scholarly journals LO015: A multi-centered regional emergency department study of renal colic management using medical expulsion therapy

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S35-S35
Author(s):  
E. Bristow ◽  
A. Kinnaird ◽  
T. Schuler ◽  
P. Pang ◽  
S. Couperthwaite ◽  
...  
Keyword(s):  
Emergency Department ◽  
Renal Colic ◽  
Practice Variation ◽  
Plain Radiographs ◽  
Medical Chart Review ◽  
Data Collection Process ◽  
Order Sets ◽  
Resident Involvement ◽  
Review Study ◽  
Initial Imaging

Introduction: Patients with renal colic present frequently to the emergency department (ED). Existing literature suggests management with medical expulsion therapy (MET) may improve outcomes, especially for those with stones > 5 mm in size. This study evaluates the use of MET in the management of adult patients seen in regional EDs with a diagnosis of renal colic. Methods: A multi-centered medical chart review study was conducted in seven Edmonton-Zone EDs. Approximately 100 cases from each site were randomly selected from administrative data from the 2014 calendar year, no repeat cases were permitted. Using a standardized data collection process and trained research assistance, data were abstracted from medical charts. Medians and inter-quartile ranges (IQR), proportions, and odds ratios (OR) with 95% confidence intervals (CIs) are reported. Results: Overall, 656 patient charts were included in the review; median age was 46 years (IQR: 35, 46) and 249 (38%) were female. Few (10%) arrived by ambulance or were on MET therapy at presentation; however, many (51%) reported a previous episode of renal colic. Many (191 {29%}) received no initial ED imaging; CT (236 {36%}) was favoured over ultrasound (39 {6%}) for initial imaging, either alone or with plain radiographs (8%). Plain radiographs were frequently ordered (204 {31%}). Only 198 (31%) of charts contained documentation of the use of MET at discharge and the median duration of therapy was 10 days (IQR: 7, 14). Initiation of MET therapy did not vary based on older age (OR = 0.8; 95% CI: 0.57, 1.14); sex (OR = 0.9; 95% CI: 0.67, 1.33); resident involvement (OR = 1.1; 95% CI: 0.63, 2.0); presentation to an academic centre (OR = 1.4; 95% CI: 0.96, 1.95) or stone size (OR = 1.3; 95% CI: 0.76, 2.06). Conclusion: Management of renal colic with MET is uncommon in this region and practice variation appears driven by physician preference rather than evidence. Practice guidelines with standardized order sets are urgently needed to improve care.

scholarly journals MP25: Implementation of pain order sets to decrease the time to analgesics in the emergency department: a quality improvement initiative in progress

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S51
Author(s):  
K. Akilan ◽  
V. Teo ◽  
D. Hefferon ◽  
A. Verma
Keyword(s):  
Emergency Department ◽  
Median Time ◽  
Acute Pain ◽  
Renal Colic ◽  
Waiting Times ◽  
Retrospective Chart Review ◽  
Quality Improvement Initiative ◽  
Chart Audit ◽  
Order Sets ◽  
Order Set

Background: Acute pain is a common presentation in the Emergency Department (ED) and inadequacy in its treatment can lengthen stay. Earlier analgesia use and discharge has been associated with positive patient experiences and improved pain management. Validated ‘fast-track pathways’ to aid physician decision making in analgesic administration is associated with decreased waiting times in renal colic diagnoses. Aim Statement: Our aim was to create an order set, for an approach to patients with acute pain, to reduce median time from point of triage to analgesia. We sought to reduce median time by 15 minutes, for ED patients with renal colic in the three months after implementation as compared to three months before. Measures & Design: We used a literature review and comparison to existing order sets at other EDs to design our draft. We focused our evaluation on patients with renal colic. We underwent multiple revisions based on stakeholder feedback and educated both physician and nursing teams about the order set. The utilization, however, was at physician discretion. We implemented the order set on March 30, 2017. After three months, an electronic retrospective chart review identified patients with a final renal colic diagnosis. For each patient, we captured triage time using electronic records and time to analgesia with the medication cart. Utilization of order sets was confirmed via manual chart audit. Evaluation/Results: A run chart showed worsening times after the intervention. Median time to analgesia in minutes, 3 months prior (n = 90) and post (n = 93) intervention, increased from 228 to 310 minutes, although the range was very large. Chart audits demonstrated a considerably low uptake of the order set with a small gradual increase from 0% to 20% over the 3-month period. Discussion/Impact: There was insufficient uptake of the Acute Pain order set preventing impact on time to analgesia. Changes in occupancy likely contributed to the worsening times. There was an increase in utilization over the 3-month period and could be due to increased awareness. This demonstrates that interventions require more than implementation to be effective. Difficulties in implementation were due to the document not being readily available. We have organized the nursing staff to attach order sets onto charts based on triage assessment and will re-assess with another PDSA cycle after this intervention.

scholarly journals Reported and unreported potentially important incidental findings in urgent nonenhanced abdominal CT for renal colic

2021 ◽  
Author(s):  
Elena Belloni ◽  
Stefania Tentoni ◽  
Ilaria Fiorina ◽  
Chandra Bortolotto ◽  
Olivia Bottinelli ◽  
...  
Keyword(s):  
Emergency Department ◽  
Health Status ◽  
Pleural Effusion ◽  
Incidental Findings ◽  
Renal Colic ◽  
Legal Issues ◽  
Abdominal Ct ◽  
Significant Difference ◽  
Original Report ◽  
The Difference

PURPOSE: To retrospectively evaluate the prevalence of reported and unreported potentially important incidental findings in consecutive nonenhanced abdominal CTs performed specifically for renal colic in the urgent setting. METHOD: One radiologist, blinded to the finalized report, retrospectively re-evaluated nonenhanced abdominal CTs performed from January through December 2017 on adult patients from the Emergency Department with the specific request of urgent evaluation for renal colic, searching for potentially important incidental findings. RESULTS: The CTs of 312 patients were included in the study. Thirty-eight findings were reported in 38 different CTs, whereas the re-evaluation added 47 unreported findings in 47 different CTs, adding to total of 85 findings (27%). The difference in the proportion of reported and unreported potentially important incidental findings between the original report and re-evaluation was significant (P<.001). No significant difference was found between the age of patients with and without reported findings. The proportion of potentially important findings did not vary significantly among the three shifts neither in the original report nor in the re-evaluation. The most frequent findings, both reported and unreported, were pleural effusion, lymphadenopaties and liver nodules. CONCLUSIONS: Potentially important additional findings are frequently present in urgent nonenhanced abdominal CTs performed for renal colic, and many are not described in the finalized reports. Radiologists should take care not to under report potentially important incidental findings even in the urgent setting because of the possible consequences on the patient’s health status and in order to avoid legal issues, while satisfying the need for timely and efficient reporting.

Determinants of pyelonephritis onset in patients with obstructive urolithiasis

2021 ◽  
pp. 039156032110352
Author(s):  
Georges Abi Tayeh ◽  
Ali Safa ◽  
Julien Sarkis ◽  
Marwan Alkassis ◽  
Nour Khalil ◽  
...  
Keyword(s):  
Emergency Department ◽  
Renal Colic ◽  
Demographic Data ◽  
Vital Signs ◽  
Kidney Injury ◽  
Stone Size ◽  
Positive Urine ◽  
Life Threatening ◽  
Fat Stranding ◽  
Obstructive Pyelonephritis

Background: Acute obstructive pyelonephritis due to urolithiasis represents a medico-surgical emergency that can lead to life-threatening complications. There are still no established factors that reliably predict progression toward acute pyelonephritis in patients presenting with a simple renal colic. Objective: To investigate clinical and paraclinical factors that are associated with the onset of acute obstructive pyelonephritis. Methods: Patients presenting to the emergency department for renal colic with obstructive urolithiasis on imaging were enrolled in the study. Demographic data, vital signs, medical comorbidities, blood test results, urinalysis, and radiological findings were recorded. Obstructive pyelonephritis was defined by the presence of two or more of the following criteria: fever, flank pain or costovertebral angle tenderness, and a positive urine culture. Results: Seventeen patients out of 120 presenting with renal colic, were diagnosed with acute obstructive pyelonephritis (14%). Parameters that were associated with the onset of obstructive pyelonephritis were: diabetes ( p = 0.03), elevated CRP ( p = 0.01), stone size (>5 mm) ( p = 0.03), dilatation of renal pelvis ( p = 0.01), peri-renal fat stranding ( p = 0.02), and positive nitrites on urinalysis ( p < 0.01). Hyperleukocytosis, acute kidney injury, multiple stones, pyuria (>10/mm3), hypertension, and were not associated with the onset of obstructive pyelonephritis. Conclusion: This study showed that known diabetic status, elevated CRP, positive urine nitrites, stone size (>5 mm), pyelic dilatation, and peri-renal fat stranding were associated with the onset of pyelonephritis in patients presenting to the emergency department with obstructive urolithiasis.

scholarly journals Renal colic, where is it headed? An observational study

2016 ◽  
Vol 88 (1) ◽  
pp. 7 ◽  
Author(s):  
Paolo Beltrami ◽  
Andrea Guttilla ◽  
Lorenzo Ruggera ◽  
Patrizia Bernich ◽  
Filiberto Zattoni
Keyword(s):  
Emergency Department ◽  
Urinary Tract ◽  
Observational Study ◽  
Clinical Management ◽  
Renal Colic ◽  
Ureteral Stone ◽  
Ureteral Calculi ◽  
Ureteral Calculus ◽  
Spontaneous Expulsion ◽  
Pain Symptoms

Aim: In the last thirty years, the treatment for renal and ureteral calculi has undergone profound variations. The objective of this study has been to evaluate the existence of parameters which can affect the spontaneous expulsion of a symptomatic ureteral stone in a reasonably brief period of time and to identify whether certain parameters such as sex, age, the location and dimension of the stone, the presence of dilation in the urinary tract together with the administered therapy, can be used for a correct clinical management of the patient. Methods: In a period of 9 months, 486 cases of renal colic were registered at emergency department. Results: The cases of renal colic due to ureteral calculus were 188 (38.7%). The patients’ charts, complete of all data and therefore, valid for this research, resulted to be 120 (64%). In the presence of a symptomatic ureteral stone, the correct approach must first of all, focalize on the dimension of the calculus itself; less importance instead, is given to the location, as reported in other studies, the presence of hydroureteronephrosis, sex and the side. Conclusion: In the cases when the pain symptoms cannot be solved by means of the administration of analgesics, it is then reasonable to take into consideration an immediate endourological treatment. If the pain symptoms are promptly solved, an attentive wait of 4 weeks should be considered reasonable in order to allow spontaneous expulsion of the calculus.

Impact of a Health Information Technology–Enabled Appropriate Use Criterion on Utilization of Emergency Department CT for Renal Colic

2019 ◽  
Vol 212 (1) ◽  
pp. 142-145 ◽  
Author(s):  
Ali S. Raja ◽  
Sarvenaz Pourjabbar ◽  
Ivan K. Ip ◽  
Christopher W. Baugh ◽  
Aaron D. Sodickson ◽  
...  
Keyword(s):  
Emergency Department ◽  
Information Technology ◽  
Health Information Technology ◽  
Health Information ◽  
Renal Colic ◽  
Appropriate Use

Practice Variation in Emergency Department Management of Children With Sickle Cell Disease Who Present With Fever

2018 ◽  
Vol 34 (8) ◽  
pp. 574-577 ◽  
Author(s):  
Katherine Eisenbrown ◽  
Angela M. Ellison ◽  
Mark Nimmer ◽  
Oluwakemi Badaki-Makun ◽  
David C. Brousseau
Keyword(s):  
Emergency Department ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Practice Variation ◽  
Cell Disease ◽  
Emergency Department Management ◽  
Department Management

scholarly journals MP10: Does arrival pain severity predict stone characteristics or short-term outcomes in emergency department patients with acute renal colic?

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S45-S46
Author(s):  
G. Splinter ◽  
K. Gourlay ◽  
J. Hayward ◽  
G. Innes
Keyword(s):  
Emergency Department ◽  
Severe Pain ◽  
Renal Colic ◽  
Pain Severity ◽  
Secondary Outcome ◽  
Advanced Imaging ◽  
Stone Size ◽  
Pain Scores ◽  
Imaging Results ◽  
Stone Characteristics

Introduction: Renal colic is among the most painful conditions that patients experience. The main outcome determinants for patients with renal colic are stone size, location and hydronephrosis; however, little is known about the association of pain with these parameters. Our objective was to determine whether more severe pain is associated with larger stones, more proximal stones or more severe hydronephrosis, findings that might suggest the need for advanced imaging, hospitalization or early intervention. Methods: We used administrative data and structured chart review to study all adult emergency department (ED) patients in two cities with a renal colic diagnosis over one-year. Patients with missing imaging results or pain scores were excluded. Triage nurses recorded numeric rating scale (NRS) pain scores on arrival. We stratified patients into mild (NRS <4), moderate (NRS 4-7) and severe (NRS 8-10) pain groups, as per CTAS guidelines. Stone size (mm) and location (proximal, middle, distal ureter, or renal) were abstracted from imaging reports, while index admissions were determined from hospital discharge abstracts. We used multivariable linear regression to determine the association of arrival pain with stone characteristics and hydronephrosis severity (primary outcome), and we used multivariable logistic regression to determine the association of pain with index hospitalization (secondary outcome). We also performed a stratified analysis looking at ureteral vs. kidney (intrarenal) stones. Results: We studied 1053 patients, 66% male, with a mean age of 48 years. After controlling for patient and disease characteristics, we found no significant association between pain severity and stone size (b=−0.0004; 95%CI = -0.0015, 0.0008) or stone location (b = 0.0045; 95%CI: -0.020, 0.029). Nor did we find an association between pain and hydronephrosis severity (b = 0.016; 95%CI: -0.053, 0.022, p = 0.418). Stratified analyses using a Bonferroni correction for multiple comparisons revealed the same absence of associations in the kidney and ureteral stone subgroups. Arrival pain did not predict index admission (OR = 0.82, 95% CI: 0.59, 1.16). Conclusion: Arrival pain scores are not associated with stone size, stone location or hydronephrosis severity, and do not predict index visit hospitalization in ED patients with renal colic. Severe pain should motivate efforts to minimize treatment delays, but do not suggest the need to modify advanced imaging or admission decisions.

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