Unplanned encounters common after ureteroscopy

Boston-Findings of a retrospective study confirm that unplanned encounters are common after ureteroscopy.

By identifying underlying factors, the research also suggests strategies for reducing the frequency of these post-procedural events. The study was presented at the 2017 AUA annual meeting in Boston.

Conducted by urologists at Washington University School of Medicine, St. Louis, the study reviewed data from 157 patients who underwent ureteroscopy for upper tract urolithiasis between January and June 2016. In order to identify patients who may have gone to another hospital for additional care, patients were surveyed about visits to an emergency department (ED) or hospital admission, and 40% of patients provided a response.

In the 30 days after the procedure, there were 44 unplanned patient-initiated phone calls (28%), 23 emergency department (ED) visits (14.6%) of which almost two-thirds involved imaging, and eight readmissions (5.1%).

Both the phone calls and ED visits were most often related to pain and involved patients having a first-time stone procedure.

“Our findings are consistent with previous literature that reports a relatively high rate of post-procedural encounters in patients who undergo ureteroscopy as an outpatient procedure,” said first author Kefu Du, MD, fellow in minimally invasive surgery and endourology at Washington University School of Medicine.

“We believe that having a clinical care pathway that provides standardized, targeted patient education, pain management, and reassurance may minimize unplanned encounters, improve quality of care, and reduce cost,” added Dr. Du, who worked on the study with Ramakrishna Venkatesh, MD, and colleagues.

The most common reasons for unplanned phone calls were pain (54.6%), particularly stent-related pain or other symptoms (45.5%), and medication-related issues (13.6%). The leading chief complaints among patients who presented at the ED were flank pain (39%) and hematuria (13%). Three (37.5%) of the eight patients who were readmitted also complained of flank pain. Other presenting issues for the readmitted patients included hematuria (12.5%) and fever (12.5%).

Unplanned phone calls were received at a median of 5 days after ureteroscopy, ED visits occurred at a median of 8 days, and readmissions occurred at a median of 3 days.

Factors analyzed as potential predictors for the post-procedural events included demographic features, urolithiasis history, stone characteristics, and operative details. Factors associated with a higher rate of phone calls were having a first-time stone procedure, intraoperative stent placement, and stent removal at home.

Next: ED visits linked with first-time procedure

ED visits linked with first-time procedure

ED visits were associated with having a first-time stone procedure and ureteral access sheath usage, while patients who were readmitted more often had lower body mass index, a bilateral procedure, and ureteral access usage compared to the rest of the study population.

“In our study, there were no phone calls, ED visits, or readmissions among the patients who had a stentless procedure, but they are a highly selected group representing only about 10% of patients who undergo ureteroscopy at our institution. From this study, we cannot determine selection criteria that would allow that option to be expanded to a larger group,” Dr. Du said.

Stone number, operative time, Charlson comorbidity index, and history of preoperative urinary tract infection were not significantly associated with any of the types of postoperative encounters.

The department was developing a formal patient education program on ureteroscopy that includes informational brochures and was hoping to implement more extensive counseling provided by dedicated nursing staff to set appropriate patient expectations.

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“We believe that many patients think that because there is no incision, they will have minimal discomfort and be able to return to work the day after ureteroscopy. That is not the case, and patients with a stent in particular can have pain that worries them and leads them to call or go to the ED,” Dr. Du said.

“We would also like to track usage of pain medications and then determine if we need to adjust our prescribing. There is a balance to consider because we don’t want to overprescribe narcotic analgesics, but we also do not want to leave patients suffering with uncontrolled pain,” he told Urology Times. Adjunct pain management should also play a larger role in order to reduce narcotic consumption.

In addition, researchers hoped to have dedicated nursing staff make routine follow-up calls to patients a few days after their procedure to identify any concerns and provide reassurance as necessary.

“This strategy involves additional staff time, but in the long run we expect it will be cost-saving because of its potential to reduce ED visits as well as improve patient satisfaction,” Dr. Du said. The clinical care pathway is currently being piloted, and data from the pathway will be reported in the near future.