Abstract
BACKGROUND: Acute renal colic is a common emergency department (ED) presentation requiring rapid diagnosis and management. National bodies emphasize timely imaging, appropriate biochemical testing, and ED throughput standards. OBJECTIVE: To evaluate and improve compliance with the National Institute for Health and Care Excellence (NICE), British Association of Urological Surgeons (BAUS), Royal College of Radiologists (RCR), and Royal College of Emergency Medicine (RCEM) standards in the ED management of acute renal colic at a United Kingdom (UK) district general hospital, with the following prespecified targets: RCEM four-hour compliance ≥90% (local "green" standard); median time from ED arrival to CT-KUB (CT scan of the kidneys, ureters, and bladder) request ≤90 minutes and CT report ≤90 minutes; >90% of scans within BAUS/NICE imaging timeframes (≤14 h/≤24 h); STONE (sex, timing, origin, nausea, erythrocytes) score documentation ≥75% and serum calcium testing ≥65% (with serum urate ≥20%); and ≥30% reduction in repeat CT within three months. METHODS: A retrospective two-cycle quality improvement project (QIP) was conducted. Cycle 1 (December 2023-March 2024) included 114 consecutive adults with suspected renal colic; Cycle 2 (March-August 2024, n = 114) assessed post-intervention impact. Metrics included urine dip turnaround, CT-KUB request and reporting times, RCEM four-hour compliance, serum testing, STONE score use, repeat CT rates, diagnostic yield, and length of stay. Interventions comprised a "Straight to CT" pathway, Integrated Clinical Environment (ICE)/iRefer STONE prompts, staff education, and workflow optimization. Categorical variables were analyzed using chi-square or Fisher's exact tests; continuous outcomes were reported as median (interquartile range (IQR)) and compared using Mann-Whitney U tests. RESULTS: Cycle 1 showed prolonged urine dip turnaround (median: 144 minutes), CT request (166 minutes), and report (124 minutes), with RCEM four-hour compliance as 16.7% (19/114). Cycle 2 improved significantly: urine dip 68 minutes (U=2102; p<0.001), CT request 75 minutes (U=1850; p<0.001), CT report 70 minutes (U=1924; p<0.001), RCEM compliance 57% (χ²=39.9; p<0.001; odds ratio (OR) 6.63 95% confidence interval (CI): 3.58-12.29). Serum calcium testing improved (χ²=5.27; p=0.022), urate testing (Fisher's exact p<0.001), STONE score use (χ²=127.0; p<0.001), and repeat CT <3 months halved (RR: 0.50, 95% CI: 0.25-0.98; p=0.038; CI width noted for cautious interpretation). Diagnostic yield showed an upward trend (68.4% vs 57.9%; p=0.090) and alternative diagnoses a decreasing trend (7.0% vs 11.4%; p=0.252). Median ED stay reduced from 7.5 to 3.9 hours (U=1765; p<0.001). CONCLUSION: This QIP demonstrated that targeted interventions significantly enhanced adherence to NICE, BAUS, RCR, and RCEM guidelines, reduced diagnostic delays, and improved emergency department efficiency in managing acute renal colic. Scalable strategies, including STONE score integration and streamlined imaging, expedited workflows, increased RCEM four-hour compliance, and boosted metabolic testing rates while reducing repeat CT scans. Non-significant trends in diagnostic yield and alternative diagnoses suggest improved clinical precision without compromising safety, offering a replicable model for optimizing renal colic care within existing resources, pending further multicenter validation.