Hossain A. et al., 2025: Improving the Acute Management of Ureteric Stones in a District General Hospital: A Two-Phase Quality Improvement Study Evaluating Practice Against NICE NG118 and GIRFT Recommendations.

Asmita Hossain, Khaldoun Fozo, Panagiotis Papikinos
Cureus. 2025 Aug 12;17(8):e89902. doi: 10.7759/cureus.89902. 

Abstract

Background: Ureteric colic is one of the most common urological emergencies. Adherence to the National Institute for Health and Care Excellence (NICE) guideline NG118 and the Getting It Right First Time (GIRFT) recommendations can improve care delivery by reducing unnecessary stenting and facilitating timely definitive management. However, implementation in district general hospitals may vary due to logistical constraints.

Objective: This study aims to evaluate current compliance with NICE NG118 and GIRFT standards in the acute management of ureteric stones at a UK district general hospital and to assess the impact of targeted interventions on adherence to these guidelines between two audit cycles.

Methods: A retrospective two-phase audit was conducted: Phase 1 (Aug-Nov 2023) and Phase 2 (Jul-Sep 2024). Data were collected on adults admitted with ureteric stones, including demographics, imaging, analgesia, treatment modality, stent use, and follow-up. Interventions between phases included creating a primary ureteroscopy (URS) and day-case extracorporeal shock wave lithotripsy (ESWL) pathway, an electronic stent recall protocol, Cerner auto-text discharge summaries, departmental poster and oral presentations, and clinician education. Outcomes were analysed using descriptive statistics and chi-square tests (significance threshold: p<0.05).

Results: A total of 154 patients were included (Phase 1: 89; Phase 2: 65). CT kidneys, ureters, and bladder (KUB) within 24 hours improved from 98% to 100%. Urgent intervention within 48 hours increased significantly (from 35% to 53%, p=0.028), while non-indicated stent placements decreased (from 83% to 57%, p=0.001). Lost stent follow-up reduced from two to 0 patients (p=0.042), and hot clinic follow-up loss dropped from 16 to one patient (p<0.001). Serum calcium testing improved (from 47% to 66%, p=0.021), and dietary counselling rates rose from 17% to 72% (p<0.001). Conservative management attempts declined (from 65% to 46%, p=0.019), with failure rates reducing from 38% to 23% (p=0.044).

Conclusion: Structured multidisciplinary interventions led to significant improvements in guideline adherence. The introduction of IT solutions, electronic recall systems, and same-day treatment pathways reduced unnecessary interventions and enhanced continuity of care. Incorporating predictive tools such as the MIMIC score into CT reporting could further optimise early stratification and decision-making.

Comment Hans-Göran Tiselius

With the aim of improving the care of patients with acute ureteral colic recommendations were formulated in NICE NG 118 and GIRFT. The application of the recommendations had the goal to carry out low-dose CT within 24h, to replace opioids by NSAIDs, to carry out stone removal with URS or SWL within 48h, to administer MET for distal ureteral stones less 10 mm, to avoid stents and to counteract recurrent stone formation by dietary and metabolic advice.
Patients were included during two periods eight months apart. The results showed that it was possible to improve adherence to the recommendations.
If enough resources are available the recommendations appear to be both possible, effective and desirable.

Hans-Göran Tiselius