Presentation Authors: Andrew Portis*, St. Paul, MN, Michael Borofsky, Minneapolis, MN, Suzanne Neises, St Paul, MN
Introduction: Opiate dependence is an important issue for urolithiasis patients that often begins in the emergency department (ED) when presenting with renal colic. Herein, we report on impact of an initiative to increase non-opiate ED management of renal colic.
Methods: ED physicians (n=57) in 3 EDs within a US metropolitan health system received structured education on the efficacy of acetaminophen and ketorolac in the management of renal colic institution specific data. They were encouraged to consider initiating care with oral acetaminophen and/or IV ketorolac rather than opiates. Treatment patterns were observed in patients presenting with CT confirmed, unilateral ureteral stones (2-10 mm), initial pain scores â‰¥6/10, and creatinine clearance >30 ml/min/1.73m2. Patients were categorized by initial medical strategy with medications administered within 10 minutes of each other considered as elements of a single strategy. Primary outcome metric was overall opiate use.â‰¥
Results: Patient and stone characteristics were similar between both periods. (Table 1) Following introduction of the initiative there was an increase in using non-narcotic agents as first line therapy (36% to 51%, P < 0.001). Administration of secondary analgesics remained stable over time but use of secondary opioids declined. Use of ondansetron declined while ED length of stay and hospital admission rate remained stable. Overall use of ketorolac remained stable while acetaminophen use increased and opiate use declined. (Figure 1) Across phases, patients with highest initial pain score (10/10) were more likely to receive opioids (odds ratio (OR) 6.4, 95% confidence interval (CI) 3.16-12.98, p < 0.001). After initiation of renal colic care change, likelihood of receiving opioids was reduced (OR 0.61, CI 0.41-0.89, p=0.012) on multivariable logistic regression, controlling for age, sex, stone size and location, and initial pain score.
Conclusions: Opiate use in ED management of renal colic declined after commencement of an opiate reduction initiative.