AUA QI Summit 2017: Follow-up After an ED Visit for Acute Renal Colic/Toolkit from AUA Imaging Stewardship Workgroup

Linthicum, Maryland (UroToday.com) Drs. Sternberg, Venkatesh, Remer, and Smith-Bindman provided an excellent panel for the working lunch discussion of the Toolkit from the AUA Imaging Stewardship Workgroup at today’s AUA Quality Improvement Summit. Dr. Sternberg also provided a few introductory slides to transition to an overview of the AUA Toolkit, discussing follow-up after an emergency department visit for the patient with acute renal colic. According to Dr. Sternberg, there are several unknowns relating to patients being discharged from the emergency department (ED), including (i) What instructions and educational information should patients be given on discharge from the ED after evaluation for suspected renal colic? (ii) Which patients should see a urologist in outpatient follow-up? and (iii) For those patients who see a urologist, who needs additional imaging and how do we choose what to order?

There are several basic discharge instructions that should absolutely be provided to the patient upon leaving the ED after a visit for renal colic:

Know when (signs/symptoms) to return to the ED or seek medical attention
Strain urine to identify definitive stone passage
Acquire your images if at an outside hospital with plans for referral
Do not be concerned about prevention measures at this point in time, as this scan be addressed after the stone episode has resolved
Know that your stone may still be present even if the pain has resolved

Patients who may benefit from seeing a urologist include those who are unsure of stone passage, for persistent symptoms, recurrent stone formers or significant risk factors for future stone development (for a metabolic evaluation and prevention discussion), and if patients are interested and/or want more information. The goals for the decision to get follow-up imaging are to ensure the stone is gone, to make sure there is no obstruction or hydronephrosis, and to do so without a CT scan whenever feasible. Several factors to consider according to Dr. Sternberg are (i) has the stone definitively passed? (ii) Was there a definitive diagnosis in the ED (ie. CT imaging)? (iii) What was the stone size and location? (iv) Was there hydronephrosis? and (v) Was the identified stone radio-opaque?

The AUA Resource Toolkit for Stewardship of Imaging highlights several important topics for imaging stewardship with numerous hyperlinks to other great resources. Many of these topics were reviewed at today’s Quality Improvement Summit, including (i) implementation of low-dose renal colic protocol CT imaging, (ii) reducing potentially avoidable staging imaging in lower risk prostate cancer patients, (iii) clinical decision support for advanced imaging (R-SCAN), (iv) development and implementation of prostate MRI programs, and (v) the American College of Radiology programs to support imaging stewardship. Other important initiatives on the website not discussed at the QI Summit today include implementation of ultrasound in urology practice and the imaging stewardship QI project library. Importantly, the AUA has partnered with the American Institute of Ultrasound in Medicine to develop accreditation programs for practices in order to demonstrate performance of high quality imaging. This section also highlights several documents, including a practice guideline for performing ultrasonography in the urology practice, standards for ultrasonography accreditation, and training guidelines for performing ultrasound examinations in clinical practice. The imaging stewardship QI project library provides additional resources regarding multiple CT scenarios, a framework for conducting a QI project in urology practice, a clinical pathway for acute nephrolithiasis for pediatric patients, and a document discussing diagnostic efficacy and radiation modulation of imaging for renal cell carcinoma.

The AUA Resource Toolkit for Stewardship of Imaging can be found at:
http://www.auanet.org/practice-resources/patient-safety-and-quality-of-care/quality-improvement-summit/resource-toolkit-for-stewardship-of-imaging

Speaker(s): Kevan Sternberg, University of Vermont, Burlington, VT, USA; Arjun Venkatesh, Yale University, New Haven, CT, USA; Erick Remer, Cleveland Clinic Foundation, Cleveland, OH, USA; Rebecca Smith-Bindman, University of California-San Francisco, San Francisco, CA, USA

Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, Twitter: @zklaassen_md, at the AUA Quality Improvement Summit - October 21, 2017- Linthicum, Maryland

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