1. No category

REQUESTING AND PERFORMING OF NON-CONTRAST
CT IN PATIENTS WITH RENAL/URETERIC COLIC
AMIN H, CHANG RTM, ADAMSON A
Standard
•  BAUS guideline (2012, due rev. 2015) “Acute Management of First
Presentation Renal/Ureteric Lithiasis” states Non-Contrast CT KUB should
be obtained within 24 hours of acute first presentation to confirm diagnosis
and plan treatment.
•  Standard of 100% set for this audit.
Aims
•  To audit whether BAUS guidelines are being met with regards to obtaining
NCCT within 24 hours of first acute presentation.
•  To highlight possible targets that may reduce time to NCCT.
Method
•  Prospectively collected patient details with proven renal tract calculi
(admitted through A&E only) over a 6-month period (n=39).
•  39 patients included in sample.
•  Retrospectively analysed data.
•  Data collected from hospital computer programs (PACS, ICE, ED
admissions log).
Result
Average Time
Range
Time of Week
Avg. Time to Reported CT
Request
8h34m
9m-52h41m
Weekdays
16h03m
Reported Scan
16h27m
1h27m-72h27m
Weekend
24h52m
•  4/8 (50%) admitted over weekend waited over 24hrs to reported NCCT
(admitted fri/sat).
•  82% pts (32/39) had CT KUB as first
imaging modality.
•  Identifiable reason for not having CT
KUB:
1. Other suspected pathology (2x CT AP
for ?appdx and ?diverticulitis)
2. Pain + Frank Haematuria (pt had CT IVU).
3. Previous iatrogenic ureteric injury (CT
IVU).
•  79% pts (31/39) had confirmatory
imaging within 24 hours of presentation.
Reasons for Delay
•  3/8 pts admitted over w/e had scan requested within 8 hours but waited until Monday for NCCT.
•  1/8 pts admitted over w/e waited over 48 hours for request (SB Consultant but scan not requested by junior w/e cover).
•  3 pts had scan requested promptly but waited over 24hours for performance. Cause unknown (?scan not discussed ?other
scans prioritised over NCCT).
Discussion
•  Wide range of time to request following acute presentation
(9m-52h41m).
•  Longer time to reported scan over weekend.
•  Time from request to scan avg. 7 hours (weekdays).
•  Time from scan to report average 30min (consistent).
•  Mixed confidence among junior doctors to acr on CT prior to report.
•  3 cases of NCCT requested by ED Consultant very promptly
(9m-45m). Scans performed within 4 hours.
•  Possible target to reduce time to NCCT?
Suggestion for improvement
•  NCCT to be performed 7 days a week?
•  Suspected renal colic to be reviewed by senior ED Doctor.
•  ED to request and discuss NCCT prior to surgical referral.
•  Should BAUS guidelines state reported NCCT?
•  Incorporate BAUS guidelines (opposite) into ED everyday practice.
Further study:
•  Look at all patients admitted with ?colic (increase cohort size).
GUIDELINES FOR ACUTE MANAGEMENT OF FIRST
PRESENTATION OF RENAL / URETERIC LITHIASIS
(Excluding Pregnancy)
ACUTE / NON ACUTE
History / Examination:
N.B. Exclude Abdominal Aortic Aneurysm, UTI.
Initial Investigations:
KUB X-ray - 60% stones visible on plain film.
Urinalysis – presence of dipstick / microscopic haematuria
supportive of clinical diagnosis in presence
of inconclusive KUB X-ray. Presence of
nitrites suggestive of UTI.
FBC,U&E – mandatory especially in presence of pyrexia and / or
single functioning kidney.
Non - Contrast CT (NCCT)
Imaging:
Within 24 hours if acute presentation and to confirm diagnosis
For planning of treatment if stone confirmed on KUB.
>99% stone identification on NCCT.
ACUTE MANAGEMENT
Analgesia:
NSAID i.e. parenteral / oral Diclofenac (Voltarol) for acute presentation,
oral for non-acute.
Unless contraindicated by PMH e.g. gastritis / peptic ulcer, renal impairment.
Opiates + anti-emetic.
Alpha adrenergic blockers may aid ureteric stone passage.
Serum Calcium / Urate: Mandatory basic metabolic studies.