Implementation of a Hospital-Wide Protocol Reduces Time to Decompression and Length of Stay in Patients with Stone-Related Obstructive Pyelonephritis with Sepsis.

Abstract

Introduction and Objectives: Patients with obstructive pyelonephritis (OPN) require urgent decompression through retrograde ureteral stent (RUS) or percutaneous nephrostomy (PCN). In 2016, the urology and interventional radiology (IR) departments at our institution established a protocol for patients with OPN with sepsis. The primary objectives were to assess this protocol's impact on improving time to decompression and whether more expedient decompression decreased length of stay (LOS). Secondarily, we assessed the impact of the protocol and clinical factors on receipt of PCN over RUS. Materials and Methods: One hundred forty-seven patients at our institution who underwent PCN from 2012 to 2017 or stent from 2014 to 2017 for stone-related OPN meeting sepsis criteria were retrospectively reviewed. Univariate descriptive statistics compared patient characteristics and outcomes between RUS and PCN pre- and postprotocol implementation. Multivariable logistic regression assessed predictors of decompression with PCN (vs RUS) and of prolonged LOS (pLOS; >5 days). Results: Utilization of PCN increased after implementation of the protocol from 4 to 14 PCN/year with a decrease in the median time from urologic consultation to PCN from 9.2 to 4.3 hours (p = 0.001) with overall median time to decompression decreasing from 5.4 to 4.5 hours (p = 0.017). Predictors of undergoing PCN (vs RUS) included increasing comorbidity and ≥1 cm obstructing stone. On multivariable analysis controlling for comorbidity, leukocytosis, and septic shock, increasing hours to decompression increased odds of pLOS (1.08, 95% confidence interval 1.02-1.15, p = 0.014). Conclusions: After implementing our OPN with sepsis protocol, time to decompression decreased with dramatic improvement in time to PCN. Quicker decompression was independently associated with reduced odds of prolonged hospital stay. A well-designed protocol engages both urology and IR in the management of these acutely ill patients and improves outcomes.