Abstracts from the New England Section of the AUA 2020: A Virtual Experience

© The Canadian Journal of Urology TM : International Supplement, August 2020 Significant Variability in Outpatient Opioid Prescriptions by Discharge Provider following Percutaneous Nephrolithotomy (PCNL) Timothy K. O’Rourke, Jr., MD, David W. Sobel, MD, Nicole Thomasian, BS, Christopher Tucci, MS, RN, Gyan Pareek, MS, MD Brown University/Rhode Island Hospital, Providence, RI Introduction: Various initiatives throughout the United States have been implemented to limit and standardize opioid prescriptions at time of discharge following urologic surgery. Efforts have been made to standardize discharge prescriptions according to procedure via non-opioid care pathways. State-level legislation introducing limitations to opioid prescribing was passed in Rhode Island in an effort to curb over-prescription in 2016. We sought to characterize the discharge prescribing patterns of residents and advanced practice providers (APPs) following percutaneous nephrolithotomy (PCNL) at a single academic institution in Rhode Island. Materials &Methods: All patients who underwent PCNLat a single institution from2016- 2018 were reviewed retrospectively. 163 patients were reviewed for a total of 182 discrete PCNLcases with associated hospital encounter and discharge. 16 urologic providers were responsible for each of these discharges (14 residents, 2APPs). Prescriptions were stratified by provider to assess for differences as a function of discharging provider. All discharge opioid medications were converted to morphine equivalent daily dosing (MEDD) for standardization purposes. One-way analysis of variance (ANOVA) was performed to detect differences in potential MEDD prescribed at time of discharge between providers. Results: Over the time interval studied, 161/182 (88.4%) PCNL cases were discharged home with an opioid analgesic. A statistically significant difference in opioid prescribing practices between the sixteen discharge providers was identified [F(15,166) = 5.26, p < .0001] (Figure 1). Additionally, a statistically significant decrease in MEDD prescribing over time was identified [F(1,180) = 23.54, p < .0001] (Figure 2). No differences in MEDD prescribed were observed for age and gender. Conclusions: Significant variability existed in the opioid-prescribing practices of urologic providers following PCNLfrom 2016 to 2018, however, the overall MEDD prescribed has declined over time. This suggests that a standardized approach to prescribing opioids may be beneficial in limiting the number of prescriptions generated. Provider education should focus on typical and expected postoperative pain requirements for individual cases. Educating patients preoperatively on expectations pertaining to discharge prescriptions may prevent requests for additional opioid pain medications at the time of discharge. Partnering with state Department of Health and legislative bodies may be helpful in the global effort curb the opioid epidemic. The High Cost of Midnight Ureteral Stents for Obstructing Urolithiasis and Infection David W. Sobel, MD , Timothy O’Rourke, MD, Alejandra Balen, MD, Marcelo Paiva, MPP, Martus Gn, MD, Rachel Greenberg, MD, Rebecca Ortiz, BA, Philip Caffery, PhD, Christopher Tucci, MS, Gyan Pareek, MD Brown University, Providence, RI Introduction: Patients who present to the emergency department (ED) with obstructing urolithiasis and evidence of urinary tract infection often require ureteral stent placement after midnight. Overnight stenting requires operating room (OR) staff to be called in from home at many institutions, including our own. We sought to elucidate the workforce cost to perform stent placement after midnight when the call team is activated to mobilize the OR and complete the case. Materials & Methods: Emergent cystoscopy and ureteral stent placement procedures performed in the OR at a single academic institution between May 2017 and December 2019 were reviewed retrospectively in an IRB-approved database. A cost analysis was performed to account for the minimal personnel required to be called into the hospital for the procedure including the anesthesiologist, surgical technician, circulating nurse, radiologic technologist, two post-anesthesia care unit (PACU) nurses, and an operating room assistant (ORA). Cost data were derived from median salary at our institution for call staff as well as specific fees from anesthesiology staff. The student’s t-test was utilized to detect differences between groups. Results: A total of 131 urgent stent placements were performed between May 2017 and December 2019. Of these, 18 (14%) procedures were performed between the hours of midnight and six o’clockAM. Ten patients (56%) stented after midnight demonstrated two, three or four systemic inflammatory response syndrome (SIRS) criteria upon presentation, while eight patients (44%) presentedwith zero or one SIRS criteria. Time fromCT diagnosis to OR (minutes) in the presence of two, three or four SIRS criteria was not significantly different between the hours of 0600-2400 (49/59 [83%] patients; mean = 274.5, SD = 228.5) versus 0000-0600 (10/59 [17%] patients; mean =191.8, SD = 153.5); t(19) = 1.4, p =.18).The cost of calling in personnel after midnight was \$2,782.00 accounting for a mandatory 4 hours of overtime pay, not including post-call substitute staff the following morning. The mean operating room utilization time was 25 minutes (R 16-34, SD 6.0). Conclusions: Patients presenting with obstructing urolithiasis and infection have high workforce costs associated with the need for decompression. At our academic institution without 24 hour staff for procedures performed outside of standard OR hours, the personnel cost of performing ureteral stent placement after midnight was \$2,782.00. Given that nearly half of the patients exhibited zero or one SIRS criteria at time of ED evaluation, further work is needed to determine which patients can safely be observed overnight with stent placement during daytime hours. In this series, potential deferment of clinically stable patients to stent placement the followingmorning could have produced a cost savings of \$22,256. Further study regarding the safety of stent placement outside of the OR (i.e., “bedside stenting”) in the appropriate clinical context is also warranted. 21 20 10 Scientific Session II: Stones I