Ultrasound First Clinical Decision Support for Suspected Nephrolithiasis
Condition: Nephrolithiasis
MeSH terms: Nephrolithiasis; Kidney Calculi
Study type: Interventional

Summary: 
      This is a randomized trial to determine the effectiveness of a clinical decision support tool
      on image ordering for patients with suspected nephrolithiasis. Patients who present with
      acute unilateral flank or abdominal pain in whom emergency department providers suspect
      nephrolithiasis will receive either the clinical decision support tool or no tool (usual
      care).
    

Detailed description: 
      CT scan is overused for patients who present to the ED with suspected nephrolithiasis (acute
      flank or abdominal pain). The investigators have developed a clinical decision support (CDS)
      tool to identify those patients in whom ultrasound is appropriate. The CDS tool is based on
      the Study of Ultrasonography vs. Computed Tomography for Suspected Nephrolithiasis in the
      Emergency Department.

      The goal of this study is to assess the effectiveness of a clinical decision support (CDS)
      tool to improve advanced imaging for suspected nephrolithiasis in the ED. The investigators
      hypothesize those randomized to receiving the CDS tool will receive CT less often (and less
      radiation) compared to those receiving control. Also, the investigators hypothesize those
      randomized to receiving CDS will have a similar ED length of stay and rate of unexpected ED
      return as those receiving control.

      Study design: Randomized trial of a CDS tool embedded in the electronic health record for
      patients with suspected nephrolithiasis. The study will be conducted at UCSF Department of
      Emergency Medicine.

      Study subjects: The investigators will enroll adult patients who present to the UCSF ED who
      present with "suspected nephrolithiasis", which is defined as those with symptoms of
      nephrolithiasis for whom an ED provider orders a CT scan for suspected nephrolithiasis.
      Symptoms of nephrolithiasis include acute unilateral flank and/or abdominal pain, typically
      described as severe and colicky. The pain is accompanied by nausea, vomiting, and urinary
      symptoms, such as hematuria. The CT imaging studies emergency physicians typically order for
      suspected nephrolithiasis include CT scan without contrast; however a substantial minority of
      patients receive CT scan with contrast, and CT scan with and without contrast for acute flank
      pain, suspected nephrolithiasis.

      Sampling, recruiting and retaining subjects: The investigators will enroll consecutive
      patients who present to the ED with the selection criteria. Those with suspected
      nephrolithiasis but have an exclusion criteria will be recorded and compared to those who
      were enrolled. Eligible patients will be randomized to either receiving CDS recommendations
      or no CDS recommendations. Subjects will not receive informed consent, and will not be
      contacted by staff.

      Intervention: The intervention is the CDS tool, which consists of 4 components:

        1. Four questions which assess the appropriateness of ultrasound for this patient

        2. A link to the evidence

        3. Buttons to remove CT scan and order ultrasound

        4. If the CT scan order is kept, reasons why ultrasonography is not appropriate

      The CDS tool will be placed or integrated into EPIC, at the point of order entry. The tool
      will be triggered by an order for CT to identify or rule out kidney stone.

      Co-primary outcomes: Proportion of study arm who receive CT, and radiation dose. Proportion
      of study arm who receive CT is defined as #CT scans ordered/#patients in study arm. Radiation
      dose will be reported as median radiation dose in mSv. The secondary outcomes will include
      proportion of patients with an unscheduled return due to missed diagnosis, cost, ED length of
      stay.
    

Intervention name(s): Ultrasound-first Clinical Decision Support tool
Intervention type(s): Behavioral
Intervention description(s): Intervention: The intervention is the CDS tool, which consists of 4 components:
Four questions which assess the appropriateness of ultrasound for this patient
A link to the evidence
Buttons to remove CT scan and order ultrasound
If the CT scan order is kept, reasons why ultrasonography is not appropriate The CDS tool will be placed or integrated into EPIC, at the point of order entry. The tool will be triggered by an order for CT scan for kidney stone.
Appropriateness criteria for ultrasound:
Adults aged >18 and < 76
Non-obese (men < 285lbs, women < 250lbs)
Low risk of Stone Emergency (Obstructing stone and any of the following: urosepsis, renal deterioration, post kidney transplant, solitary kidney, intractable symptoms)
Low risk of clinically significant alternative diagnosis (e.g. appendicitis, cholecystitis, AAA, ovarian torsion) If all responses are affirmative, then the subject should receive US, and US order is provided.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Investigator, Outcomes Assessor)
Primary purpose: Diagnostic