CONSISTENCY TO CONSENSUS: HOW STANDARDIZATION OF POSTNATAL MANAGEMENT OF PRENATAL HYDRONEPHROSIS IMPACTED CARE

BACKGROUND: With the increased use of antenatal ultrasounds, urinary tract dilation (UTD) is the most common anomaly diagnosed in antenatal screens (diagnosed in 1-5% of all pregnancies at tertiary care centres). Postnatal management of prenatally detected hydronephrosis (HN) lacks consensus, prompting the release of the Urinary Tract Dilation (UTD) system to address this lack of consistency. Despite being a common finding, this diagnosis lacks standardization of practice in its postnatal management. There is inconsistent practice in ordering the initial postnatal ultrasound and whether a voiding cystourethrogram (VCUG) is also warranted.

A national survey evaluating the current practices (Urology, 2014), confirmed a lack of management guidelines and called for efforts to obtain consistency in the management protocols for this common condition. The UTD (Urinary Tract Dilation) Guidelines were developed in 2014, by a multidisciplinary committee, to create consistency in antenatal and postnatal management of antenatally diagnosed urinary tract dilation. The risk stratification into UTD P1 (low risk postnatal urinary tract dilation), UTD P2 (intermediate risk postnatal urinary tract dilation), and UTD P3 (high risk postnatal urinary tract dilation) were clearly defined as per the ultrasound findings postnatally. The management of each risk category were also discussed in details.

We aimed to establish 90% compliance to guidelines by utilizing the recent UTD recommendations.

OBJECTIVES

1. We aim to achieve a 90% compliance rate to the newly published postnatal management of antenatal urinary tract dilation guidelines (Journal Of Pediatric Urology, December 2014), for neonates with the prenatal diagnosis of the same.

2. To reduce the number of inappropriate ultrasounds (the ultrasounds that don’t adhere to the recommendations and are either too early or too late or inadequate in terms of description of all parts of urinary tract requiring repeat) to 10%

3. To reduce the number of inappropriate VCUGs to 10%

DESIGN/METHODS: We piloted a quality initiative to standardize the postnatal management of hydronephrosis based on the Urinary Tract Dilation (UTD) guidelines employing convenience sampling.

A retrospective review (n=28) of existing practices (2010 SFU consensus) was conducted (Jan-Dec 2014), prior to the release of the UTD guidelines.

Prospectively collected feasibility data was then obtained on protocol compliance from Jan 2015- May 2016 (n= 72), divided into 3 periods: (1) briefing of involved staff and standardized data collection forms, (2) training residents and staff in grand rounds, and (3) distribution of standardized protocol flowcharts.

First, we implemented the guidelines in January 2015 for 8 months (period 1). At the end of the period 1, we planned to reinforce adherence by giving a talk (period 2: 2nd Intervention) on the Division of General Pediatric Rounds, to the general Pediatricians, residents and fellows of the department. Our Pediatric Nephrologist was also present during the rounds, held 1 week before the initiation of the period in October 2015. Period 2 was continued for the next 12 weeks. At the end of period 2, flowcharts (phase 3) were distributed for easy reference, 2 days prior to initiation of period 3 in January 2016. Period 3, which was started in January 2016, was continued for the next 20 weeks.

Primary outcomes assessed were (1) number and timing of postnatal US, and (2) number of unnecessary VCUGs and US.

The balancing measure was progress to higher degree of dilation in subsequent follow up.

RESULTS: Variability of management was observed throughout the 2014 year and in period 1 of 2015. Following training at grand rounds, compliance in management for all 3 UTD risk groups increased to 100%. Post flowchart distribution (period 3), 100% compliance observed in undertaking the first ultrasound in intermediate and high risk categories was achieved, though the overall compliance was still at 83%.(Table 1) Along with the above, a reduction of unnecessary ultrasounds by 17%, 5% and 15% for low (UTD P1), intermediate (UTD P2) and high risks (UTD P3) postnatal urinary tract dilation categories, respectively by the end of the 3 periods. In the final pilot period, an overall reduction in the use of inappropriate US (Table 2) and VCUG indications was observed. 100% compliance with VCUG guidelines was seen in intermediate category in Periods 1 and 2. In period 3, VCUGs were appropriately undertaken with a 100% compliance in Low and high risk categories. No extra VCUGs were done in the last 2 periods. 1 newborn with UTD P1 (low risk) category progressed to UTD P2 (intermediate risk) category at 1 month of age (balancing measure) in the period 2. This accounted for 5% of the total studied population in the phase.

CONCLUSION

1. Compliance rate: A 100% compliance rate for the appropriate timing of the first ultrasound in the intermediate and high risk categories were achieved after the last 2 periods. The overall compliance rate was reduced due to lack of adherence to protocol seen in the low risk category. There was less compliance in the low risk category. 2. An increase in inappropriate ultrasounds (the ultrasounds that don’t adhere to the recommendations and are either too early or too late, requiring a repeat) were seen in the intermediate UTD P2 and high UTD P3 risk categories, during period 2 (after the Talk). The difference was attributed to over zealous assessment by physicians of the potential risk for findings of reflux or obstruction and by the inconsistency in ultrasound reporting by radiologists. 3. Overall compliance rate for appropriate use of VCUGs also improved. The decrease in compliance for VCUGs noted for UTD P3 (high risk) category in period 2 (post talk) and UTD P2 (intermediate risk) in period 3 (post flowchart), were due to inability of doing a VCUG, when needed, again due to inappropriate categorization of the newborn and its postnatal results. Though no extra VCUGs were done. Surprise Finding and Lessons Learned: On detailed study of the ultrasound reports, it was found that there was high interobserver variability. When consistency to reporting ultrasounds were compared, it was found that 42% of total ultrasounds in the pre guidelines phase, 30% in period 1 and period 2 and 45% in period 3 (post flowchart), were not appropriately reported, often not commenting on additional parameters especially status of ureters and bladder. This resulted in underestimating the risk categories by the clinician. Consistency was 100% when reporting UTD P3 ultrasounds, because usually, all the parts of the urinary tract were involved in such a high risk grade, underlining the importance of reporting. Future Directions: The above calls for more studies to assess the UTD guidelines and its ultimate impact on the urinary tract infection in this population. We are intending evaluate the UTI incidence after the implementation of guidelines. Additionally, calls for consistency in reporting of the ultrasounds were also made.

TABLE 2

Inappropriate Ultrasounds Done In The Respective Periods

Open in new tabDownload slide