The acute stone clinic model: Improving waiting times and patient care in a public funded health care system

ABSTRACT

Introduction & Objective: The management of patients with ureteric stones can be logistically challenging in large volume centres with long waits for outpatient clinics and definitive interventions. Many units in publicly funded health systems resort to temporising obstructed kidneys with stent insertion and a subsequent plan for elective ureteroscopy at a later date. This can result in unnecessary stent insertions, repeated attendances to the emergency department and an overall poor experience for patients. We aimed to reorganise resources to improve waiting times for definitive intervention, reduce the need for pre-stenting, reduce emergency department re-attendance and improve the overall patient experience. Methods: All patients diagnosed with ureteric stones between March-September 2017 were collected as baseline data. Time to clinic review and definitive treatment were measured. By collaborating with the emergency department, radiology and operation schedulers, our intervention for improvement where a consultant led acute stone clinic (ASC) with a pathway for primary ureteroscopy was implemented and a second cycle was performed June 2018-January 2019. Further data was collected January-October 2020 to assess performance during the COVID-19 pandemic. Results: After implementing the ASC model, median time from diagnosis to clinic consultation reduced from 77 to 9 days. Median time to definitive procedure reduced from 56 to 25 days. Emergency ureteric stent insertion reduced from 69.1% to 27.9%. Reattendance to the emergency department reduced from 3.0 to 1.6 episodes/month. Primary definitive treatment increased from 31.0% to 72.1%. Patients receiving definitive treatment within 4 weeks improved from 26.2% to 51.2% post intervention and sustained at 54.5% during the pandemic period. Conclusions: Implementation of the ASC model has led to a reduced time from diagnosis to clinic review and from diagnosis to definitive treatment. Further improvement is limited by the lack of extra operating lists to reduce the waiting times for ureteroscopy. The ASC model can provide a blueprint for other hospitals to improve outcomes and care of patients with acute ureteric stones.