1. Choosing wisely @ Monash Health
Renal Colic Management
Gabriel Blecher
Director of Quality and Safety, Emergency Department, Monash Medical Centre

2. Choosing Wisely Australia challenges the way we think about health care, questioning the notion
'more is always better'.
Working with the professional colleges to form recommendations for best practice based on:
best available evidence
truly necessary
minimising patient harm
Choosing Wisely is an international campaign starting in America (American Board of Internal Medicine) and spreading to Canada, UK, Australia and some parts of Europe.
Choosing Wisely Australia is a NPS MedicineWise initiative and is helping the healthcare community and consumers start an important conversation about eliminating the use of unnecessary, and sometimes harmful, tests, treatments and procedures

3. Choosing Wisely @ Monash Health
Monash Health’s Strategic intent –
“relentless pursuit of excellence”
This important work is aligned with several of Monash Health’s Strategic Plan principles but in particular:
“We consistently provide safe, high quality and timely care”
Monash Health is currently focusing on 2 clinician led initiatives supported by professional college recommendations.
Reducing unnecessary testing and treatment of asymptomatic bacteriuria and
Reducing unnecessary radiation exposure from CTU in patients with suspected renal colic

4. The Problem
The median was 6mSv (300 CXRs = 2.6 yrs of background radiation) with a range of 2-15, within a year. They directly investigated and extrapolated the radiation dose received, almost half the patients received more than 50mSv, which is more than the yearly dose of a worker in a nuclear power plant. One in ten patient were exposed to more than the five year dose allowance. This research is consistent with international evidence and of particular concern because renal colic is so common, a young persons disease and recurrent.
There was a ten-fold difference in mSv with different providers. There is now consensus that a low dose CTU should be no more than 4mSv.

5. Imaging use and kidney stone diagnosis, as a proportion of flank pain presentations (Hyams et al. JURO 2011)
= CT
= Kidney stones diagnosed
So a few people were getting burnt but what about the general population of patients with suspected renal colic? A literature revealed fertile ground for over investigation and diagnosis.
As you can see the rates of CT ordering increasing in a linear fashion, while diagnosis remains unchanged.

6. Gaby Blecher performed this retrospective review of over 600 patients having CTU at Monash Health three EDs. We found only 15% lead to any urological intervention and alternate diagnosis were uncommon with less than 3% being emergent. This figure of at least 85% of stones passing spontaneously is consistent with international evidence. It doesn’t include the people with spontaneous stone passage who don’t have a CTs. Surprising the evidence tells us what we already knew from our clinical experience - renal colic while often dramatic is a largely benign self-limiting condition.

8. Imaging for suspected renal colic in the Emergency Department: A prospective cohort study
As with most research we concluded that more research was needed and Shirley Wong performed one of the few prospective studies internationally. These results have been presented at the 2014 ASM. We enrolled 220 patients with suspected renal colic over a three-month period at two EDs. We wanted to see what proportion of patients with suspected renal colic was having CTU performed and if the CTU changed management or found important alternate diagnosis.
Results:
74% underwent CTU
74% of these were positive for a stone
18% underwent intervention
Alternate diagnosis in 2.5%
Shirley Wong
Diana Egerton-Warburton
Robert Meek
Gabriel Blecher
Philip McCahy
Presented at the ACEM ASM, 2014

9. 28th February 2011 Presentation title
Introduction of a revised protocol to Clayton reduced CTU proportion from 76% to 54%;
No change to protocol was made at Dandenong – and the proportion was 72% initially and 75% post intervention.
28th February 2011
Presentation title

10. RED FLAGS F Fever or clinical UTI L Loss of renal function
AG AGe >50 years
S Suspect other
causes

11. Key POINTS: RENAL COLIC @ MOnash
Only 1 in 7 patients at Monash require urological intervention for renal colic - usually delayed
75% of patients underwent a CTU
Stone detection rates in patients undergoing CTU were below 60%
< 3 % of CT scans discover an acutely important alternate diagnosis
CTU use could be better targeted by introducing a guideline incorporating ‘red flags’ and monitoring response to analgesia
The issue of potential patient harm relating to the unnecessary contribution to cumulative radiation and incidental findings is of concern
While dramatic in presentation, only 1 in 7 patients at Monash require urological intervention for renal colic, and usually in a delayed manner.
In a Monash retrospective study 75% of patients with suspected renal colic underwent a CTU

12. NEW Guideline ‘Renal Colic (Adult) Emergency Department’
Developed in consultation with Urology, Digital Imaging, Emergency
Will be considered by Clinical Council on November 27th

13. implementation Raise Awareness Registrar / Consultant education
Engagement of key stakeholders
Build electronic integration
Ultrasound training
Patient awareness
Raise Awareness – posters, s, ducks
Registrar / Consultant education – please have the conversation with your colleagues
Engagement of key stakeholders – consider influence on junior doctors
Build electronic integration – EMR and Symphony prompts
Ultrasound training - continuing
Patient awareness – patient flyer, survey (possibly)

14. TIMELINE Guideline consultation Clinical guideline Audit #1 Audit #3
BCV funded project officer
BCV Status update
BCV Status update
Baseline data
Intervention
Awareness campaign
Staff education
The working group commenced some time ago - lead by Gabriel Blecher and supported by CCE to commence planning implementation.
An injection of funds from Better Care Victoria allowed recruitment of a project officer dedicated to supporting implementation.
BCV final report due -

15. Junior doctor perceptions
Registrar and Consultant role:
From a qualitative study with Junior medical staff in Sydney, factors contributing to over ordering were identified. These are also factors consistent with anecdotal information and initial Monash survey results.
“Over ordering occurs when there are high social cost to JMO’s for under-ordering, and little cost for over-ordering.”
Key concerns:
Testing is not considered a risk to the patient
Fear of negative feedback for under-ordering or for asking too many questions – no feedback or setting of expectations for over-ordering
Seniors’ instruction over-rides clinical guidelines
Medico legal concerns only relate to missing a diagnosis and not for breaching clinical guidelines?
Consequences of over-ordering versus under-ordering

16. Patient support
Patient expectations for renal colic management may be influenced by outside sources or past experience outside Monash Health control, therefore patient support through careful explanation will be required. 
To assist with consumer acceptance of being discharged without receiving a CTU, a patient information flyer has been developed for distribution at the point of care.

17. Audit and feedback
Utilise Symphony patient record information and Digital Imaging RIS data to compare pre and post implementation.
For ED patients aged < 50 years, based on the presenting problem or diagnosis in Symphony matching a specified criteria – will measure how many receive a CTU.
Limitations:
Systematic review is limited without EMR
Diagnosis is not always conclusive on discharge
Understand the data will not capture all suspected cases accurately however is expected to be a suitable comparator
Monthly feedback will be distributed by site
(Criteria = Renal colic, renal problem, urinary calculus, loin pain, groin pain, urinary problem)

18. Baseline

19. ChoosingWisely@monashhealth.org queries Questions?
We are looking at having an award for the best implementation of a Choosing Wisely initiative on an ongoing basis