19 Collaborative Application of Guidelines Changes Imaging Utilization and Impacts Length of Stay in Acute Renal Colic

Abstract

Applying guidelines to the management of acute renal colic in the emergency department (ED) provides an opportunity to improve resource utilization and clinical care for this patient population. We engaged in a collaborative effort across specialties within our academic institution to influence practice patterns in the ED through the formation of diagnostic and treatment algorithms that incorporated guidelines from multiple specialty societies and Choosing Wisely statements. We sought to investigate the changes in imaging utilization and ED length of stay (LOS) before and after the employment of these efforts. We conducted a before and after study following introduction of a renal colic order set and evaluation algorithm (Figure 1). A retrospective chart review was completed of patients diagnosed with nephrolithiasis in the ED at a single academic institution. Two reviewers were utilized to identify renal colic patients by searching final ED diagnosis. Individual patient encounters were subsequently analyzed for rates of imaging utilization and ED LOS. The pre-intervention and post-intervention cohorts included 456 and 174 patients respectively. The utilization of imaging and ED LOS are summarized in Table 1. There was a statistically significant decrease from 57% to 44% in CT utilization after the intervention. The average ED LOS for patients receiving bedside ultrasound was 199 minutes (95% CI 182 to 216 minutes), while average ED LOS for patients receiving CT imaging was 336 minutes (95% CI 316 to 356 minutes). Overall ED LOS for the pre-intervention cohort was 291 minutes (95% CI 277 to 305 minutes), while overall ED LOS for the post-intervention cohort was 269 minutes (95% CI 250 to 288 minutes). Our collaborative educational initiative and employment of evidence-based algorithms impacted imaging utilization in our ED patients with nephrolithiasis. The CT utilization rate was reduced in a statistically significant manner. Patients who had bedside US performed had a significantly decreased LOS, as compared with those receiving CT. The average overall ED LOS was lower in the post-protocol group, though this reduction did not reach statistical significance. Further study will involve the evaluation of impacts in clinical outcomes, as well as predictive factors for downstream urological intervention.View Large Image Figure ViewerDownload Hi-res image Download (PPT)