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The High Cost of Midnight Ureteral Stents for Obstructing Urolithiasis and Infection
David W. Sobel, MD, Timothy O'Rourke, MD, Alejandra Balen, MD, Marcelo Paiva, MPP, Martus Gn, MD, Rachel Greenberg, MD, Rebecca Ortiz, BA, Philip Caffery, PhD, Christopher Tucci, MS, Gyan Pareek, MD.
Brown University, Providence, RI.

Background: Patients who present to the emergency department (ED) with obstructing urolithiasis and evidence of urinary tract infection often require ureteral stent placement after midnight. Overnight stenting requires operating room (OR) staff to be called in from home at many institutions, including our own. We sought to elucidate the workforce cost to perform stent placement after midnight when the call team is activated to mobilize the OR and complete the case.
Methods: Emergent cystoscopy and ureteral stent placement procedures performed in the OR at a single academic institution between May 2017 and December 2019 were reviewed retrospectively in an IRB-approved database. A cost analysis was performed to account for the minimal personnel required to be called into the hospital for the procedure including the anesthesiologist, surgical technician, circulating nurse, radiologic technologist, two post-anesthesia care unit (PACU) nurses, and an operating room assistant (ORA). Cost data were derived from median salary at our institution for call staff as well as specific fees from anesthesiology staff. The student's t-test was utilized to detect differences between groups.
Results: A total of 131 urgent stent placements were performed between May 2017 and December 2019. Of these, 18 (14%) procedures were performed between the hours of midnight and six o'clock AM. Ten patients (56%) stented after midnight demonstrated two, three or four systemic inflammatory response syndrome (SIRS) criteria upon presentation, while eight patients (44%) presented with zero or one SIRS criteria. Time from CT diagnosis to OR (minutes) in the presence of two, three or four SIRS criteria was not significantly different between the hours of 0600-2400 (49/59 [83%] patients; mean = 274.5, SD = 228.5) versus 0000-0600 (10/59 [17%] patients; mean =191.8, SD = 153.5); t(19) = 1.4, p=.18).The cost of calling in personnel after midnight was $2,782.00 accounting for a mandatory 4 hours of overtime pay, not including post-call substitute staff the following morning. The mean operating room utilization time was 25 minutes (R 16-34, SD 6.0).
Conclusions: Patients presenting with obstructing urolithiasis and infection have high workforce costs associated with the need for decompression. At our academic institution without 24 hour staff for procedures performed outside of standard OR hours, the personnel cost of performing ureteral stent placement after midnight was $2,782.00. Given that nearly half of the patients exhibited zero or one SIRS criteria at time of ED evaluation, further work is needed to determine which patients can safely be observed overnight with stent placement during daytime hours. In this series, potential deferment of clinically stable patients to stent placement the following morning could have produced a cost savings of $22,256. Further study regarding the safety of stent placement outside of the OR (i.e., “bedside stenting”) in the appropriate clinical context is also warranted.

Table 1: Personnel cost per case
Personnel:Cost / Fee
Anesthesiologist$2,000.00
Surgical technician$98.00
Circulating nurse$168.00
Radiologic technologist$120.00
Two PACU Nurses$336.00
Operating room assistant (ORA)$60.00
Total$2,782.00


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