Does Senior Emergency Medicine Physician Referral for Computed Tomography of Kidneys, Ureter and Bladder (CT KUB) result in increased utilisation of radiology resources at Middlemore Hospital?

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Renal colic is a common clinical presentation in the ED. It is generally caused by calculi in the upper urinary tract (urolithiasis) obstructing the flow of urine. Over the past decade, CT KUB use has become widespread, and is now considered the first-line imaging method in the evaluation of suspected renal colic. In our tertiary-level urban hospital, any ED doctor can refer a patient to radiology for a CT KUB. However, all referrals for diagnostic imaging modalities other than plain radiography are discussed with a liaison radiologist for vetting and acceptance prior to the imaging being performed. After-hours (1630h to 0830h), the liaison radiologist is the lone on-call radiology registrar, who is also responsible for all acute CT reporting. Historically, this referral process has been put in place to rationalise radiology resources and prevent unnecessary or inappropriate imaging. However, the current referral process is time- and resource-intensive. The typical process necessitates multiple steps: (1) ED medical staff locates the liaison radiologist by telephone or in person; (2) ED medical staff summarises relevant clinical findings and justification for CT KUB imaging to liaison radiologist; (3) liaison radiologist accepts CT KUB referral; (4) ED medical staff delivers the accepted CT KUB referral form to radiographer. Delays in the current process occur depending on the clinical workload and the concurrent availability of ED medical staff and the liaison radiologist at the time when the clinical decision to proceed with imaging is made. The current referral process is perceived by the ED medical staff to unnecessarily time-consuming, for what is a common ED clinical presentation with a usually straightforward management pathway. To streamline the CT KUB referral process, we instituted a process change between the ED and radiology for auto-acceptance of CT KUB referrals. Patients presenting to the ED with suspected renal colic were automatically accepted for CT KUB imaging by the radiographers, after approval from the ED senior medical officer (SMO) on duty. This would bypass the previous vetting process through the liaison radiologist. The auto-acceptance referral process was designed to improve access to CT KUBs when clinically indicated, and reduce the time spent on vetting referrals, thereby allowing more time for discussion of complex cases. With improved access to CT KUBs, there is concern that the auto-acceptance referral process will lead to increased use of CT KUBs as a screening tool, given its ability to diagnose alternative pathologies. The purpose of this study is to evaluate whether introduction of the auto-acceptance referral process alters the utilisation and outcomes of CT KUBs for ED patients with suspected acute renal colic.

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