Emergency department (ED) visits after ureteroscopy (URS) for urinary stone disease are significant events for both patients and providers. To inform future efforts targeted at reducing postoperative ED visits, we assessed their frequency and drivers using clinical registry data from the Michigan Urological Surgery Improvement Collaborative (MUSIC).
Reducing Operative Complications from Kidney Stones (ROCKS) is an initiative from MUSIC involving 11 diverse urology practices consisting of 64 urologists in the State of Michigan. For patients with upper tract stones undergoing URS, trained abstractors prospectively record standardized data elements from the health record in a web-based registry including patient demographics, comorbidity, stone characteristics, and surgical details. We identified all patients undergoing a primary URS treated between August 2016 and September 2017. We determined the proportion that had an ED visit within 30 days of surgery, and we evaluated preoperative and operative factors associated with such a visit.
1278 URS procedures were analyzed. At the time of surgery, 36% had an indwelling ureteral stent. Usage of ureteral access sheaths and fragment retrieval were 39% and 60%, respectively. Post-operative ureteral stents were placed in 74% (practice variation from 44% to 98%). The overall ED visit rate was 9.2%. Frequency of ED visits among 9 practices performing >10 cases varied from 2.5% to 12.2% (Fig. 1a). Most (73%) ED visits occurred in the first 7 days. Factors significantly associated (p<0.01) with higher rates of ED visits included patient comorbidity, positive preoperative urine culture, renal (vs ureteral) stone location, ureteral dilation at time of surgery, placement of stent on string, and presence of residual fragments. Flank pain/hematuria/urinary symptoms accounted for 42% of ED visits, and of these, 73% had a stent placed after URS (Fig. 1b).
Nearly 1 in 10 patients among diverse urology practices in Michigan visit the ED within 30 days after URS. Our analysis reveals that nearly half of these encounters are related to potentially modifiable factors such as procedural pain and stent symptoms that may be targeted using quality improvement strategies aimed at patient education.