Download Stone-targeted dual-energy CT - Utilisation of a new diagnostic

Storyboard Entry Form 2014
Main author: K. Raj Babu
Email: [email protected]
Telephone: 07400206922
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1. Storyboard title: a clear concise title which describes the work
Stone-targeted dual-energy CT: Utilisation of a new diagnostic approach
to facilitate expeditious treatment of patients with urinary tract stones.
2. Brief outline of context: where this improvement work was done;
what sort of unit/department; what staff/client groups were involved
Urinary tract stone disease is common, affecting 10% of the population in
their lifetime, potentially causing pain, obstruction and renal failure. Noncontrast CT scan (NCCT) is recognised as the standard radiological
investigation of choice. The successful treatment of urinary tract stones is
largely dependent on stone composition. With standard NCCT it is not
possible to determine the chemical composition of stone.
Dual-energy CT (DECT) imaging has evolved recently as an advanced
imaging technique, which provides additional information about the
urinary tract stone by applying X-rays at two different energies which
incurs negligible increase in total radiation dose.
DECT has many clinical applications and has been used in clinical trials for
renal stones in the US. We were the first centre in the UK to use DECT for
investigation and management of renal calculi.
ABM Urology and Radiology departments have utilised this technique to
characterise the stone composition in patients who present with urinary
tract stone disease which has had significant beneficial influence on their
management.
3. Brief outline of problem: statement of problem; how you set out to
tackle it; how it affected patient/client care
Renal colic is one of the commonest urological emergencies with
approximately 400 emergency admissions per year in our hospital. If the
NCCT shows a ureteric stone <5 mm, the stone is more likely to pass with
conservative management with hydration and analgesia.
For larger symptomatic renal or ureteric stones invasive surgical procedures
requiring hospitalisation are often required. A significant proportion of stones
are suitable for dissolution medication and if this can be identified early then
surgery can be avoided.
For example, uric acid stones can be treated with oral solution, hydration, and
urinary alkalinisation while calcium stones are usually treated either with
surgical extraction or shock wave lithotripsy.
Prior to the introduction of DECT scanning service, almost all stone
composition was determined after expulsion or surgical extraction.
4. Assessment of problem and analysis of its causes: quantified
problem; staff involvement; assessment of the cause of problem;
solutions/changes needed to make improvements
In the last 2 year 61 patients with renal colic had DECT using Fastswitched kV DECT (Toshiba's Aquilion ONETM) as the radiological
investigation.
The numbers are lower than the total number of admissions for renal colic
as DECT is currently performed by specific radiographers, who are familiar
with this novel technique and application.
Uric acid stones were all colour coded red by the software and all calcified
stones appeared blue. The chemical compositions of stones retrieved were
comparable.
Fig 1: Uric acid stone
Fig 2: Calcium based stone
5. Strategy for change: how the proposed change was implemented;
clear client or staff group described; explain how you disseminated the
results of the analysis and plans for change to the groups involved
with/affected by the planned change; include a timetable for change
Nine patients were diagnosed with uric acid stones on DECT and were
managed with immediate oral dissolution therapy preventing unnecessary
delay and potential surgical procedures.
21 Patients had pure calcium based stones and the remainder had mixed
stone. These patients underwent appropriate treatment options described
previously depending on their clinical presentation (e.g., Lithotripsy or
surgery).
6. Measurement of improvement: details of how the effects of the
planned changes were measured
Patients were followed up at appropriate intervals with A repeat scan at 3
months. Patients who were diagnosed with uric acid stones and managed
with oral dissolution therapy showed excellent resolution of their stone
burden and prompt alleviation of their symptoms.
7. Effects of changes: statement of the effects of the change; how far
these changes resolve the problem that triggered the work; how this
improved patient/client care; the problems encountered with the process
of changes or with the changes
Patients diagnosed with urinary tract stones, may need some form of
intervention depending on the clinical presentation. In some cases the
operative intervention would not only delay their return to work but also
mean they would continue to experience symptoms until the intervention.
If a patient has a stone which can be dissolved with oral medications, then
operative intervention and protracted admission can often be avoided. By
introducing this service, patients who are diagnosed with uric acid stones
now avoid an unnecessary delay in treatment and unnecessary
interventional procedures.
8. Lessons learnt: statement of lessons learnt from the work; what
would be done differently next time
DECT scanning capability is dependent upon appropriately trained
radiology staff and is not 24/7 yet although as a result of the successful
application of this technique provision to expand this service is planned.
In the interim, patients who require emergency interventions based on
clinical presentation will continue to have standard CT and we aim to
obtain DECT in patients who are admitted out of hours.
9. Message for others: statement of the main message you would like
to convey to others, based on the experience described
This is a novel approach utilised to identify the chemical composition of
urinary calculi with radiation doses comparable to standard CT and is the
first application of DECT scanning for urinary tract stone disease in the
UK.
DECT can be used to effectively guide the management of urinary tract
stone disease. It has shown to significantly improve management of
patients with urinary tract stone disease and expedite medical
management for patients with uric acid stones who otherwise would have
been subjected to interventional procedures.
The technique is very valuable both in emergency and elective urological
practice.
Our results are due to be presented in the annual meeting of the British
Association of Urological Surgeons to increase awareness of this major
advance in the treatment of urinary stone disease.
The NHS Wales Awards are organised by the 1000
Lives Improvement Service in Public Health Wales.
www.1000livesi.wales.nhs.uk