Inpatient Urologic Consultation is not Necessary to Ensure Follow up in Patients with Uncomplicated Ureterolithiasis
Meredith C. Wasserman, MD MS, David W. Sobel, MD, Siddharth Marthi, BS, Edmond Godbout, PA, Chris Tucci, MS RN, Gyan Pareek, MD MS.
Brown University, Providence, RI.
BACKGROUND: The incidence of nephrolithiasis continues to increase and efficacious and safe emergency department management of acute renal colic is critical to patient outcomes. In 2016 we developed a novel Stone Observation Pathway (SOP) within our institution's Clinical Decision Unit (CDU) for patients with acute renal colic to have up to 24 hours of observation in order to control pain and treat associated symptoms with the goal of a safe discharge on MET without requiring hospital admission or urologic consultation. We found the overall follow-up rate was 54% prompting further investigation into factors that may affect this. METHODS: A retrospective review of all patients discharged from the CDU through the SOP for uncomplicated ureterolithiasis from January 2016 to November 2019 was conducted. Patient characteristics, axial imaging, and follow-up information were analyzed. Of note, it was assumed if a patient did not follow up with a urologist within our department, they did not follow up. Patients known to follow with an outside urologist were excluded from analysis. Inpatient urologic consultation was not required during observation, however the on-call urologist was alerted to patients with acute kidney injury, severe hydronephrosis or calculi >10mm. It was to the urologist's discretion if an inpatient consult was performed. Statistical analysis was performed using the chi-squared test. RESULTS: 141 patients with uncomplicated ureterolithiasis discharged from the CDU without intervention were included in the analysis. The mean stone size for all patients discharged was 4.1mm (SD +/- 1.9mm). Table 1 summarizes results and data analysis. 76 patients discharged from the CDU followed up with a urologist (54%). 28% of patients had a urologic consultation while under observation in the unit. Inpatient urologic consultation was not associated with follow-up rates (chi squared = 1.678, p<0.05). Outpatient follow-up with a urologist was, however, associated with a prior stone history as well as prior care established with a urologist (chi squared = 0.0064, p<0.05; chi squared = 0.0146, p<0.05, respectively). Of note, 54 of 76 patients (71%) who followed up had never seen a urologist before and 40 of 61 patients (66%) with a history of nephrolithiasis followed up with a urologist
CONCLUSIONS: Inpatient urologic consultation for patients admitted to a CDU with uncomplicated ureterolithiasis undergoing stone observation does not affect outpatient urologic follow-up rates. Additionally, patients with a history of nephrolithiasis were less likely to follow up suggesting these patients may be more comfortable with outpatient MET. Based on these results, in person consultation by a urologist is likely not necessary to ensure follow up in patients with uncomplicated ureterolithiasis and may represent an area to improve overuse of urgent inpatient specialty care. 
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