Improving Guideline Adherence for the Radiological Investigation of Acute Renal Colic: A Two-Cycle Quality Improvement Project.

Introduction Renal colic is a frequent complaint presented to healthcare services. Delayed diagnosis can result in life-threatening complications, including renal failure and sepsis. Low-dose, non-contrast computerised tomography of the kidneys, ureters, and bladder (CT KUB) is regarded as the investigation of choice when investigating acute renal colic in the adult population, with a high sensitivity and specificity for detecting calculi. This audit is aimed at improving guideline adherence in the radiological investigation of renal colic, regarding the prompt and regulated use of CT KUB to ensure an acceptable diagnostic yield of urinary calculi and minimal patient complications secondary to delayed diagnosis and radiation exposure. Methods A retrospective study was conducted for all patients referred to radiology for suspected renal colic from accident and emergency (A&E) and primary care. A first-cycle audit in June involved reviewing 78 patients' records, of whom 75 (96%) were included in the study to assess for the use of appropriate imaging modality (CT KUB), the diagnostic yield of urinary calculi with CT KUB, and whether patients were investigated within 24 hours as per stipulated guidance. Data collected were analysed and presented to each department with recommendations, following which a second-cycle audit was undertaken in October to assess their impact. Eighty-one patients' records were screened, with 75 (93%) included in our study. Exclusions included pregnant women, those who are known, recurrent stone formers and had a CT KUB in the last three months, and those aged less than 18. Results The first cycle study revealed that only 42 (56%) patients were appropriately investigated for renal colic with CT KUB. Many patients faced significant delays, with only 50 (66.7%) investigated within 24 hours. Of those investigated with CT KUB, 17 (40.5%) scans were positive for urinary calculi. This demonstrated a significant deviation from the recommended standards in the guidelines. Following a period of re-education, raising awareness of guidelines, and emphasising the importance of a thorough clinical history in scan requests, the second cycle demonstrated a significant improvement in the use of CT KUB to investigate renal colic, with the total reaching 55 (73.3%) patients, along with a concurrent increase in the proportion of patients with positive findings for calculi to 36 (65.5%). No significant improvement was demonstrated in the number of patients investigated within 24 hours, with 24 (32.0%) patients facing delay. Conclusion This two-cycle audit highlights the importance of timely and appropriate use of CT KUB in investigating renal colic. The first audit revealed significant delays and suboptimal adherence to institutional guidance. After educational intervention, the second cycle showed improved CT KUB utilisation towards the required standard, with an associated higher diagnostic rate of scans for urinary calculi (above the minimum of 44%-64%), reducing the likelihood of developing complications from missed diagnoses. Ongoing education in the form of posters and departmental lectures will ensure an increasing trajectory towards the 100% target for CT KUB use in investigating renal colic, and future efforts to reduce investigation delays will include introducing streamlined referral and communication pathways between primary and secondary care. A third-cycle study will assess the impact of these changes.