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Time to operating room is significantly longer if emergency department presentation occurs “after hours” for patients with pyelonephritis and obstructing stones
Timothy K. O'Rourke, Jr., MD, David W. Sobel, MD, Marcelo Paiva, M.P.P., Praveen Rajaguru, M.P.H., Christopher Tucci, MS., R.N., Gyan Pareek, MS., MD.
Brown University/Rhode Island Hospital, Providence, RI.

BACKGROUND: Obstructive pyelonephritis secondary to obstructing ureteral calculi is considered a urological emergency. Patients with hemodynamic instability and signs of florid sepsis are emergently taken for ureteral stent or percutaneous nephrostomy tube placement. However, for patients without these presenting signs or symptoms but still in need of decompression, there is question as to the necessity of emergency surgery. We sought to explore time from diagnosis to operating room (OR) in patients with regard to the time of day and day of the week that the patient presented to the emergency department (ED) and its effect on hospital length of stay, a surrogate measure for clinical course and morbidity.METHODS: A retrospective review of all patients presenting to the ED with obstructive pyelonephritis secondary to obstructing ureteral calculi at a single academic institution between May 2017 and December 2019 was performed. Patient demographics, day of the week of presentation, as well as time of ED presentation and clinical course including times of imaging completion confirming diagnosis and time to OR were analyzed. Patients were categorized as having presented during “business hours” 6 AM - 6 PM or “after hours” 6 PM - 6 AM. Student's t-test and one-way analysis of variance (ANOVA) were utilized to detect differences between groups.RESULTS: A total of 131 patients with infected or septic stones who underwent urgent or emergent cystoscopy and ureteral stent placement were reviewed. Patients who presented to the ED during standard business hours were taken to the operating room on average more expeditiously (Mean = 250 minutes, SD = 220) than those who presented after hours (Mean = 406 minutes, SD = 207; t(29) = 3, p=.005). No significant difference in LOS was detected between these two groups (Mean = 69.8 hours, SD = 59.6 [business hours] versus mean = 53.1 hours, SD = 49.6 [after hours]; t(40) = 1.4, p=.16). No differences were detected in time from imaging diagnosis to OR [F(6,106) = 0.99, p=.44] nor length of stay [F(6,122) = 1.88, p=.09] based on the individual day of the week of ED presentation. CONCLUSIONS: The time to operating room is significantly different based whether patients with pyelonephritis and an obstructing stone present to the ED during “business hours” or “after hours.” Patients who presented to the ED “after hours” experienced a significant delay in time from diagnosis to arrival to the OR for definitive surgical management compared to those presenting during “business hours.” Despite this, there was no difference in hospital length of stay between these groups, suggesting no significant impact on morbidity or clinical course in those deemed clinically stable for non-emergent stent placement. This suggests that in the appropriate clinical context stent placement may be performed non-emergently without significant effect on a patient's overall clinical course. Further studies should focus on the effect this may have on hospital and surgeon resources.


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