Emergency Program, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia.
Monash Emergency Research Collaborative, Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.
Emerg Med J. 2017 Nov;34(11):749-754. doi: 10.1136/emermed-2016-206572. Epub 2017 Jul 18.
Patients presenting to the ED with suspected renal colic are frequently imaged with CT urography (CTU), which rarely alters diagnosis or management. To reduce use of CTU in this population, we instigated a new imaging and management guideline in our ED.
This was a quasi-experimental prospective study, whereby a new guideline was commenced at the intervention site (Monash Medical Centre) and the existing guideline continued at the control site (Dandenong Hospital). The new guideline promotes focused ultrasound for diagnosing renal colic and restricts CT to those with poor response to analgesia or 'red flags'. A consecutive series of patients with suspected renal colic were prospectively enrolled and outcomes compared between the sites. The primary outcome was CTU utilisation and secondary outcomes were radiation exposure, stone rate on CTU, admission, ED length of stay and rates of urological intervention and returns to ED at 4-week follow-up.
Preintervention CTU rates were 76.7% at Monash and 72.1% at Dandenong. 324 patients were enrolled; 148 at Monash and 176 at Dandenong. Median age 47 years vs 49 years, males 76.4% vs 66.5% and medianSex, Timing, Origin, Nausea, Erythrocytes (STONE) score 10 vs 10 for Monash and Dandenong, respectively. CTU was performed in 54.1% vs 75.0% (p<0.001), median radiation exposure 2.8 vs 4.0 mSv (p<0.001) and urological intervention occurred in 16.4% vs 15.7% for Monash and Dandenong, respectively.
We found that use of CTU for renal colic was significantly reduced by introduction of a guideline promoting ultrasound and encouraging selective CTU. Although intervention rates were similar between the two sites, further prospective study is needed to ensure other patient-centred outcomes do not differ.
急诊科中疑似肾绞痛的患者常进行 CT 尿路造影（CTU）检查，但这种检查很少改变诊断或治疗。为了减少此类人群中 CTU 的使用，我们在急诊科引入了新的影像学和管理指南。
这是一项准实验性前瞻性研究，在干预点（莫纳什医疗中心）实施新指南，而在对照点（丹德农医院）继续使用现有指南。新指南提倡使用聚焦超声诊断肾绞痛，并将 CT 限制用于镇痛效果不佳或存在“警示信号”的患者。连续纳入疑似肾绞痛的患者，比较两个地点的结果。主要结局是 CTU 的使用率，次要结局是辐射暴露、CTU 上的结石率、入院率、急诊科停留时间以及泌尿外科干预率和 4 周随访时返回急诊科的比率。
莫纳什的 CTU 使用率为 76.7%，丹德农为 72.1%。共纳入 324 例患者，莫纳什 148 例，丹德农 176 例。中位年龄分别为 47 岁和 49 岁，男性分别为 76.4%和 66.5%，STONE 评分中位数分别为 10 分和 10 分。莫纳什和丹德农分别有 54.1%和 75.0%的患者进行了 CTU 检查（p<0.001），中位辐射暴露分别为 2.8 和 4.0 mSv（p<0.001），莫纳什和丹德农分别有 16.4%和 15.7%的患者接受了泌尿外科干预。
我们发现，通过引入促进超声检查和鼓励选择性 CTU 的指南，肾绞痛患者的 CTU 使用率显著降低。尽管两个地点的干预率相似，但仍需要进一步的前瞻性研究以确保其他以患者为中心的结局没有差异。
