Re-audit to optimise computed tomography kidneys, ureters, bladder (CT KUB) imaging in investigation of renal colic Dr Adesh Ajmani, Foundation Doctor

Background Aim

Renalstones or calculiaremade of crystalloidandorganicmatrix.Thepassage of thesestonesthroughtheurinarytractcanresult in acuterenalcolicpain.This is acommonconditionand typicallyaffectspeoplebetweentheages 20-40;moreoftenaffectingmenthanwomen.Symptomsincludeabdominalpain in theflankregionwhichmayradiate to thegroinand is intermittently like spasms.Theymayhavefever,sweats,nausea,vomitingandhaematuria.Thegoldstandard to investigaterenalcolic is withnon-contrastcomputedtomographykidneys, ureters,bladder(CTKUB) in UK practice.Thisimagingmodalityworks by usingx-ray beamsthatrotate in acirclearoundthebodywhichallowsdifferentviews(axial,coronalandsagittal) to be generated.Therearerisksinvolvedwith CT scanningdue to theradiationexposure.Onlyessentialanatomicalareasshould be scanned to ensurethepatient is notexposed to excess radiation. In theinstance of CT KUB,onlytheupperpole of thehighestkidneyneeds to be scanned.Scanninghigherthanthispoint is notneeded.

An initialauditwascarriedout in 2017 to assess if patientsbeinginvestigatedforrenalcolicwithnon-contrast CT KUB at St HelensandKnowsleyteachinghospital(STHK)werebeingoverscannedandreceivedunnecessaryradiation.Theyhadfoundthat 26% of patientswerebeingscannedaspertheauditstandard.

Further,theaim of the re-auditconducted in 2019was to assess if therehasbeen an improvement in results of patientsbeingscannedaspertheauditstandard. To assesshowcurrent practice is compared to bestpractice.

Standard/Method Results

Local standard at STHKoutlines that 100% of CT KUB scans carried out should not exceed 10% excess scan length. Radiographers scan two scout views -lateral and coronal -from above the upper pole of the kidney to below the pubic symphysis. If the kidneys are not visible on the scout, then the radiographer should scan from the middle of the stomach.

Summary of audit standard

Title of guideline Non-contrast KUB (CURIT) guideline

Setting Local (STHK)

Standard Excess scan length above upper pole of highest kidney should not exceed more than 10% of total scan length

Criteria Coronal scout is used to plan the scan and visualise the upper pole of the kidney

Exception If kidney is not visualised on the coronal scout, then the patient should be scanned from the middle of the stomach

Target 100% of CT KUB performed for investigation of renal colic Suggested number

Patients who had CT Urinary tract without contrast between 6/5/2019 to 17/6/2019 were searched using PACS. This totalled 201 patients.

Systematicsamplingwasused to collectdatafroma samplesize of 100 patients.Their CT KUBscanwas measured in coronalsection.Thedistancebetween theupperpole of thehighestkidneyandthetop of the scanwasmeasured in mm.Thenthetotallength of scanwasmeasured in mm.This is shown in figure1

The percentage of over scan was calculated as follows:

Over scan = excess scan length. 59 patients were over scanned. Of those 59, 32 had the upper pole of the upper pole of the kidney. 3 patients scans were unable to be measured because in these cases the upper pole of the highest kidney had not been scanned and cut off. One of these 3 patients had had a second series done to include the upper pole. The finding from this audit compared to the results from the audit in 2017 can be seen in the table below.

As per the audit standard, no more than 10% was allowed. In cases where there was over-scan the coronal scout image was visualised to assess whether the upper pole of the kidneys could be seen. This is shown in figure 2 and 3.

Therehasbeen a reduction in the number of patients being over scanned in practice compared to the results in the last audit. However, the audit standard target has not been met. Also, 1/3 patients that had been under scanned required a second series which meant the patient was exposed to higher levels of radiation. The recommendation is that the findings are presented at the audit meeting. This means positive feedback can be given but provides opportunity to encourage further vigilance and recap the trust guidelines. Should it be necessary, staff could receive further training.

Strengths and limitations of this audit: reasonable sample size of 100 patients to ensure that there were a sufficient data X only included patients within a 6 week time frame X only 1 person was assessing the coronal scouts which allows for observer bias

Discussion Conclusion

Thisauditshowsevidence in thereduction of patientsbeingoverscannedwhen investigatedforrenalcolicwith CT KUB;morepatientsarebeingscannedasperthe standardcompared to theresults in 2017

Introduction

RCP Guideline for Stroke recommends urgent CT scan for patients within 1 hour of hospital admission for suspected acute stroke1

Door to scan time is an important measure used to compare performance across stroke units nationally. An urgent CT head scan is vital to deliver appropriate treatment promptly, particularly in the context of thrombolysis (which has a narrow time window of 4.5 hours from time of symptom onset).

Delays in CT scanning for stroke patients

Dr T. Ambulkar, Dr. P. Meenamkuzhy-Hariharan Nottingham University Hospitals NHS Trust

Results

First audit cycle (February –March 2021)

Learning points

• Importance of raising awareness in frontline healthcare professionals about the importance of an urgent CT head (including indications for urgent scanning)

• Low threshold for clinical suspicion of stroke –if in doubt, escalate to a senior/stroke specialist

Future plans

• Continue to audit door to scan times and compare local performance with national data

• Raise awareness about the indications for urgent CT scanning in stroke patients

• Endeavour to improve data collection on qualitative reasons for scan delay (for e.g. recording reason for delayed scan in admission booklets)

PDSA Methodology

First audit cycle:

• 56.0% of all patients with suspected stroke scanned within 1 hour

• Most important qualitative reasons for scan delay:

• Others: delayed medical clerking/triage

• CT scan associated factors

• Complex clinical assessment

Second audit cycle (September –October 2021)

Methodology

• Random selection of 75 patients admitted to to the Stroke Department, Queens Medical Centre (Nottingham)

• 2 completed audit cycles:

First cycle data collection: February-March 2021

Second cycle data collection: September –October 2021

• Electronic information sources used: DHR/Medway/NOTIS/Nervecentre

• Data collection proforma used

• Percentage of scans occurring within 60 minutes were compared to percentage of scans being performed after 1 hour

• Potential qualitative factors that could contribute to scan delay were identified: Ø CT scan associated factors; difficult cannulation; complex clinical assessment

Second audit cycle:

• 46.7% of all patients with suspected stroke scanned within 1 hour

• Most important qualitative reasons for scan delay were identified as:

• Complex clinical assessment: atypical presentation of strokes (generally unwell, dizziness)

• CT scan associated factors: limited scanning facilities, scan requested promptly but performed late

Conclusions

There was a reduction in number of scans being performed within 60 minutes when the results from the second cycle are compared to the first cycle. However, not all patients included fit the criteria for an urgent CT scan.

Complex clinical assessment and delayed medical triage and clerking (in the Emergency Department) are the most important factors contributing to scan delay. Emphasis on improving these factors through educational seminars on stroke presentation and increasing collaboration between the Stroke department and the Emergency Department may help improve door to scan times.

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References

1.RCP London. 2022. RCP guideline calls for suspected stroke patients to be scanned within 1 hour of hospital admission [online] Available at: <https://www.rcplondon.ac.uk/news/rcpguideline-calls-suspected-stroke-patients-be-scanned-within-1hour-hospital-admission> [Accessed 18 April 2022].

2.Nice.org.uk. 2022. Recommendations | Stroke and transient ischaemic attack in over 16s: diagnosis and initial management | Guidance | NICE. [online] Available at: <https://www.nice.org.uk/guidance/ng128/chapter/Recommen dations> [Accessed 18 April 2022].

3.NUH Hospital logo: www.facebook.com. 2022. Facebook [online] Available at: <https://m.facebook.com/nottinghamhospitals/photos/a.702100 206476604/3493007134052550/> [Accessed 22 April 2022].

Special acknowledgements

o Dr Sunil Munshi (Stroke Consultant, Nottingham University Hospitals NHS Trust)