Advances in Urology

Among the most prevalent causes for acute urologic consultation is nephrolithiasis. According to Ojas Shah, MD, Chief of the Division of Endourology and Director of the Comprehensive Kidney Stone Center at NewYork-Presbyterian/Columbia University Irving Medical Center, it is the number one condition that urologists see in the emergency department. Although many patients presenting to the ED with nephrolithiasis can be discharged home, those with uncontrolled pain, persistent nausea/vomiting, renal failure, or possible infection may require acute intervention. Delaying care for these patients can result in increased morbidity and mortality.

Dr. Ojas Shah

In 2015, the Department of Urology at NewYork-Presbyterian/Columbia implemented the first phase of an Acute Care Urology (ACU) service to improve outcomes for patients presenting to the ED with nephrolithiasis. The program was patterned after the Acute Care Surgery model that has become a standard for delivering emergent surgical care at many institutions throughout the world.

Previously, acute urologic consultations at the hospital had been managed by an on-call urologist, who was simultaneously holding scheduled office visits and/or performing elective surgical cases. “Because of this, patients would often undergo a stent procedure as a stopgap intervention, which delayed definitive treatment for the kidney stone,” says Dr. Shah. “Once the acute problem was managed, the patient would then be scheduled for elective surgery. However, the waiting time between patients having a stent placed to the procedure to treat the kidney stone could take several weeks, and at some institutions the waiting period could be months. By putting in a stent and not actually treating the stone, theoretically you are prolonging the period of how long the stone is causing an issue and decreasing the quality of life for the patient.”

Leaving a stent in for a long period of time is uncomfortable for the patient and could cause infection, voiding symptoms, hematuria, and pain severe enough to require management with analgesics (and quite often narcotic analgesics). In addition, protracted indwelling stents are susceptible to encrustation and obstruction, and nephrostomy tubes are at risk for dislodgement, infection, bleeding and clogging. With this in mind, the Columbia urologists were seeking an approach to care for patients presenting to the ED with nephrolithiasis that would reduce the time-to-treatment interval, thereby minimizing the risk for adverse events, stent morbidity, and the use of opioids.

The Acute Care Urology service model was implemented in two phases. The first phase involved a rotation of five urologists who managed acute care at NewYork-Presbyterian/Columbia during the weekdays, separate from the on-call physician. The ACU physician was responsible for rounding with a resident on all acute urology consults, signing consult notes, and performing any acutely indicated interventions. On nights and weekends, all acute issues continued to be managed by the on-call urologist. Through the ACU service, most patients were able to see a subspecialty-trained urologist during their hospital stay or shortly after discharge.

To further improve continuity of care, the second phase of the program rolled out in 2018 with a dedicated ACU resident who rotated monthly through the service. The ACU service also began to include urology fellows in the weekly rotation, always with a faculty urologist available as backup.

Gauging the Effectiveness of the ACU Service

To understand the impact and benefit of the ACU Service, Dr. Shah and his colleagues conducted a retrospective review from 2013 to 2019 of all patients in the Emergency Department at NewYork-Presbyterian/Columbia who underwent urology consults for nephrolithiasis and required surgical intervention. Patients were divided into three cohorts:

• Pre-ACU (2013 to 2014)
• Phase 1 (2015 to 2017)
• Phase 2 (2018 to 2019)

The Columbia team drew on medical records for demographic and clinical data and identified three categories of clinical infection status: sepsis, suspected infection, and no infection. The primary outcome was time from consult to a definitive stone procedure. Stent/nephrostomy removal was considered the definitive procedure for patients who did not require an additional intervention for the stone.

Before the ACU service was implemented, the median time from consult to definitive intervention was 36 days. After implementation, median time to intervention decreased to 22 days in Phase 1 and 15 days in Phase 2, including a significant increase in primary ureteroscopic intervention at the time of ED presentation.

In their review, the results of which were published in the March 2022 issue of the Journal of Endourology, Dr. Shah and his colleagues identified:

• 733 patients who had urology consults for nephrolithiasis requiring acute intervention:
  • 162 pre-ACU
  • 334 Phase 1
  • 237 Phase 2
• Before ACU implementation, the median time from consult to definitive intervention was 36 days
• After ACU implementation, median time to intervention decreased to 22 days in Phase 1 and 15 days in Phase 2
• Rates of the primary definitive intervention without initial decompression and loss of patients to follow-up were also significantly improved compared to the pre-ACU cohort

In the five years since establishing the ACU service, the Columbia team “found a substantial and durable improvement in timeliness and quality of care for patients with acute nephrolithiasis. The ACU service was associated with decreased time to definitive intervention, increased likelihood of primary definitive intervention, and improved rates of follow-up.”

“We manage close to 800 to 1,000 ureteroscopies a year from our team of urologists, of which probably a minimum of four a week come through the ED,” says Dr. Shah. “In addition to treating kidney stones, the Acute Care Urology service helps us manage patients presenting to the ED with any acute urologic condition. Logistically it makes sense.”

Dr. Shah and his team have also developed a protocol for the management of obstructive pyelonephritis and kidney stones with plans to establish the program across the NewYork-Presbyterian enterprise. In addition, colleagues at other hospitals have shown an avid interest in starting similar Acute Care Urology services.

Adds Dr. Shah, “Hopefully other places can develop the same type of acute care program as ours to expedite care for patients with kidney stones and spare them needless pain and discomfort.”