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An Emergency Department’s Adherence to Guidelines for the Evaluation and Management of Nephrolithiasis
Jessica Jackson, Karen Wheeler, Jack Farhi, Richard Rueb, Chris Thomas, Noah Schenkman
University of Virginia, Charlottesville, VA

Introduction:Recent publications showed significant variation in national practice patterns for the management of nephrolithiasis in the emergency department (ED). The American Urological Association (AUA) and the American Academy of Family Physicians (AAFP) have published guidelines for nephrolithiasis. This study assessed a single institution’s ED adherence to these guidelines.
Methods: A retrospective chart review of patients diagnosed with nephrolithiasis was performed at a single institution’s ED from 2013 to 2015.
Results: 296 patients were diagnosed with nephrolithiasis. Results summarized in Table 1 and Figure 1.
First Time Stone FormersRecurrent Stone FormersTotal % of
296 patients
Percent of Total Patients Diagnosed with Nephrolithiasis54.7%45.3%
Diagnostic Evaluation
No Urine Analysis or Urine Culture6.2%6.0%6%
Urine Analysis Only60.9%51.5%57%
Urine Analysis and Urine Culture32.9%42.5%37%
No Basic Metabolic Panel9.9%12.7%11%
Imaging
KUB Only4.3%9.7%7%
US Only6.2%23.1%14%
KUB and US Only8.7%9.7%9%
CT Abd/Pelvis without Contrast67.1%53.0%60%
CT Abd/Pelvis with Contrast13.7%4.5%9%
Management
Discharged Home95.0%94.0%94%
Admitted5.0%6.0%6%
No Narcotics or Tamsulosin Prescribed20.5%20.9%21%
Prescribed Narcotics Only31.1%31.3%31%
Prescribed Narcotics and Tamsulosin41.6%41.0%41%
Prescribed Antibiotics11.8%18.7%15%
Prescribed Antibiotics without Urine Culture42.1%20.0%21%


Conclusion: Guideline driven evaluation for nephrolithiasis would warrant inclusion of urine analysis and urine culture more frequently in the ED. KUB is an underused modality in this study as both guidelines advocate use for recurrent stone formers. Although, variations in imaging modality for patients at the extremes of age may be due to a wider differential, tighter compliance to non-contrast CT use in the middle aged cohort may represent an area for improvement. Finally MET should be prescribed to a majority of patients with acute renal colic and antibiotics should be given only after urine culture obtained. Implementation of ED specific protocols would provide more effective evaluation and management of renal colic.


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