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Abstract
Ureteric colic constitutes a large proportion of acute hospital attendances, across the UK, putting pressure on urological services. The British Association of Urological Surgeons (BAUS) guidelines indicate that for patients managed expectantly, a clinic review should be undertaken within 4 weeks of presentation. This quality improvement project reports the benefit of a dedicated virtual colic clinic to facilitate an efficient care pathway and reduce patient waiting times. A retrospective cycle analysed patients referred from the emergency department (ED) with uncomplicated acute ureteric colic (excluding those admitted for immediate intervention) over 2 months in 2019. A further cycle was carried out 12 months later following the introduction of a new dedicated virtual colic clinic with updated ED referral guidance. The mean time from ED referral to urology clinic review fell from 7.5 to 3.5 weeks. The percentage of patients reviewed in clinic within 4 weeks increased from 25% to 82%. The mean time from referral to intervention including shockwave lithotripsy and primary ureteroscopy fell from 15 to 5 weeks. The introduction of a virtual colic clinic improved the time to definitive management of ureteric stones for patients managed expectantly as per BAUS guidelines. This has reduced waiting times for both clinic review and stone treatment which has enhanced patient experience within our service.
- Surgery
- Time-to-Treatment
- Quality improvement
- Telemedicine
Data availability statement
Data are available on reasonable request.
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What is already known on this topic?
Ureteric colic puts significant strain on emergency departments and urological services across the UK.
For patients managed expectantly, patients should be followed up in clinic within 4 weeks according to national guidance.
What this study adds?
The introduction of a dedicated virtual colic clinic has shown to reduce referral times and streamline definitive management.
How this study might affect research, practice or policy?
The integration of a similar model may be beneficial to other National Health Service trusts in the UK, with modifications for patient demographics, radiological provisions and geographical locations.
Problem
Ureteric stones are a common problem and constitute a significant number of presentations to the emergency department (ED). Our urology department operates within a local urology area network comprising a teaching hospital trust and a district general hospital. All patients with acute uncomplicated ureteric colic are seen face to face in a general urology one-stop clinic setting. Current UK best practice, as evidenced by the British Association of Urological Surgeons (BAUS) guidelines, recommends a maximum 4-week timeline from diagnosis to clinic review for patients managed expectantly. However, given a patient population of over one million, and an increasing volume of presentations, this timeline can be challenging. More recently, the COVID-19 pandemic has further complicated the suitability of face-to-face consultations given social distancing rules and patient safety concerns. The primary aim of this quality improvement (QI) project was to implement a dedicated virtual clinic service for ureteric colic patients to reduce the time from referral to clinic review in order to adhere to the 4-week timeline recommended by BAUS guidelines. This intervention would in turn reduce the need for in-person consultations during the pandemic and in future, thus enabling a more efficient distribution of clinic resources to other patients.
Background
Ureteric colic is a frequent reason for acute hospital attendances across the UK.1 Patients are typically managed conservatively with analgesia and followed up in a urology clinic. The high volume of cases puts urological services under pressure, leading to an increase in time to follow-up.2 These delays can expose patients to risk, including ongoing pain and potential loss of renal function. BAUS recommend a 4-week target from diagnosis to clinic review in patients managed expectantly.3
The rapid growth of ‘Telemedicine’ and remote working in healthcare provision has been made possible through technological innovations and offers a potentially significant clinical and fiscal benefit for both patients and healthcare bodies.4 Consultations between healthcare professionals and patients can now take place within a virtual clinic, instead of the traditional face-to-face interaction model.5 The use of virtual clinics in urology have been demonstrated as an effective means to deal with the increasing demands of urological services by reducing patient waiting times, while maintaining a high standard of patient-centred care.6 7 The COVID-19 pandemic accelerated the need for a virtual healthcare framework, as physical attendance to outpatient clinics had the potential to put patients at risk of both contracting and spreading the virus. Use of a virtual clinic model offers a safe way for patients to access their care, and the growing demand for this service in response to COVID-19 has been advocated by National Health Service (NHS) guidance.8
Baseline measurement
The preliminary audit retrospectively analysed all patients referred to our urology department with uncomplicated, acute ureteric colic during a snapshot period from May to June of 2019. Patients who were admitted from the ED (ie, for stenting, primary ureteroscopy or extracorporeal shockwave lithotripsy (ESWL)) were excluded, as were patients with ‘complicated’ ureteric colic (infection, single kidney, pregnancy, urinary tract reconstruction). All patients had a CT KUB (Kidney, Ureter, Bladder) at presentation and stone size (mm) and position was confirmed by the reporting radiologist. Patients with bladder or non-obstructing renal stones without ureteric stones were excluded. The on-call urology consultant of the week would triage all urology (including stone clinic) referrals at least once per week and allocate patients into clinic slots based on clinical priority.
A total of 55 patients with ureteric calculi on imaging were referred to clinic for follow-up. Mean age was 46 years (range: 20–84 years) and mean stone size was 4.3 mm (range: 1–12 mm). The mean time from referral to clinic was 7.5 weeks (range: 3–17 weeks). Overall, 14/55 patients (25%) were reviewed in clinic within 4 weeks. Ten patients (18%) did not attend clinic. Seventy-three per cent (33/45) had further imaging, 67% (30/45) passed the index stone and 62% (28/45) were discharged without intervention. Eighteen per cent (8) of attendees were referred for ureteroscopy and 4% (2) for ESWL. The mean time from referral to first treatment was 15 weeks (range: 7–20 weeks).
In order to assess the impact of the intervention, time from referral to clinic review and the percentage of patients seen within 4 weeks was compared before and after the introduction of the virtual clinic. This was an objective and accurate measurement of how effective the intervention was in achieving the primary aim of reducing patient waiting time. This information was manually collected from clinic lists provided by urology service managers and cross checked with electronic patient record, e-noting patient information system and PACS (imaging service). Additionally, a telephone questionnaire was conducted by an independent clinician to assess patient’s experience and satisfaction with the new virtual colic clinic service. The plan–do–study–act (PDSA) cycle, a 4-stage model for continuous development was used to review the effects at several points before and after the intervention.
Design
A weekly consultant-led virtual clinic was established, solely for acute uncomplicated ureteric colic. All referrals were triaged by a consultant urologist with the aim for follow-up review to be undertaken within 4 weeks. The use of the online booking platform ‘Zesty’ was trialled to organise referral bookings and subsequent imaging, including ultrasound scans for patients.9 Patients reviewed in the virtual clinic would have one of the following outcomes: discharge, repeat imaging, a further clinic appointment or direct referral for stone intervention.
A new ‘colic’ referral pathway was designed for use in the ED (figure 1). A telephone questionnaire was conducted targeting patients who were discharged to assess their experience and satisfaction with the new service. A new patient information leaflet was produced to provide patients with relevant information of their presentation including diet and lifestyle advice.
ED flow chart renal colic. CRP - C-reactive protein; ED - emergency department; EPR - electronic patient record; CKD - chronic kidney disease; OP - outpatient.
Strategy
PDSA cycle 1
The findings of the initial audit were presented to the urology stone unit and service managers, which highlighted the shortcomings of the current service and need for improvement. The implementation of a virtual clinic to replace the traditional face-to-face consultation was discussed and suggestions on how best to facilitate this were made. It was agreed that this clinic would focus exclusively on new presentations of acute uncomplicated ureteric colic, occur weekly and reduce patient waiting times.
PDSA cycle 2
A new ureteric colic referral pathway was designed and discussed with the ED consultant lead for suggestions on its use and implementation (figure 1). Referral criteria including imaging, biochemical markers, urinalysis and severity of patient’s symptoms were examined and triggering parameters for urgent discussion with a urologist were added to the pathway. The time period between diagnosis and clinic review was made clear: a clinic appointment should be booked within 3–4 weeks for stones less than 5 mm (stone likely to pass), and within 1 week if greater than 5 mm (stone less likely to pass). Input from the referring ED team was sought and they noted that management was unclear if a patient passed a stone in the department, hence rendering them stone free (outcome: no routine follow-up required and leaflet for further stone prevention given), therefore this was added to the pathway.
PDSA cycle 3
The online booking platform ‘Zesty’ was trialled to organise appointments for both imaging and subsequent clinic review. This was positively received by the urology team as patients were given time slots immediately for their follow-up scans during their consultation, hence avoiding the need for a postal letter and further administrative tasks. Discussions were made with the ED team on how to implement direct clinic bookings using ‘Zesty’. It was felt that there would have to be a duplicate booking made on our hospital system in order to track referrals and prevent ‘lost to follow-up’ scenarios, which the ED administrative staff were unable to action. A further limitation was that the stone clinic still needed to generate a letter or text confirmation for the patient with their appointment date and time. We were then subsequently introduced to DrDoctor, which was able to send immediate text confirmation to patients with their colic clinic appointment. DrDoctor was already in use by our trust in other specialties, but it is not integrated into the existing clinic booking software. It requires an additional administrative step by the stone clinic to transfer the DrDoctor bookings onto PiMS (Patient information Management System).
ED staff were introduced on how to use this application during the daily morning briefing and an email was circulated throughout the department with user guidance. This highlighted the importance of liaising with all teams who are involved in the pathway, and the benefit of trialling other software systems to choose the best available.
PDSA cycle 4
A telephone questionnaire was carried out on patients who were discharged from the colic clinic to evaluate their experience. High satisfaction scores were reported and asymptomatic patients were found to be more amenable to telephone consultations. However, understandably if in pain, patients reported preferring to be seen in person. When asked if patients had ‘received enough information on dietary and lifestyle changes required’ the mean score was marginally lower at 3.5/5; a new patient information leaflet was designed to include detailed information on lifestyle management and distributed to patients from the ED.
Results
The reaudit analysed all patients referred with uncomplicated ureteric colic for 3 months (June–August 2020). Fifty-six patients with ureteric calculi on imaging were referred for follow-up, of which the mean age was 45 years (range 20–68) and mean stone size 3.9 mm (2–8 mm). The mean time from referral to virtual clinic review was 3.5 weeks (1.5–7 weeks). Overall, 46/56 patients (82%) were reviewed in clinic within 4 weeks. The remaining 10 patients (18%) were seen within 7 weeks, of which only 1 did not attend. In total 5% (3) did not attend clinic. Fifty-two per cent (29/56) of patients had further imaging and subsequently 84% (47) were discharged without intervention. Eleven per cent (6) were asked to return for a future clinic appointment—these patients passed their ureteric stones but were found to have concurrent non-obstructing renal calculi on imaging which required future elective management. Of those who required treatment, 5% (3) of patients were referred for ESWL and 1.8% (1) scheduled for ureteroscopic management. The mean time from referral to stone intervention was 5 weeks (range 4–7 weeks).
The mean time from referral to clinic review fell from 7.5 to 3.5 weeks, while the percentage of patients seen within a 4-week target increased from 25% to 82%. In addition, the average time from referral to stone intervention including ESWL and ureteroscopy fell from 15 to 5 weeks. The failure to attend rate dropped from 18% to 5%.
A telephone questionnaire was conducted by an independent clinician on 19 patients who were discharged from the clinic to evaluate satisfaction and experience. Overall, 12/19 (63%) were willing to have a telephone consultation in future and be discharged. However, of these 3/12 would prefer a face-to-face interaction if they were in pain or had symptoms. Most patients (17/19, 89%) were aware of the guidance to drink 2–3 L of water per day. Feeling that they had received enough information about ‘the amount of water they should drink’ was mean 4.4/5 (Likert scale 1–5), whereas for ‘dietary and lifestyle changes required’ it was 3.5/5.
Lessons and limitations
The project aim was to reduce patient waiting times for specialist clinic review and intervention for ureteric colic managed expectantly by implementing a dedicated virtual clinic. While this model has been trialled in different specialties, for example, in the management of fractures, our aim was to introduce this into a busy tertiary service focusing solely on uncomplicated ureteric colic. The use of PDSA cycles to improve and renew our strategy proved to be a useful lesson in continuous evaluation of the project (figure 2).
PDSA diagram. BAUS, British Association of Urological Surgeons; ED, emergency department; PDSA, plan–do–study–act; USS - ultrasound scan.
Feedback gained from different members of the multidisciplinary team and stakeholders involved in the project, including service managers, administrative staff, ED clinicians, clinic staff and junior doctors, proved essential in its development and an important lesson in engaging various members of the team early in the process. This identified issues within aspects of its introduction which were missed during the initial planning of the project. The insight from secretarial and IT staff on the usage of new booking platforms was valuable, and discussions with this team earlier could have anticipated potential problems with integrating a new system. Certain members of staff had prior experience of using the booking system ‘DrDoctor’, which helped to influence senior members of the ED department who were initially reluctant to transition to a new referral method, particularly due to the perceived lack of reliability of the current IT system. This highlighted important challenges of implementing policy change in a department with a longstanding routine, in which clinicians may have experienced similar unsustainable system changes.
Reporting and evaluation of this QI project limitations: the use of a snapshot cross-sectional study approach can evaluate appropriate data at a certain time point, but the benefits observed when introducing the virtual clinic could have been caused by unmeasured confounding factors. A large part of the work involved in clinic is done by the clinician prior, including the vetting process for follow-up time, reading the online referral and drafting treatment options which will play a significant role in the efficiency of the clinic and reduction in patient waiting times. Consequently, the shortening of time from presentation to clinic review is not solely associated by initiating a virtual consultation clinic, but possibly by a range of different factors that include clinic preparation and appropriate clinician triaging.
When starting this QI project, we did not have access to experts in data analysis to help implement time series data or run charts. We chose to do a pre and post audit analysis as we felt this was the most suitable way to gain results following intervention during the COVID-19 time period. We have demonstrated what is possible in day-today clinical NHS practice with no additional time, human resource and no data specialists.
The initial data collection and analyses of this project occurred prior to the COVID-19 pandemic, and the interventions involved occurred during the height of it with variable insight into the effectiveness of the projects aims. Patient arrival numbers in the ED varied throughout the pandemic; periods of low attendances were met with sudden spikes in numbers which is a significant confounding factor in assessing the effectiveness of the project’s intervention. Due to the initial positive results of our intervention—further cycles of data collection were not carried out during the remainder of the COVID-19 period. Our view was to aim for a longer-term follow-up and re-evaluation in the postpandemic era to observe any sustained change.
Conclusion
This QI project aimed to improve patient waiting times for uncomplicated ureteric colic by implementing a new dedicated virtual colic service. In response to the COVID-19 pandemic, the rapid implementation of this virtual clinic has been viewed as an acceptable method to replace traditional in-person consultations. The use of QI methodology, particularly PDSA cycles, has helped to focus resources, identify potential issues and to aid in their solutions. The introduction of this new service has reduced referral times and streamlined definitive management of ureteric colic for patients managed expectantly. The average time between referral and clinic review for this presentation is now within the 4-week target as recommended by national BAUS guidelines. Integration of a similar virtual clinic model may be beneficial to other NHS trusts in the UK; however, modifications may be required for local patient population demographics, differences in radiology and ultrasound provisions, and geographical locations.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Acknowledgments
We would like to express our appreciation for the administrative staff in Guy’s Hospital for their assistance in facilitating our data collection.
Footnotes
Contributors Conceptualisation, JC; methodology, JC and FK; data collection, JC, FK, LS, VI and RC; writing—original draft preparation, JC and FK; writing— review and editing, LS, FK, RC and SW; supervision, SW; Guarantor, JC. All authors have read and agreed to the published version of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.