Acute Management of Renal Colic and Compliance with National Standards: Closure of the Audit Loop

Citation: Goonewardene SS , Rajjayabun P (2016) Acute Management of Renal Colic and Compliance with National Standards: Closure of the Audit Loop. Arch Renal Dis Manag 2(1): 008-010. DOI: 10.17352/2455-5495.000008 008 Opiates. If stones are present, mandatory metabolic studies must be conducted. Renal drainage is required in the presence of sepsis/ an infected obstructed kidney, a single functioning kidney or intractable pain.


Introduction
Renal (ureteric) colic is a common surgical emergency. It is usually caused by calculi obstructing the ureter, but about 15% of patients have other causes, e.g. extrinsic compression, intramural neoplasia or an anatomical abnormality [1]. Up to 12 percent of the population will have a urinary stone during their lifetime, and recurrence rates approach 50 percent [2]. Fifty-five percent of those with recurrent stones have a family history of urolithiasis [3] and having such a history increases the risk of stones by a factor of three [4]. Upon presentation to the A&E department, suspected acute renal colic patients must have a clinical examination and radiological investigations to confirm the diagnosis [5].
The best imaging study to confirm the diagnosis of a urinary stone in a patient with acute flank pain is unenhanced, helical CT of the abdomen and pelvis [6]. If CT is unavailable, plain abdominal radiography should be performed, since 75 to 90 percent of urinary calculi are radiopaque [5]. Although ultrasonography has high specificity (greater than90 percent), its sensitivity is much lower than that of CT, typically in the range of 11 to24 percent [5]. Thus, ultrasonography is not used routinely but is appropriate as the initial imaging test when colic occurs during pregnancy [7]. Urgent intervention is indicated in a patient with an obstructed, infected upper urinary tract, impending renal deterioration, intractable pain or vomiting, anuria, or high-grade obstruction of a solitary or transplanted kidney [5]. Infection proximal to obstruction is suggested by fever, urinalysis showing pyuria and bacteriuria, and leukocytosis, and the presence of urosepsis is associated with an increased risk of complications [5]. Impaired glomerular filtration inhibits the entry of antibiotics into the collecting system and requires emergency decompression by means of either percutaneous nephrostomy or ureteral stenting [8,9].
There are very strict guidelines produced by the BAUS and the College of Emergency Medicine. Despite this, over a quarter of UK A&E departments did not perform any radiological investigations when patients presented with renal colic. Shockingly some departments do not even offer renal colic patients any analgesia [5].
British Association of Urology Guidelines (2008) [10], specify clinical assessment must exclude UTI/ AAA. Initial investigations must include x-ray KUB, urinalysis and FBC/U+Es. Within 24 hours a Non contrast CT must be conducted to confirm the diagnosis, or IVU if CT is unavailable. In addition analgesia must be administered: NSAIDS/ • Emergency Senior Urological referral to determine if disobstruction required and method / timing of renal drainage.
Results will be analyzed via percentages and compared to previous audit to close the audit loop.

Results
40 cases were admitted to Worcestershire Acute Hospitals with a diagnosis of renal colic. One patient declined analgesia (results documented in notes). 25% had severe pain (10 cases, pain score 7-10), time to analgesia 30 minutes. 25% had moderate pain (10 cases, score 4-6), time to analgesia was 40.4 mins. 50% had mild pain score (20 cases, pain score 1-5), time to analgesia 81.8 mins. 72.5% (29 patients) had their pain re-assessed within one hour after receiving analgesia. 77.5% (31 patients) received appropriate analgesia (NSAID/ Opiate). 45% (18 patients) had clinical history/ examination to rule out UTI/ AAA. 100% of patients had urinalysis, but in 2 cases, results were not documented in notes. 65% (21 cases) had X-ray KUB as the initial investigation, 79% the same day, 9 cases then had NCCT. 75% (30 cases) had NCCT, 50% (15 cases) were the same day. 27.5% (11 cases) had stones on CT. One case had an OP IVU. The Radiology plan was documented in notes in 92.5% (37 cases). 100% had blood for FBC and U+ES which were all documented in notes. Only 3 cases had urate and calcium levels tested. 100% of cases had senior Urology review.
We analyzed 32 case notes, from Dec 2009 to September 2010 admitted with a provisional diagnosis of renal colic to Worcestershire Acute Hospitals. We demonstrated the mean time to analgesia from triage for severe pain was 106 minutes, 62 minutes for moderate pain and 46 minutes for mild pain. 84% received the appropriate analgesic (NSAID/Opiate). The reasons for not giving analgesia were documented in all cases. In only 18% (6 cases) pain was re-evaluated  (Table 1).

Discussion
We have demonstrated that in the majority of guidelines present, our practice has improve. The majority of patients are currently having their pain re-assessed within one hour after receiving analgesia and are receiving the appropriate analgesic. However whilst 79% of those having X-ray KUB as the primary radiological investigation the same day, only 50% of those having CT are having it done the same day. This demonstrates our interventions have been effective, however we can still improve, especially with regards to timing of radiological investigations. We can aid our service by development of a renal colic protocol/ proforma, on which will be recorded all the information that needs to be addressed, e.g. analgesia, time to analgesia, etc. Included in this will be testing for calcium and urate levels in patients with renal stones, which is currently not done as part of routine care in all patients diagnosed with renal stones. We can review whether this is effective with another re-audit.