Abstract
Background Fetal hydronephrosis is a common finding during antenatal ultrasound scans (USS) with an incidence of 1–2% of all pregnancies, yet 85% resolve spontaneously. The existing practice with a lower threshold for routine postnatal evaluation resulted in unnecessary scans, overload on the radiology divisions, and unnecessary hospital visits by families. The primary objective of this project was to reduce unnecessary postnatal ultrasound evaluation for antenatally diagnosed hydronephrosis (ANH).
Methods Data collected in our NICU unit of Al Wakrah hospital for 6 months from July 2020 to December 2020 showed that 46% of unnecessary USS were done for antenatal hydronephrosis with renal pelvis dilation (RPD) of > 4mm. A quality improvement project was initiated to reduce the rate of postnatal scans from 46% in 2020 to 5% by 2022. A consensus meeting was held in January 2021 between pediatric urologists, nephrologists, radiologists, and neonatologists, and agreed upon revising the guidelines based on the literature evidence to do postnatal scans only for RPD > 10mm as postnatal management of ANH.1–3 Serial educational sessions were arranged for staffs, key performance indicators (KPI) identified, and data was collected prospectively after the implementation of the consensus guideline between July 2021 to June 2022.
Results There was a significant reduction in unnecessary ultrasound scans from 46% to 8%, hence meeting the objective (figure 1). There were two positive balance measures; 50% reduction in total number of family visits to the well-baby clinics (figure 2) after the implementation of the consensus guidelines, and reduction in costs which offered a positive financial impact on the hospital.
Conclusion Implementation of consensus guidelines for the postnatal management of hydronephrosis has resulted in reduction of unnecessary USS and well-baby clinic visits leading to reduced workload, improved health care costs and better patient and family benefits though the patient benefits are not easily quantified.
Run chart showing reduction in the number of unnecessary ultrasound scans after implementation of the new guidelines
Run chart showing reduction in total number of well-baby visits by family for follow up of hydronephrosis
References
Laurence S Baskin. Postnatal management of fetal hydronephrosis. UpToDate May 2017.
Capolicchio JP, Braga LH, Szymanski KM. Canadian urological association/pediatric urologists of canada guideline on the investigation and management of antenatally detected hydronephrosis. Can Urol Assoc J 2018;12:85–92. doi:10.5489/cuaj.5094.
SNguyen HT, Benson CB, Bromley B, Campbell JB, et al. Multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilation (UTD classification system). J Pediatr Urol. 2014;10(6):992–998.
Ethical Approval/IRB Statement Approval to conduct this quality improvement initiative was obtained from the Quality Department of Al Wakra Hospital.
Disclosures and Acknowledgments This work did not have any funding or financial disclosures. We would like to extend our sincere thanks to all the physicians Dr Rajesh Pattuvalppil, Dr Rajai Al-Bedaywi, Dr Abedalkhalek Khedr and staff nurses Sandra Latonio, Ruby Bondoc, Walaa Abdellatif, and quality reviewer Muna Atrash for being part of the team.
