Standardization of the management of pediatric urolithiasis in the emergency department

Abstract

The incidence of urolithiasis in the pediatric population is rising and medical expulsive therapy (MET) using alpha-adrenergic antagonists has been found to be effective in aiding in the passage of ureteral stones in children. A prior review of patients presenting to our quaternary children's hospital with urolithiasis found only 54% were prescribed MET and these patients had increased rates of spontaneous stone passage. Thus, an ED urolithiasis management protocol was created to standardize evaluation and care of children with suspected urolithiasis. To compare management of children with urolithiasis presenting to the ED before and after urolithiasis management protocol implementation. This is a retrospective review of patients with urolithiasis who presented to our children's ED from 2011 to 2022. The primary outcome was rate of MET prescribing before and after pathway implementation in July 2017, thus the pre-implementation group comprises patients who presented to the ED from July 2011 to July 2017, and the post-protocol group includes those who presented from August 2017 to April 2022. Secondary outcomes included CT utilization in the ED, surgical intervention rate, proportion with spontaneous stone passage, and frequency of urology consultation. Two-sample t-test and Fisher's exact test were used to compare the outcomes of interest before and after protocol implementation. Of 337 patients who presented to the ED after protocol implementation, 120 met inclusion criteria. When comparing outcomes before and after implementation of the protocol, there was significantly decreased use of CT scans (79% vs 50%, p<0.0001) and increased prescribing of MET (54% vs 82%, p<0.0001). There was a significant decrease in opioids prescribed (44% vs 26.7%, p=0.0040), and an increased rate of spontaneous stone passage (34% vs 46%, p=0.0483). Lastly, there was a significant reduction in the rate of surgery for stone management after the implementation of protocol (35% vs 17%, p=0.0020) DISCUSSION: As the ED is the primary site of presentation for many children with urolithiasis, standardization of evaluation and management provides an opportunity to improve outcomes in this population. We found that implementation of an ED urolithiasis management protocol was associated with decreased use of CT scans, decreased opioid prescribing, increased spontaneous stone passage, and decreased rate of surgical management for children with ureteral stones. This study demonstrates the positive impact of standardizing care for children presenting to the ED with urolithiasis.