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

© The Canadian Journal of Urology TM : International Supplement, August 2020 59 Emergency Department Factors that Predict Prolonged Length of Stay after Stent Placement for Obstructing Urolithiasis and Infection Alejandra Balen, MD , David Sobel, MD, Marcelo Paiva, MPP, Timothy O’Rourke, MD, Martus Gn, MD, Rachel Greenberg, MD, Rebecca Ortiz, BA, Philip Caffery, PhD, Christopher Tucci, MSN, Gyan Pareek, MS MD Brown University, Providence, RI Introduction: Infected obstructing ureteral calculi represent a surgical emergency and studies have shown that time to stent insertion correlates with hospital length of stay (LOS). This study sought to assess the factors present at time of emergency department (ED) presentation that were associated with increased LOS after emergent stent insertion for infected obstructing ureteral calculi. Materials & Methods: A retrospective review of 131 patients stented for infected obstructing ureteral stones at a single academic institution between May 2017 and December 2019 was performed. Demographic data, ED presentation course, task-time analysis, LOS, and number of patients meeting Systemic Inflammatory Response Syndrome (SIRS) criteria by having two or more of the following criteria: fever > 38.0°C or hypothermia < 36.0°C, tachycardia > 90 beats/minute, tachypnea > 20 breaths/minute, leukocytosis >12*10 9 /l or leukopenia < 4*10 9 /l as a measure of severity of illness were obtained. Linear regression analysis was performed to characterize the relationship of the above factors and hospital length of stay. Results: Patient characteristics are shown in Table 1. Mean LOS was 66.7 hours (R 5.7- 243.8, SD 57.7). The mean time frompresentation to operating room (OR) was 9.3 hours (R 3.3-48.6, SD 6.0). The elapsed time from presentation to OR did not affect LOS. 62 patients (47.3%) met SIRS criteria and LOS increased by 6.8 additional hours for each systemic inflammatory response syndrome (SIRS) criterion present during ED evaluation (t = 2.33, p = .02). Elevated serum lactate (t = 2.96, p = .004), serum creatinine (t = 2.8, p = .006), and presence of pyuria (t = 3.23, p = .002) were also correlated with increased LOS (6.9 hours, 5.9 hours, and 0.2 hours, respectively, for each rise in value). Correlations between ED factors and LOS are described in Table 2. Conclusions: In patients presenting to the emergency department with obstructing urolithiasis and infection, presence of SIRS criteria, elevated serum lactate, creatinine and increased urine WBC count were all predictive of increased length of stay after stent placement. Time from presentation to stent insertion was not, however, significantly associated with length of hospital stay. These data question the true urgency of ureteral Continued Feasibility and Success of a Non Opioid Pathway for Postoperative Pain after Ureteroscopy Mohannad A. Awad, MD 1 , David W. Sobel, MD 2 , Nikolas Moring, MS 41 , Kevan M. Sternberg, MD 1 1 UniversityofVermontMedicalCenter,Burlington,VT; 2 TheMinimallyInvasiveUrologyInstitute at the Mariam Hospital, Warren Alpert Medical School of Brown University, Providence, RI Introduction: The opioid crisis continues to be a major focus in the United States. The contributionofphysicianprescribingpatternsand theneedfor improvement in themedical communityhavebeen increasinglyaddressed inthe literature.Wehavepreviouslyreported on the feasibility of implementing anon-opioid protocol for outpatient ureteroscopy (URS) with stent placement. Our initial experience demonstrated the success of a non-opioid approachforpaincontrolandstent-relatedsymptoms.Inthisstudy,wereportourextended experience over a 3 year period. Materials & Methods: Charts of patients who underwent URS with stent placement by a single surgeon from November 2016 to November 2019 were retrospectively reviewed. During this time period, efforts were made to substitute opioid pain medications on discharge for either no prescription or Diclofenac, an NSAID.All patients received similar adjunct medications including Tamsulosin, Tylenol, and Pyridium. Patients with an allergy to NSAIDs or CKD stage II or greater were excluded from the non-opioid pathway as they wereunabletobeprescribedNSAIDs.Frequencyofpostoperativeadverseevents including visits to the emergency department (ED) for stent-related symptoms, stent-related clinic telephone calls, and requests for prescription refills for pain medication were measured. Results: Four hundred and sixty-four patients underwent URS with stent placement over the 3 year period. 38 with reported NSAID allergy or CKD stage II or greater or both were ineligible for the non-opioid pathway and excluded, and 35 were excluded for having other concurrent procedures such as cystolitholapaxy. 391 patients were included in the final analysis. A total of 357 patients were discharged without opioid medications (91.3%). 34 patients received opioids (8.7%). Of those discharged without an opioid, 276 received Diclofenac and 81 received no pain medication (opioid or prescription NSAID). Both patients receiving opioids and non-opioids had a low number of postoperative visits to the ED for genitourinary-related concerns (3 patients receiving opioids [8.8%] and 26 patients without opioids [7.3%]). Telephone calls made to the urology clinic for concerning symptoms and prescription refills were made by 11 patients receiving opioids (32.4%) and 45 patients without opioids (12.6%). Conclusions: More than 90% of patients were able to be discharged without opioids after URS and stent placement over a 3 year period without impact on ED visits, or clinic telephone calls. This was achieved through patient counseling and commitment to change practice patterns. We hope our experience will encourage others to take similar measures to decrease opioid prescriptions in this setting. 58 26 Scientific Session VI: Stones II/ Basic Science