Emergency department factors that predict prolonged length of stay after stent placement for obstructing urolithiasis and infection.
Alejandra Balen, MD, David Sobel, MD, Marcelo Paiva, MPP, Timothy O'Rourke, MD, Martus Gn, MD, Rachel Greenberg, MD, Rebecca Ortiz, BA, Philip Caffery, PhD, Christopher Tucci, MSN, Gyan Pareek, MS MD.
Brown University, Providence, RI.
BackgroundInfected obstructing ureteral calculi represent a surgical emergency and studies have shown that time to stent insertion correlates with hospital length of stay (LOS). This study sought to assess the factors present at time of emergency department (ED) presentation that were associated with increased LOS after emergent stent insertion for infected obstructing ureteral calculi. MethodsA retrospective review of 131 patients stented for infected obstructing ureteral stones at a single academic institution between May 2017 and December 2019 was performed. Demographic data, ED presentation course, task-time analysis, LOS, and number of patients meeting Systemic Inflammatory Response Syndrome (SIRS) criteria by having two or more of the following criteria: fever >38.0°C or hypothermia <36.0°C, tachycardia >90 beats/minute, tachypnea >20 breaths/minute, leukocytosis >12*109/l or leukopenia <4*109/l as a measure of severity of illness were obtained. Linear regression analysis was performed to characterize the relationship of the above factors and hospital length of stay. ResultsPatient characteristics are shown in Table 1. Mean LOS was 66.7 hours (R 5.7-243.8, SD 57.7). The mean time from presentation to operating room (OR) was 9.3 hours (R 3.3-48.6, SD 6.0). The elapsed time from presentation to OR did not affect LOS. 62 patients (47.3%) met SIRS criteria and LOS increased by 6.8 additional hours for each systemic inflammatory response syndrome (SIRS) criterion present during ED evaluation (t=2.33, p=.02). Elevated serum lactate (t=2.96, p=.004), serum creatinine (t=2.8, p=.006), and presence of pyuria (t=3.23, p=.002) were also correlated with increased LOS (6.9 hours, 5.9 hours, and 0.2 hours, respectively, for each rise in value). Correlations between ED factors and LOS are described in Table 2. ConclusionsIn patients presenting to the emergency department with obstructing urolithiasis and infection, presence of SIRS criteria, elevated serum lactate, creatinine and increased urine WBC count were all predictive of increased length of stay after stent placement. Time from presentation to stent insertion was not, however, significantly associated with length of hospital stay. These data question the true urgency of ureteral stent placement for patients who are not critically ill. Further study and workflow analysis are needed to identify and reduce barriers to discharge after stent placement.
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