Table of Contents  

Rafiq, Rafiq, Rafiq, Salman, and Hafeez: Standard of outpatient management of renal colic

Introduction

Renal colic is described as colicky lumbar pain due to the expulsion of a calculus within the pelviureteric system.1 The pelvicalyceal and ureteral system does not guarantee free passage to this mass. Calculi can become lodged at any site within the system.2 The result is acute colic that can radiate from the flanks to the perineum or urethra depending on the exact site of the calculus.3

Renal calculi have been classified depending on their constituents. Calcium-containing calculi are the most common. These are crystals of calcium with subconstituents of oxalate, phosphate and triphosphate. Uric acid and cysteine calculi are less common.4

Passage of renal calculi depends on a number of factors, one of the most important being the size of the calculus. A calculus of 5 mm or less allows a comparatively uncomplicated passage and expulsion from the urinary tract. This is termed ‘spontaneous expulsion’.5 Larger stones do not follow this trend and are associated with a number of complications. These can include obstruction, impaction, pain of varying intensity (but usually severe), hydroureter and hydronephrosis, reduced renal perfusion and function and, in extreme cases, infection leading to pyonephrosis6 and urosepsis.7

Simple renal colic and calculi are treated on an outpatient basis whereas cases with complications require admission-based management. Emergency management of renal colic differs between centres. Various guidelines have been devised, including the Royal College of Emergency Medicine’s (RCEM) guidelines for the management of renal colic.8 Individual guidelines differ in their approach, including differences in type and use of analgesia. The emergency department of Khyber Teaching Hospital, Peshawar, has no explicit guidelines for the management of renal colic and, in most cases, the RCEM guidelines for renal colic are followed.

This audit study was carried out to assess the standard of management of patients with renal colic at the emergency outpatient department of Khyber Teaching Hospital compared with the RCEM guidelines for the management of renal colic.

Materials and methods

A retrospective clinical audit of 197 randomly selected patients presenting to the emergency department with renal colic was carried out over a 1-year period from June 2014 to June 2015. Approval from the hospital’s ethical and research committees was obtained.

Data were collected using a printed proforma from the outpatient sheets. The variables included in the data were individual points from the RCEM guidelines for the management of renal colic. These formed the basis for the audit standards and comparison. Inclusion criteria for the audit consisted of the following:

  • all patients over the age of 18 years;

  • cases diagnosed as renal colic based on clinical and/or radiological evidence;

  • patients with moderate to severe pain.

The RCEM guidelines for the management of renal colic require pain scoring on admission on a points basis from 1 to 10, with 10 being the most severe pain. Based on this scoring system, the RCEM defines pain as follows:

  • moderate pain: pain score 4–6;

  • severe pain: pain score 7–10.

Exclusion criteria included:

  • patients younger than 18 years of age;

  • patients with mild pain: pain score < 4.

All data were recorded using IBM SPSS Statistics version 20 (IBM Corporation, Armonk, NY, USA). For the purpose of this audit, data were expressed in terms of frequency and percentage.

Audit standards

The RCEM guidelines for the management of renal colic set the standard for this audit. The guidelines are as follows:

  • Record pain score on admission.

  • For severe pain (pain score 7–10), patients should receive analgesia as follows:

    • 50% of patients within 20 minutes of admission;

    • 75% of patients within 30 minutes of admission;

    • 98% of patients within 60 minutes of admission.

  • For moderate pain (pain score 4–6), patients should receive analgesia as follows:

    • 75% of patients within 30 minutes of admission;

    • 90% of patients within 60 minutes of admission.

  • Ninety per cent of patients with severe pain should have documented re-evaluation within 60 minutes of their first dose of analgesia.

  • Seventy-five per cent of patients with moderate pain should have documented re-evaluation within 60 minutes of their first dose of analgesia.

  • Patients with a pain score of 4–10 who have not received analgesia should have documented reasons for lack of analgesia in their outpatient sheets or charts.

  • All patients with a pain score of 4–10 should be prescribed urine analysis (urine R/E; routine examination of urine), radiological investigations (radiography of the kidney, ureter and bladder; ultrasonography of the abdomen and pelvis), full blood count and investigation of urea and electrolyte levels, and this should be documented in their outpatient sheets or charts.

  • Patients 60 years and older should also be considered for possible abdominal aortic aneurysm (AAA), excluded by ultrasonography [focused assessment with sonography for trauma (FAST) scan] and the results recorded in their documents.9 The best practice guidelines for the management of patients with a diagnosis of ruptured AAA state that patients 50 years and older should be considered for this diagnosis and managed accordingly.10 The present audit followed these guidelines, with assessment at 50 years and older for AAA.

  • All patients should have documented evidence of a review at the end of their outpatient session with referral to a specialist centre, if required.

Local criteria

Local practices for management of renal colic based on the RCEM guidelines and the present audit included the following:

  • Admission time was time of hospital admission, recorded as a computer printout on all outpatient sheets.

  • Analgesia used for renal colic at the emergency department included:

    • intravenous ketorolac;

    • intramuscular iclofenac.

  • Urine analysis included urine R/E.

  • Radiological investigations for renal colic included:

    • ultrasonography of the abdomen and pelvis;

    • radiography of the kidney, ureter and bladder.

  • Diagnostic modality available from the hospital for AAA:

    • FAST scan.9

  • Management plan:

    • outpatient management of uncomplicated renal colic;

    • referral to specialist centre for complicated renal colic. Complications were defined as obstruction, infection and management requiring urological endoscopic interventions.

Results

Over a 1-year period, a total of 197 outpatients with renal colic were included and analysed. Pain score on admission was not noted in any of the 197 cases. For moderate pain (pain score 4–6), the number of patients receiving analgesia within the first 20, 30 and 60 minutes was 8 (5.1%), 104 (65.8%) and 46 (29.1%), respectively. For severe pain (pain score 7–10), the number of patients receiving analgesia within the first 20, 30 and 60 minutes was 23 (59%), 16 (41%) and 0 (0%), respectively. A total of 11 patients (5.6%) did not receive any analgesia. Of these, in one patient (0.5%) there was no reason documented for lack of analgesia, eight patients (4.1%) had received analgesia elsewhere and in two cases (1%) the patients reported being pain free after assessment.

Re-evaluation of pain was carried out in 98 patients (62%) with moderate pain and 39 patients (100%) with severe pain. Re-evaluation was not performed in 60 patients (38%) with moderate pain and in 0 patients (0%) with severe pain.

Urine R/E and radiological examinations were performed in 197 patients (100%), full blood count in 73 patients (37.1%) and urea and electrolyte levels were investigated in eight patients (4.1%). Full blood count and urea and electrolyte levels were not performed and documented for all patients. However, where these were performed, they were also documented in each case. Full blood count was performed and documented in 73 patients (37.1%) whereas urea and electrolyte levels were carried out and noted in eight cases (4.1%).

A total of 47 patients (23.9%) qualified for assessment through FAST scan for AAA. In all cases, neither FAST nor routine ultrasonography was performed specifically looking for AAA. A total of 192 patients (97.5%) received an outpatient review or referral to a specialist centre at the end of their outpatient management, whereas five patients (2.5%) did not receive this. This data analysis is shown in Table 1.

TABLE 1

Comparison of findings with RCEM guidelines for renal colic

Audit Action No. of patients RCEM guidelines
Pain score was noted on admission Yes 0 100%
No 197 (100%)
Analgesia received for severe pain; pain score 7–10 Within 20 minutes 23 (59%) 50%
Within 30 minutes 39 (100%) 75%
Within 60 minutes 39 (100%) 98%
Analgesia received for moderate pain; pain score 4–6 Within 20 minutes 8 (5.1%)
Within 30 minutes 112 (70.9%) 75%
Within 60 minutes 158 (100%) 90%
Re-evaluation within 60 minutes after first dose of analgesia for severe pain Yes 39 (100%) 90%
No 0 (0%)
Re-evaluation within 60 minutes after first dose of analgesia for moderate pain Yes 98 (62%) 75%
No 60 (38%)
Documented reason for not receiving analgesia Yes 10 (90.9%) 100%
No 1 (9.1%)
Urine R/E Performed 197 (100%) 100%
Documented 197 (100%) 100%
Radiological examination Performed 197 (100%) 100%
Documented 197 (100%) 100%
Full blood count Performed 73 (37.1%) 100%
Documented 73 (37.1%) 100%
Urea and electrolyte levels Performed 8 (4.1%) 100%
Documented 8 (4.1%) 100%
AAA Cases qualifying 47 (23.9%) All patients 50 years and older
Cases assessed 0 (0%) 100%
Documented 0 (0%) 100%

Discussion

The audit was carried out for the emergency department of the Khyber Teaching Hospital. There are no explicit local guidelines for outpatient management of renal colic. The hospital generally follows RCEM guidelines for management of various clinical conditions. Therefore, deviations from the RCEM guidelines for the management of renal colic were expected.

The RCEM guidelines require that the time of patient admission be noted. It is unclear if this is time of hospital admission, when the case notes or outpatient sheets for the patient are prepared or admission to the surgical unit of the emergency department. For the purpose of this audit, admission was taken as the time of admission to the emergency department, which is the same as time of hospital admission for Khyber Teaching Hospital. This time is printed on all outpatient sheets.

Local practice does not require the pain score to be noted on admission. Pain is arbitrarily assessed by the attending doctors as mild, moderate and severe from patient response and examination. Therefore, local practices fell short of RCEM guidelines in all 197 cases. However, local practice for the first dose of analgesia, for both severe and moderate pain, performed considerably better than RCEM guidelines in all categories, except for moderate pain at 30 minutes, as shown in Table 1. The proportion of patients receiving the first dose of analgesia for severe pain within 20, 30 and 60 minutes of admission was 59%, 100% and 100%, respectively. The RCEM guidelines require these to be 50%, 75% and 98%, respectively. Similarly, the proportion of patients receiving the first dose of analgesia for moderate pain within 20, 30 and 60 minutes of admission was 5.1%, 70.9% and 100%, respectively. The RCEM guidelines require these to be ‘un-specified’, 75% and 90%, respectively.

Re-evaluation of pain within 60 minutes of receiving the first dose of analgesia for severe pain was better than RCEM guidelines (100% compared with 90%), but was below the guideline percentage for moderate pain (62% compared with 75%). The RCEM guidelines require that in all cases reasons for lack of analgesia should be noted and documented, but this was recorded in only 10 patients (90.9%) with no reason noted for one patient (9.1%).

Local practice requires laboratory and radiological investigations to be performed in all cases of renal colic, and this does not include all investigations required by the RCEM guidelines. These investigations were performed in all patients, as required by local practice, but investigations required by only the RCEM guidelines were not performed in most of the cases. As per local practice, urine R/E and radiological examination is required for all cases and these were performed in all 197 patients (100%). The RCEM also requires these to be performed in all patients with renal colic. The RCEM guidelines require that a full blood count and urea and electrolyte levels should be investigated in all cases. Since this is not part of local practice, these were performed in only 73 (37.1%) and 8 (4.1%) cases, respectively.

Analysis of data revealed that, of the 197 patients, 47 patients (23.9%) qualified as cases that should have been assessed and investigated for AAA. The RCEM guidelines require that all such cases should be assessed for AAA, and investigated using a FAST scan, and that this should be documented in the patient notes or outpatient sheets. However, none of these cases was assessed and investigated for AAA.

The laboratory and radiological investigations prescribed for patients with renal colic are attached to outpatient sheets as laboratory or ultrasonography slips on which results and findings are printed out by the pathology and radiology departments of the hospital. Therefore, in all cases where individual investigations were carried out, these were also recorded in the patient notes. This is in line with RCEM guidelines, which require these to be documented in all cases.

Conclusions

The RCEM guidelines, which are not part of local practice, performed poorly in the audit. This was particularly evident for pain score on admission, which was not noted in any of the cases. Ordering full blood count and investigation of urea and electrolyte levels for all cases also performed poorly, as it is not part of local practice. Documentation of re-evaluation after analgesia, reasons for lack of analgesia, full blood count, urea and electrolyte levels and assessment and management of suspected cases of AAA also performed poorly. In none of the cases qualifying for suspected AAA assessment was a FAST scan carried out or the appropriate documentation completed.

Recommendations

To meet RCEM guideline standards for management of renal colic, the following recommendations are made:

  • Presentations about RCEM guidelines for management of renal colic should be given to junior doctors before their rotations start, and posters detailing RCEM guidelines should be visible in the emergency department.

  • Nurses should be educated on these guidelines via presentations or by doctors already familiar with the guidelines and their implementation.

  • Pain scores for all cases of renal colic should be made part of local practice.

  • Re-evaluation after analgesia and reasons for lack of analgesia should be performed in all cases.

  • Documentation of all aspects of RCEM guidelines in outpatient sheets should be ensured.

  • Full blood count and investigation of urea and electrolyte levels should be made part of local practice for all cases of renal colic.

  • Cases qualifying for assessment as AAA should be managed as per RCEM guidelines, namely a FAST scan should be performed and the proper documentation completed in all such cases.

References

1. 

Katz DS, Lane MJ, Sommer FG. Non-contrast spiral CT for patients with suspected renal colic. Eur Radiol 1997; 7:680–5. http://dx.doi.org/10.1007/BF02742925

2. 

Ordon M, Schuler TD, Ghiculete D, Pace KT, Honey RJ. Stones lodge at three sites of anatomic narrowing in the ureter: clinical fact or fiction? J Endourol 2013; 27:270–6. http://dx.doi.org/10.1089/end.2012.0201

3. 

Xavier A, Maxwell AP. Which patients with renal colic should be referred? Practitioner 2011; 255:15–17, 2.

4. 

Shahnani PS, Karami M, Astane B, Janghorbani M. The comparative survey of Hounsfield units of stone composition in urolithiasis patients. J Res Med Sci 2014; 19:650–3.

5. 

Sfoungaristos S, Kavouras A, Perimenis P. Predictors for spontaneous stone passage in patients with renal colic secondary to ureteral calculi. Int Urol Nephrol 2012; 44:71–9. http://dx.doi.org/10.1007/s11255-011-9971-4

6. 

Etafy M, Morsi GA, Beshir MSM, Soliman SS, Galal HA, Vanderdys CO. Management of lower ureteric stones: a prospective study. Cent European J Urol 2013; 66:456–62. http://dx.doi.org/10.5173/ceju.2013.04.art19

7. 

Zanetti G, Paparella S, Trinchieri A, Prezioso D, Rocco F, Naber KG. Infections and urolithiasis: current clinical evidence in prophylaxis and antibiotic therapy. Arch Ital Urol Androl 2008; 80:5–12.

8. 

The Royal College of Emergency Medicine. Renal Colic – RCEM Clinical Standards. The Royal College of Emergency Medicine; 2011. URL: www.rcem.ac.uk/shop-floor/clinical standards/renal colic (accessed 16 January 2016).

9. 

Bentz S, Jones J. Accuracy of emergency department ultrasound scanning in detecting abdominal aortic aneurysm. Emerg Med J 2006; 23:803–4. http://dx.doi.org/10.1136/emj.2006.041095

10. 

Vascular Society. Best Practice guidelines ruptured AAA. National vascular database; 2016. URL: http://www.vascularsociety.org.uk/guidelines-for-raaa/ (accessed 16 January 2016).




Add comment 





Home  Editorial Board  Search  Current Issue  Archive Issues  Announcements  Aims & Scope  About the Journal  How to Submit  Contact Us
Find out how to become a part of the HMJ  |   CLICK HERE >>
© Copyright 2012 - 2013 HMJ - HAMDAN Medical Journal. All Rights Reserved         Website Developed By Cedar Solutions INDIA