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Patient and institutional characteristics associated with initial computerized tomography in children presenting to the emergency department with kidney stones.

ABSTRACT: Professional associations recommend ultrasound as the initial imaging study in children with suspected nephrolithiasis but computerized tomography remains frequently used. We identified patient and institutional characteristics associated with computerized tomography as the first imaging study in children with nephrolithiasis diagnosed in the emergency department.We performed a cross-sectional study of children 2 to 18 years old with nephrolithiasis who were referred to a freestanding pediatric hospital from 2003 to 2012. We identified the imaging modality first used to evaluate the child. Medical directors at the emergency department where children were first evaluated were sent a questionnaire to ascertain emergency department characteristics. Multivariate hierarchical logistic regression models were used to determine patient and institutional characteristics associated with initial computerized tomography.Of 536 eligible children 323 (60.2%) were evaluated at emergency departments from which surveys were returned. Of the 323 children 238 (71%) underwent computerized tomography as initial imaging. Ultrasound was available at all emergency departments. Older patient age was associated with higher initial computerized tomography use (OR 1.09, 95% CI 1.04-1.16). A more recent year of diagnosis (OR 0.80, 95% CI 0.72-0.88) and a clinical care pathway that used ultrasound as initial imaging (OR 0.29, 95% CI 0.01-0.38) were associated with lower initial computerized tomography use.A clinical care pathway in the emergency department was the only institutional characteristic associated with lower computerized tomography use. Future studies are needed to determine whether care pathways using ultrasound for initial imaging in children with suspected nephrolithiasis would decrease inappropriate computerized tomography and improve adherence to national guidelines.

SUBMITTER: Ziemba JB

PROVIDER: S-EPMC5070648 | biostudies-literature | 2015 May

REPOSITORIES: biostudies-literature

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Patient and institutional characteristics associated with initial computerized tomography in children presenting to the emergency department with kidney stones.

Ziemba Justin B JB Canning Douglas A DA Lavelle Jane J Kalmus Angela A Tasian Gregory E GE

The Journal of urology 20141008 5 Suppl

<h4>Purpose</h4>Professional associations recommend ultrasound as the initial imaging study in children with suspected nephrolithiasis but computerized tomography remains frequently used. We identified patient and institutional characteristics associated with computerized tomography as the first imaging study in children with nephrolithiasis diagnosed in the emergency department.<h4>Materials and methods</h4>We performed a cross-sectional study of children 2 to 18 years old with nephrolithiasis ...[more]

PMID: 25305359

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Project description:PurposeMore than 1 million patients annually seek care in an emergency department for kidney stones but a minority require hospital admission or a urological procedure. We describe predictors of hospital admission or urological intervention.Materials and methodsThis secondary analysis of prospective data included patients with an obstructing ureteral stone that was confirmed by computerized tomography in an emergency department. All patients also underwent point of care limited renal ultrasound. The need for urological intervention at 90 days was assessed by a followup interview. Logistic regression was used to identify predictors of admission and urological intervention, which were further stratified by disposition. Separate regression models with and without computerized tomography findings (point of care limited renal ultrasound only) were compared using c-statistics.ResultsAmong a cohort of 475 patients with a symptomatic stone on computerized tomography 95 (20%) were admitted and 68 (72%) received an intervention. Of 380 discharged patients 66 (17%) required urological intervention. Admitted patients were more likely to have undergone a prior procedure, have evidence of kidney injury or infection, need opiate analgesia or have larger stones or hydronephrosis on point of care limited renal ultrasound. Predictors of intervention varied by disposition. However, regression models with and without computerized tomography findings demonstrated similar c-statistics. Discharged patients with larger stones, a longer pain duration at presentation and prior procedures were more likely to undergo intervention.ConclusionsIntervention was common among admitted patients but it occurred in a minority of those discharged. Predictors of intervention varied by disposition. Models incorporating computerized tomography findings were similar to those that did not incorporate such findings. These data support ultrasound first or delayed computerized tomography diagnostic pathways for patients deemed clinically suitable for discharge home.

Project description:ObjectivesKidney stones affect nearly one in 11 persons in the United States, and among those experiencing symptoms, emergency care is common. In this population, little is known about the incidence of and factors associated with repeat emergency department (ED) visits. The objective was to identify associations between potentially mutable factors and the risk of an ED revisit for patients with kidney stones in a large, all-payer cohort.MethodsThis was a retrospective cohort study of all patients in California initially treated and released from EDs for kidney stones between February 2008 and November 2009. A multivariable regression model was created to identify associations between patient-level characteristics, area health care resources, processes of care, and the risk of repeat ED visits. The primary outcome was a second ED visit within 30 days of the initial discharge from emergent care.ResultsAmong 128,564 patients discharged from emergent care, 13,684 (11%) had at least one additional emergent visit for treatment of their kidney stone. In these patients, nearly one in three required hospitalization or an urgent temporizing procedure at the second visit. On multivariable analysis, the risk of an ED revisit was associated with insurance status (e.g., Medicaid vs. private insurance; odds ratio [OR] = 1.52, 95% confidence interval [CI] = 1.43 to 1.61; p < 0.001). Greater access to urologic care was associated with lower odds of an ED revisit (highest quartile OR = 0.88, 95% CI = 0.80 to 0.97; p < 0.01 vs. lowest quartile). In exploratory models, performance of a complete blood count was associated with a decreased odds of revisit (OR = 0.86, 95% CI = 0.75 to 0.97; p = 0.02).ConclusionsRepeat high-acuity care affects one in nine patients discharged from initial emergent evaluations for kidney stones. Access to urologic care and processes of care are associated with lower risk of repeat emergent encounters. Efforts are indicated to identify preventable causes of ED revisits for kidney stone patients and design interventions to reduce the risk of high-cost, high-acuity, repeat care.

Project description:Study objectiveReduced-dose computed tomography (CT) scans have been recommended for diagnosis of kidney stone but are rarely used in the emergency department (ED) setting. Test characteristics are incompletely characterized, particularly in obese patients. Our primary outcome is to determine the sensitivity and specificity of a reduced-dose CT protocol for symptomatic ureteral stones, particularly those large enough to require intervention, using a protocol stratified by patient size.MethodsThis was a prospective, blinded observational study of 201 patients at an academic medical center. Consenting subjects underwent both regular- and reduced-dose CT, stratified into a high and low body mass index (BMI) protocol based on effective abdominal diameter. Reduced-dose CT scans were interpreted by radiologists blinded to regular-dose interpretations. Follow-up for outcome and intervention was performed at 90 days.ResultsCT scans with both regular and reduced doses were conducted for 201 patients, with 63% receiving the high BMI reduced-dose protocol. Ureteral stone was identified in 102 patients (50.7%) of those receiving regular-dose CT, with a ureteral stone greater than 5 mm identified in 26 subjects (12.9%). Sensitivity of the reduced-dose CT for any ureteral stone was 90.2% (95% confidence interval [CI] 82.3% to 95.0%), with a specificity of 99.0% (95% CI 93.7% to 100.0%). For stones greater than 5 mm, sensitivity was 100% (95% CI 85.0% to 100.0%). Reduced-dose CT identified 96% of patients who required intervention for ureteral stone within 90 days. Mean reduction in size-specific dose estimate was 18.6 milligray (mGy), from 21.7 mGy (SD 9.7) to 3.4 mGy (SD 0.9).ConclusionCT with substantial dose reduction was 90.2% (95% CI 82.3% to 95.0%) sensitive and 98.9% (95% CI 85.0% to 100.0%) specific for ureteral stones in ED patients with a wide range of BMIs. Reduced-dose CT was 96.0% (95% CI 80.5% to 99.3%) sensitive for ureteral stones requiring intervention within 90 days.

Project description:BackgroundRapid magnetic resonance imaging (MRI) protocols may be effective in the emergency department (ED) to evaluate nontraumatic neurologic complaints. We evaluate neuroimaging (rapid MRI [rMRI]), head computerized tomography [HCT], and full MRI) use following widespread implementation of rMRI protocols in a pediatric emergency department (ED).MethodsWe conducted a retrospective study in a tertiary care pediatric ED of encounters with neuroimaging during two 9-month periods: one prior to (control period) and one after generalized availability of 4 rMRI protocols (rMRI period). The primary outcome was differences in neuroimaging rates between the two periods. Secondary outcomes included ED process measures, unsuccessful imaging, and undetected pathology, with full MRI within 14?days as the reference standard.ResultsThere were 1052 encounters with neuroimaging during the control and 1308 during the rMRI periods. Differences in neuroimaging between periods were 27.7% for rMRI (95% CI, 24.4, 31.0), -?21.5% for HCT (95% CI, -?25.5, -?17.5), and?-?6.2% for full MRI (95% CI, -?9.3, -?3.1%.) Time to imaging (182 [IQR 138-255] versus 86 [IQR 52-137] minutes) as well as ED length of stay (396 [IQR 304-484] versus 257 [IQR 196-334] minutes) was longer for rMRI versus HCT (p?<?0.01). Between the control and rMRI periods, there were differences in types of neuroimaging performed for patients with altered mental status, headache, seizure, shunt dysfunction, stroke, syncope, trauma, vomiting, infection, and other neurologic complaints (p?<?0.05). rMRI studies were unsuccessful in 3.6% of studies versus 0.0% of HCTs (p?<?0.01). The 22 unsuccessful rMRI studies were unsuccessful due to artifacts from dental hardware (n?=?2) and patient motion (n?=?20). None of the rMRI studies with full MRI follow-up imaging had undetected pathology; the false negative rate for the HCT exams was as high as 25%.ConclusionsAfter routine ED use of 4 rMRI protocols, there was a more than 20% decrease in HCT use without missed diagnoses. Time to neuroimaging and length of stay were longer for rMRI than HCT, with higher rates of unsuccessful imaging. Despite these limitations, rMRI may be an alternative to HCT for nontraumatic complaints in the ED.

Project description:BackgroundEmergency Department (ED) visits for suicide attempts have been described worldwide; however, the populations studied were predominantly Western European, North American, or East Asian. This study aims to describe the epidemiology of ED patients presenting post-suicide attempt to an academic medical center in Lebanon and to report on factors that affect ED disposition.MethodsA retrospective cohort study was conducted between 2009 and 2015. Patients of any age group were included if they had presented to the ED after a suicide attempt. Patients with unintentional self-harm were excluded. Descriptive analysis was performed on the demographics and characteristics of suicide attempts of the study population. A bivariate analysis to compare the two groups (hospitalized or discharged) was conducted using Student's t test and Pearson Chi-square where appropriate. A multivariate analysis was then conducted to determine the predictors of hospital admission.ResultsOne hundred and eight patients were included in the final analysis. Most patients were females (71.4%) and between 22 and 49 years of age. A considerable number of patients were unemployed (43%), unmarried (61.1%), and living with family (86.9%). Most suicide attempts were performed at home (93.5%) and on a weekday (71.3%). The most common mechanisms of injury were overdose with prescription medications (61.3%), overdose with over-the-counter drugs (27.9%), and self-inflicted lacerations (10.1%). The classes of medication most commonly abused were benzodiazepines (39.3%) followed by acetaminophen (27.3%). A large portion of our patients were admitted (70.3%), with the majority going to the psychiatric ward (71.1%). Of note, a quarter (27.5%) of our patients left the ED against medical advice, with 23.5% of admitted patients leaving the hospital before completion of treatment. The main predictors of admission were found to be overdose on prescription medications OR 9.25 (2.12-40.42 CI95%).ConclusionsThe characteristics of our suicide attempters mirror those of international and regional suicide attempters. Further work is required to quantify the effect of voluntary refusal of hospital treatment, the repercussions of family, and financial barriers to healthcare and suicide as a whole in our society.

Project description:Background and objectivesIn 2011, there were approximately 131 million visits to an emergency department in the United States. Emergency department visits have increased over time, far outpacing growth of the general population. There is a paucity of data evaluating emergency department visits among kidney transplant recipients. We sought to evaluate the incidence and risk factors for emergency department visits after initial hospital discharge after transplantation in the United States.Design, setting, participants, & measurementsWe identified 10,533 kidney transplant recipients from California, New York, and Florida between 2009 and 2012 using the State Inpatient and Emergency Department Databases included in the Healthcare Cost and Utilization Project. We used multivariable Poisson and Cox proportional hazard models to evaluate adjusted incidence rates and time to emergency department visits after transplantation.ResultsThere were 17,575 emergency department visits over 13,845 follow-up years (overall rate =126.9/100 patient-years; 95% confidence interval, 125.1 to 128.8). The cumulative incidences of emergency department visits at 1, 12, and 24 months were 12%, 40%, and 57%, respectively, with median time =19 months; 48% of emergency department visits led to hospital admission. Risk factors for higher emergency department rates included younger age, women, black and Hispanic race/ethnicity, public insurance, depression, diabetes, peripheral vascular disease, and emergency department use before transplant. There was wide variation in emergency department visits by individual transplant center (10th percentile =70.0/100 patient-years; median =124.6/100 patient-years; and 90th percentile =187.4/100 patient-years).ConclusionsThe majority of kidney transplant recipients will visit an emergency department in the first 2 years post-transplantation, with significant variation by patient characteristics and individual centers. As such, coordination of care through the emergency department is a critical component of post-transplant management, and specific acumen of transplant-related care is needed among emergency department providers. Additional research assessing best processes of care for post-transplant management and health care expenditures and outcomes associated with emergency department visits for transplant recipients are warranted.

Project description:BackgroundThe emergency department (ED) triage system to classify and prioritize patients from high risk to less urgent continues to be a challenge.ObjectiveThis study, comprising 80,433 patients, aims to develop a machine learning algorithm prediction model of critical care outcomes for adult patients using information collected during ED triage and compare the performance with that of the baseline model using the Korean Triage and Acuity Scale (KTAS).MethodsTo predict the need for critical care, we used 13 predictors from triage information: age, gender, mode of ED arrival, the time interval between onset and ED arrival, reason of ED visit, chief complaints, systolic blood pressure, diastolic blood pressure, pulse rate, respiratory rate, body temperature, oxygen saturation, and level of consciousness. The baseline model with KTAS was developed using logistic regression, and the machine learning model with 13 variables was generated using extreme gradient boosting (XGB) and deep neural network (DNN) algorithms. The discrimination was measured by the area under the receiver operating characteristic (AUROC) curve. The ability of calibration with Hosmer-Lemeshow test and reclassification with net reclassification index were evaluated. The calibration plot and partial dependence plot were used in the analysis.ResultsThe AUROC of the model with the full set of variables (0.833-0.861) was better than that of the baseline model (0.796). The XGB model of AUROC 0.861 (95% CI 0.848-0.874) showed a higher discriminative performance than the DNN model of 0.833 (95% CI 0.819-0.848). The XGB and DNN models proved better reclassification than the baseline model with a positive net reclassification index. The XGB models were well-calibrated (Hosmer-Lemeshow test; P>.05); however, the DNN showed poor calibration power (Hosmer-Lemeshow test; P<.001). We further interpreted the nonlinear association between variables and critical care prediction.ConclusionsOur study demonstrated that the performance of the XGB model using initial information at ED triage for predicting patients in need of critical care outperformed the conventional model with KTAS.

Dataset Information

Patient and institutional characteristics associated with initial computerized tomography in children presenting to the emergency department with kidney stones.

Publications

Patient and institutional characteristics associated with initial computerized tomography in children presenting to the emergency department with kidney stones.

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