between the control and intervention periods were compared using a paired t-test, with P < 0.05 considered statistically significant.

Results

PVR urine volume was measured in the current case, checked eight times each in February and March, and the data were compared. Self-urination was 431 mL and 521 mL in the 2 months, respectively, which was not a significant change. In contrast, PVR urine volume decreased significantly from 245 mL to 80 mL (P < 0.05), indicating a 67.3% remarkable decrease (Fig-2).

Fig-2: Changes in PVR and self-urination for 2 months

Ethical Considerations

This study was approved by the ethics committee in the hospital. The participants were informed in writing and through verbal explanation about the purpose, method, and voluntary participation. In addition, it was explained that there would be no disadvantages for refusal and that their personal information would be protected. Written consent was obtained from the case. To make the medical presentation, written consent was also obtained from the family, with consideration given to protecting the patient’s personal information and privacy.

Discussion

This research aimed to investigate the clinical efficacy of Gatch-up 45-degree positioning for patients with UTI problems. By changing the posture, the bed can be adjusted to the adequate angle [6]. The obtained results showed a remarkable decrease in PVR, associated with significant changes (P < 0.05) between the control and intervention periods. With the concept of Long-term Acute Care (LTAC) services for the elderly, we can possibly apply these measures to decrease PVR, protect against UTI, and improve their clinical progress.

The effect of body positioning on PVR has been previously investigated, though studies specifically examining intermediate angles are scarce. Riehmann et al. [5] compared PVR between standing (90-degree) and supine (0-degree) positions, finding significant differences, particularly in nursing home residents (standing: 60.5 mL vs. lying: 84.8 mL, P < 0.05). Our finding with the 45-degree position builds upon these results, suggesting that an intermediate angle might provide similar benefits while being more practical for patients with limited mobility.

The relationship between PVR and urinary symptoms is complex. While increased PVR is often associated with an incomplete emptying sensation, studies using the International Consultation on Incontinence Questionnaire have shown that this correlation is not absolute [7]. This suggests that objective PVR measurement, as performed in our study, is crucial for accurately assessing bladder emptying efficiency.

The clinical significance of elevated PVR in elderly patients is well-documented. A large-scale Japanese study of hospitalized patients demonstrated that UTI-related admissions increase dramatically with age [8], highlighting the importance of PVR management in this population. Studies of elderly inpatients have shown that elevated PVR (≥150 mL) is more common than expected, occurring in approximately 24% of cases [9]. Furthermore, research has demonstrated that patients over 75 years of age with neurological conditions are particularly susceptible to increased PVR (aOR 3.699) [10]. These findings support the clinical relevance of our positioning intervention, particularly for elderly patients with neurological disorders.

Several limitations should be acknowledged in this study. First, as a single case report, the generalizability of our findings is limited, and larger studies are needed to confirm the effectiveness of this positioning intervention. Second, our patient, like many elderly individuals, had multiple comorbidities, including multiple system atrophy and diabetes, which may have influenced the results.

In summary, this case report demonstrates that 45-degree Gatch-up positioning may be an effective intervention for reducing PVR volume in elderly patients receiving long-term care. Given that UTI-related readmissions remain a significant challenge in healthcare systems [11], simple and cost-effective interventions such as appropriate positioning could contribute to improved patient outcomes. These findings may serve as a foundation for future research investigating positioning strategies in the prevention of UTI among elderly patients receiving LTAC services.

Conflict of Interest

The authors have read and approved the final version of the manuscript. The authors have no conflicts of interest to declare.

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