Improving the effectiveness of the emergency management of renal colic in a district general hospital: a completed audit cycle

A renal colic fast track pathway to improve waiting times and outcomes for patients presenting to the emergency department

Introduction

Renal colic is commonly encountered in the emergency department (ED). We validated a fast track renal colic (FTRC) initiative to decrease patient waiting times and streamline patient flow.

Method

The FTRC pathway was devised according to the National Institute for Health and Care Excellence clinical summary criteria for the management of patients with suspected renal colic. ED triage nurses use the pathway to identify patients with likely renal colic suitable for fast track to analgesia, investigation and management. Investigations, diagnosis and patient demographics were recorded for 1157 consecutive patients coded as renal colic at a single-center ED over 12 months.

Results

Three hundred and two patients were suitable for the FTRC pathway (26.1%), while 855 were seen by the ED clinicians prior to onward referral. Also, 83.9% of patients underwent computed tomography scan. In the FTRC group, 57.3% of patients had radiologically confirmed calculi versus 53.8% in the non-FTRC group (p=0.31). Alternative diagnoses among FTRC patients (2.6%) included ovarian pathology (n=1), diverticulitis (n=2) and incidental renal cell carcinoma (n=2), while 26.1% had no identifiable pathology. No immediately life-threatening diagnoses were identified on imaging. Computed tomography scans performed in the non-FTRC group identified two ruptured abdominal aortic aneurysms and alternative diagnoses (2.57%) including ovarian pathology (n=7), cholecystitis (n=2), incidental renal cell carcinoma (n=3) and inflammatory bowel disease (n=1); 31.2% identified no pathology. Time in ED and time to radiologist-reported imaging were lower for the FTRC group versus non-FTRC group (p<0.0001).

Conclusion

The FTRC pathway is a safe and efficacious method of reducing diagnostic delay and improving patient flow in the ED.

Describing wait time bottlenecks for ED patients undergoing head CT

STUDY OBJECTIVES

Facing increased utilization and subsequent capacity and budget constraints, ED's must better understand bottlenecks and their effect on process flow to improve process efficiency. The primary objective of this study was to identify bottlenecks in obtaining a head CT and investigate patient waiting time based on those bottlenecks.

METHODS

This observational study included all patients undergoing a head CT between July 1, 2013 and June 30, 2014 at a large, urban academic ED with over 100,000 visits per year. The primary study outcome was total cycle time, defined as the elapsed time between patient arrival and head CT preliminary report, divided into four components of workflow.

RESULTS

8312 patients who had a head CT were included in this study. The median cycle time from patient arrival to head CT preliminary report was 3h and 13min with 39min of waiting time resulting from bottlenecks. In the 4-step model (time from patient arrival to head CT order, time from head CT order to head CT scheduled, time from head CT scheduled to head CT completed, and time from head CT completed to head CT preliminary report), each process was the bottleneck 30%, <1%, 27%, and 42% of the time, respectively.

CONCLUSION

Demand capacity mismatch in head CT scanning has a significant impact on patient waiting times. This study suggests opportunities to improve wait times through future research to understand the causes of delays in CT ordering, CT completion and timeliness of radiology reports.

Analgesia delivery in the ED

OBJECTIVE

The aim of this study was to evaluate the effectiveness of analgesia delivery, in the emergency department setting, to patients presenting with acute pain, with regard to guidelines from the British Association of Accident and Emergency Medicine (BAEM).

METHODS

A retrospective analysis of patient records. We measured the time intervals between patient arrival, assessment, and the delivery of analgesia. Clinical outcomes were compared with national target guidelines.

RESULTS

The mean interval for patients with moderate pain was 3 hours and 46 minutes, and for those with severe pain, 1 hour and 12 minutes. The range was from 8 minutes to 4 hours and 11 minutes. The number of patients not receiving analgesia within BAEM best practice guidelines was 68%.

CONCLUSION

There is a significant delay in patients with acute pain receiving any form of analgesia. Performance in relation to BAEM guidelines is poor. Several areas have been identified to make practical changes to service provision and patient care.