Medical expulsive treatment in pediatric urolithiasis

Available online http://ccforum.com/content/13/5/194Page 1 of 2(page number not for citation purposes)AbstractAdverse events affect approximately 3% to 12% of hospitalizedpatients. At least a third, but as many as half, of such events areconsidered preventable. Detection of these events requiresinvestments of time and money. A report in a recent issue ofCritical Care used the medical emergency team activation as atrigger to perform a prospective standardized evaluation of charts.The authors observed that roughly one fourth of calls were relatedto a preventable adverse event, which is comparable to theprevious literature. However, while previous studies relied onretrospective chart reviews, this study introduced the novelelement of real-time characterization of events by the team at themoment of consultation. This methodology captures importantopportunities for improvements in local care at a rate far higherthan routine incident-reporting systems, but without requiringsubstantial investments of additional resources. Academic centersare increasingly recognizing engagement in quality improvement asa distinct career pathway. Involving such physicians in medicalemergency teams will likely facilitate the dual roles of these as aclinical outreach arm of the intensive care unit and in identifyingproblems in care and leading to strategies to reduce them.Adverse events, defined as undesirable outcomes caused bymedical care rather than underlying disease processes, affectapproximately 3% to 12% of hospitalized patients. At least athird, but as many as half, of such events are consideredpreventable [1-3]. These estimates come from large nationalstudies based on chart reviews, in which nurses look for‘flags’ or ‘triggers’ (for example, death or unplanned admis-sion to an intensive care unit), and physician reviewers thendetermine whether any adverse outcomes resulted primarilyfrom medical care. Studies that have used direct observationor more active forms of surveillance have yielded higher ratesof adverse events [4,5]. All of these detection methodsrequire substantial investments of time and money. Moreover,especially in the case of chart review, missing information oftenlimits the ability of reviewers to identify adverse events or judgetheir preventability. Thus, an efficient method for identifyingadverse events which yielded sufficient clinical detail to guideassessments of preventability and did not require substantialinvestments of additional resources would represent apotentially powerful quality improvement tool for hospitals.As Iyengar and colleagues [1] report in a recent issue ofCritical Care, medical emergency teams (METs), knownwidely in North America as rapid response teams, mayprovide just such a method. The rationale for the developmentof METs rose from observations that, in the majority ofpatients, premonitory signs and symptoms of cardio-pulmonary instability are often present hours before clinicaldeterioration [6]. By encouraging early responses to patientswith these signs, METs would presumably prevent progres-sion to cardiopulmonary arrest. While the evidence regardingtheir success in improving patient outcomes remainsconflicting [7,8], METs likely achieve other benefits, such asincreasing nurse satisfaction and retention, and may alsoidentify specific quality improvement targets related torecurring problems encountered [9].By standardizing MET calls with added information on thepreactivation period and performing a physician review of allcases after 1 week, Iyengar and colleagues [1] were able toscreen 65 MET calls over a 4-week period. They identified23 adverse events, 16 of which were judged MEDICAL EXPULSIVE TREATMENT IN PEDIATRIC UROLITHIASIS INTRODUCTION • • INVASIVE TREATMENTS • • • • • • • COMPLICATIONS OF INVASIVE TREATMENTS • • • • • •  MEDICAL EXPULSIVE TREATMENT (MET) SHOULD BE THOUGHT FOR A SPECIFIC GROUP OF PATIENTS MEDICAL EXPULSIVE TREATMENT • • • EVIDENCE BASED EVIDENCE Author Medical expulsive treatment Number of patients (n) Stone size (mm) Location of stone Stone passage Time (day) Stone passage rate Sayed tamsulosin diclofenac 45 45 5-10mm Distal ureter 7.32 12.53 88.9% 51.1% Porpiglia Nifedipine+ deflazacort Control 48 5.8 ± 1.8 mm Distal ureter 79% 48 5.5 ± 1.4 mm 20 35% Nifedipine Tamsulosin Control 30 28 28 4.7mm 5.42mm 5.35mm 9.3 7.7 12 80% 85% 43% Porpiglia Distal ureter 1) Sayed MA, Abolyosr A, Abdalla MA, El-Azab AS Efficacy of tamsulosin in medical expulsive therapy for distal ureteral calculi Scand J Urol Nephrol 2008 2) Porpiglia F, Destefanis P, Fiori C, Fontana D Effectiveness of nifedipine and deflazacort in the management of distal ureter stones Urology 2000 3) Porpiglia F, Ghignone G, Fiori C, Fontana D, Scarpa RM Nifedipine versus tamsulosin for the management of lower ureteral stones J Urol 2004 EVIDENCE BASED EVIDENCE • • • • • • • • • EVIDENCE BASED EVIDENCE Author Medical expulsive treatment Number of patients (n) Stone size (mm) Location of stone Follow-up period Stone passage rate Aydogdu Doxazosin Ibuprofen 19 20