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Specialty: Emergency Medicine, Urology, Radiology

Keywords: renal colic, ultrasonography, delphi-method

Background:  There are about 2 million emergency department visits in the United States annually due to renal colic. In over 90% of diagnosed cases of kidney stones, CT is performed and its utilization has significantly increased for suspected renal colic. However, patient-centered outcomes, such as admission rate, urologic intervention rates, and costs remain unchanged. Although CT is highly accurate, it exposes patients to significant ionizing radiation and is not necessary in all presentations of renal colic. In 2014, the STONE trial demonstrated that ultrasonography reduced radiation exposure without adversely affecting patient outcomes compared to CT. In 2019, Moore et. al conducted a systemic review and multi-specialty consensus that showed   point-of-care ultrasound or no additional imaging could be safely used in 76% of cases. Despite this evidence, ultrasound remains underutilized and is used in less than 7% of kidney stone cases and reduced radiation dose CT is used in fewer than 10% of patients. There continues to be a significant gap between evidence-based recommendations and current clinical practice. 

Objective: Current imaging practices for patients with suspected renal colic have not been systematically evaluated at Olive View-UCLA. This study investigates baseline provider imaging preferences in emergency medicine, radiology, and urology across 16 selected clinical scenarios of renal colic. We will compare institutional consensus to prior evidence-based guidelines (Moore et al, 2019) to identify practice patterns, knowledge gaps and interspecialty disagreement. We plan to develop evidence-based, multispecialty clinical guidelines and an educational intervention such as a clinical decision algorithm tool to bridge the gap between current practice and evidence based recommendations. 

Methods: This study uses the modified Delphi process, we surveyed full-time attending physicians across emergency medicine, radiology and urology at Olive View-UCLA, targeting a 70% response rate per department. Participants will meet to discuss and evaluate optimal imaging strategies across 16 scenarios of renal colic. After consensus is reached, we plan to compile these results to inform institution-specific imaging guidelines and outline a clinical decision algorithm tool or visual flow chart. The drafted guidelines will be further revised with department leadership, survey participants and other stakeholders with an educational intervention prior to implementation of suggested guidelines. 

Results: Data collection is still ongoing, preliminary results will be presented at Discovery Scholarship Day. Initial survey results will be analyzed to identify baselines preferences and areas of variation amongst specialties. We will compare alignment and gaps between institutional practice patterns to Moore et. al. consensus and employ iterative Delphi rounds until consensus threshold is met. These findings will inform draft guidelines, which will be reassessed following an educational intervention to evaluate shifts in provider knowledge and practice preferences. 

Conclusions: We anticipate that multispecialty consensus on optimal imaging across different clinical scenarios will be reached, with the majority supporting the use of ultrasonography over CT. Findings intend to inform institutional guidelines for imaging utilization in the setting of suspected renal colic in the acute setting. By aligning provider imaging preferences with currently established evidence based guidelines, we expect to improve interspecialty agreement and guideline adherence at our institution. The resulting clinical decision tool and educational intervention aims to standardize care, reduce unnecessary radiation exposure and serve as a reproducible model for other academic centers seeking to optimize imaging practices for renal colic.