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Nurse-initiated telephone follow up after ureteroscopic stone surgery.

This article presents findings of a quality improvement (QI) project using the DMAIC (define, measure, analyze, improve, and control) model designed to decrease the rate of emergency department (ED) visits and nurse advice line calls after ureteroscopic stone surgery. Results indicated that nurse-initiated follow-up phone calls can decrease ED visits.

Key Words: Ureteroscopic stone surgery, nurse advice lines, telephone triage.


Background and Significance Of the Problem

Ureteroscopic surgery is a common outpatient procedure to treat stones within the ureters or kidneys, collectively known as the upper urinary tract. Using both flexible and semi-rigid ureteroscopes, urologists are able to look into the bladder and traverse the ureter under direct vision. Once a stone is located, a small laser is inserted through the scope and used to break the stone into very small pieces. Many of these small stones will pass on their own, and any larger pieces can be collected and removed with a stone basket. In the majority of cases, a ureteral stent is placed to allow the kidney to drain while edema in the ureter decreases.

Scales and colleagues (2014) reported that kidney stones have increased in prevalence in the last 15 years and now affect one in 11 persons. The Urological Diseases of America project estimated that the treatment of kidney stones cost $10 billion annually, which makes it one of the most expensive urologic conditions treated (Scales et al., 2014). Tan et al. (2011) examined 1,798 ureteroscopic kidney stone (UKS) surgeries and found that 3.9% were readmitted to the hospital, with an average length of stay of 1.4 days. The main reasons for admission were postoperative urinary tract infection and postoperative pain.

The Affordable Care Act (ACA) added section 1886(q) to the Social Security Act. This act requires the Centers for Medicare and Medicaid Services (CMS) to reduce payments to hospitals as of October 1, 2012, for readmissions of patients within 30 days of discharge with diagnosis of acute myocardial infarction, heart failure, and pneumonia. In fiscal year 2015, CMS added chronic obstructive pulmonary disease, total hips arthroplasty, and total knee arthroplasty to the list of readmissions that receive payment reductions for readmissions within 30 days of discharge (CMS, 2014). Due to these changes in healthcare laws, several healthcare-related organizations now assess reasons for recurrent emergency department (ED) visits. Findings from these assessments have been the basis for the implementation of evidence-based strategies to prevent unnecessary ED visits and postoperative advice line calls.


The overall purpose of this quality improvement (QI) initiative was to promote safe, effective, and timely care by utilizing nurse-led postoperative phone calls. The primary aim was to decrease the number of postoperative patients with UKS returning to the ED within 30 days

of surgery. An additional aim was to decrease the rate of postoperative UKS patients who call the nurse advice line within 30 days of surgery. The rationale for the project was based on the Institute of Medicine's (IOM) guidelines for redesigning healthcare by offering alternative forms of care in an effort to reduce costs to patients and the healthcare system (Terry, 2015). With this in mind, this project was designed to attempt to improve the delivery of healthcare to patients undergoing UKS surgery.

DMAIC Improvement Methods

The DMAIC (define, measure, analyze, improve, and control) model was used to guide the project. Define is to identify the process intended to be improved and the opportunity for improvement. The second part is to measure means to establish a way to quantify the information so that it can be measured. Analyze is to review the information for gaps between what is actually occurring and what the goal is for performance. Improve includes creating solutions to the gaps in goal performance, testing, and implementing the improvement initiative. Finally, control is to observe the implemented improvement initiative for success (Gibilisco, 2012).

Description of the Facility

The location of the project was an outpatient urology clinic affiliated with a large academic medical center. The clinic employs three full-time urologists who collectively perform approximately 10 to 15 UKS surgeries per month. Since this is an outpatient procedure, all of the patients were discharged home the same day of their surgery.

Definition of the Problem And Measurement of Current Practice

Retrospective chart audits. The problem was defined and measured through routine chart audits to assess the number of patients returning to the hospital after UKS surgery. Chart audits were performed using a data collection spreadsheet to ensure the same information was collected on all patients from January 1, 2014, to September 15, 2014. Chart audits included all patients who underwent UKS surgery during that time. These audits revealed that 70 patients (N = 35 male; 35 female) had UKS surgery. Twenty-one percent of patients returned to the hospital within 30 days after UKS surgery, and 59% of patients called the nurse advice line. Of the female patients, eight (23%) presented to the emergency department (ED) within 30 days of kidney stone surgery. Five of the eight (63%) presented for postoperative pain (two after stent removal); two (25%) for postoperative urinary tract infection, and one (12.5%) for hematuria. Both women with postoperative urinary tract infections were hospitalized.

Of the male patients, seven (20%) presented to the ED, and five (14%) were admitted. The seven male patients presented for different reasons, including fever, urinary retention, feeling weak and dizzy, hematuria, postoperative pain, renal injury, and postoperative urinary tract infection. Of the five men admitted, two were admitted for postoperative urinary tract infection, one for renal injury, one for renal hematoma, and one for complications related to B-cell lymphoma.

The major reasons patients called the advice line after surgery were due to postoperative pain, irritative voiding symptoms, and dysuria. These complaints were predominantly related to the indwelling ureteral stent. Of the patients returning to the ED, six called the advice line and spoke to a nurse prior to their ED arrival. This retrospective patient chart analysis revealed that 21% of patients went to the ED after UKS surgery, and 59% called the advice line. This was higher than the rate of 3.9% as reported in the literature by Tan et al. (2011). The majority of patients called the advice line for postoperative concerns. All of these patients received preoperative instructions about what to expect postoperatively. Despite this, information obtained from the chart reviews suggested there were miscommunications between patients and healthcare providers that resulted in ED visits and advice line calls. This supported the need for a QI initiative to reduce ED visits.

Literature Review

PICO. An evidence-based model, the PICO (population, intervention, comparison, outcome) process, was used to frame the question and guide the literature review (Duke University & University of North Carolina, 2016; Terry, 2015). The project's clinical question was: "Do postoperative telephone calls within 24 to 48 hours of UKS surgery decrease ED visits and nurse advice line calls?" This question was formed using the following four PICO elements:

* P = Adult patients undergoing ureteroscopic surgery for kidney stones.

* I = Nurse practitioner postoperative telephone calls within 24 to 48 hours of surgery.

* C = Current practice of not calling patients postoperatively.

* O = Decrease in ED visits and advice line calls within 30 days of UKS surgeries.

Search methods. A comprehensive review of the literature was conducted using the search engines CINAHL, Medline, EBSCO host, Academic Search Premier, and Google Scholar. Of the 122 articles reviewed, 31 articles were appropriate for the QI project. The search criteria focused around post-discharge telephone follow-up calls, nurse-led telephone follow-up calls, postoperative telephone follow-ups, and telehealth nursing. Because follow-up calls were to postoperative patients with UKS who typically had ureteral stents, search criteria also included issues from ureteral stenting and complications from UKS surgery. Articles were excluded if they were greater than five years old, focused on preventing hospital readmissions of chronic diseases, and/or focused on surgical technique.

Articles reviewed. Literature was reviewed to determine the most common reasons patients returned to the ED. Findings of the literature review were compared to the initial chart audits in the analysis phase of the DMAIC project.

This search included a study by de la Rosette et al. (2014) that reviewed 11,885 patients who underwent UKS surgery at 114 facilities in 32 countries. The study showed a low rate of postoperative complications (3.5%). Fever was the most common complication, while ureteral stent discomfort and flank pain were the most frequent reasons for readmission.

In a study by Ahn, Kim, Park, Moon, and Bae (2012), the causes of pain were reviewed in 135 charts of patients undergoing UKS surgery. This study showed that age, psychiatric illness, history of urinary tract infection, stone size, and procedure-specific factors of ureteral dilation, use of stone basket, and operative time were risk factors in the univariate analysis for postoperative pain. The multivariate analysis showed that age, psychiatric illness, history of urinary tract infection, and ureteral dilation were associated with postoperative pain. The study also revealed that 10 patients with moderate postoperative pain had a ureteral stent, but no patient with severe postoperative pain had a stent. The majority of patients with severe postoperative pain required a stone basket intra-operative.

Pengfei et al. (2011) performed a systematic review of 16 randomized control trials concerning the necessity and effects of ureteral stenting after UKS, surgery. The study involved 1,573 patients. Of these patients, 797 did not have a stent placed after surgery, while 776 had a stent placed. The study found that patients with a stent had an increase in lower urinary tract symptoms and pain. The authors concluded there were disadvantages to ureteral stents, including pain and lower urinary tract symptoms, but stents were not found to decrease the rate of urinary tract infections, fever, requirements for pain medication, postoperative complications, or unplanned medical visits. They also concluded that having a stent postoperatively does not increase the stone-free rate.

The benefits of contacting patients by telephone were examined in patients receiving nurse-led discharge phone calls by 10 nursing units with specialties that included medical, surgical, orthopedics, obstetrics, and cardiology (D'Amore, Murray, Powers, & Johnson, 2011). The purpose was to determine if the discharge phone calls decreased 30-day readmission rates or increased patient satisfaction. Phone calls were made during the day by nurses using a script. Messages were not left for patients to call back. All patients (N = 10,559) received a survey through Press Ganey to assess satisfaction with nurse-initiated discharge telephone calls. The results from the survey showed no statistical difference in patient satisfaction between patients who received a phone call versus those who did not receive a phone call.

Eggenberger, Garrison, Hilton, and Giovengo (2013) used discharge phone calls by clinical nurse leaders to decrease hospital readmissions and to increase patient satisfaction. Their research led to an increase in patient satisfaction by 17.5% over a two-year period, an increase in patient understanding of discharge information by 4.7%. There was also an increase in willingness to recommend the facility by 4.4%.

Inman, Maxson, Johnson, Myers, and Holland (2011) performed research to assess if nurse-led postoperative phone calls after prostatectomy could reduce the use of additional healthcare resources and increase patient satisfaction. The study compared 60 postoperative prostatectomy patients who received nurse-led postoperative phone calls within three to five days of surgery to 60 post-prostatectomy patients who received no postoperative phone call. These phone calls assessed how the patient was doing, if they had any concerns, and reinforced postoperative education, and assessed whether they had been back to the emergency department, been hospitalized, or called a doctor or nurse within 30 days of surgery. They were also asked if the postoperative phone calls were helpful. Sixty percent of patients in the nonintervention group used additional healthcare resources postoperatively compared to 47% in the intervention group. All but one patient in the intervention group thought the postoperative phone calls were helpful.

Glavind, Bjork, Sofie, and Lindquist (2014) used nurse-initiated telephone calls three months postoperatively in place of face-to-face visits to assess women's postoperative course after uncomplicated cystocele repair. The phone calls were performed by continence nurses who followed a script and used the International Consultation on Incontinence Vaginal Symptoms Form and the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form to guide the phone calls. Patients were also asked if they thought they needed an examination by a surgeon. The study found that of the total sample [N = 59), 44 women were satisfied with the telephone call from the nurse and did not need a face-to-face visit with a surgeon. The researchers concluded that telephone follow up was a sufficient form of follow up for most patients, allowing for surgeons to see more new patients in clinic, which increases revenue.

Flanagan (2009) assessed the best time to perform postoperative telephone calls. Patients who had arthroscopic knee surgery were called at 12, 24, and 72 hours postoperatively to assess their needs. Interestingly, 12 hours after surgery, patients were likely to experience nausea, vomiting, and sore throat, but not pain because of the residual effect of the anesthesia. At 24 hours postoperatively, patients experienced pain and anxiety because they did not feel prepared for the recovery. Seventy-two hours after surgery, patients became more comfortable with the recovery process, and concerns shifted to pain and constipation. The study concluded that the best time to call patients postoperatively is within the first 24 hours of surgery.


To structure the improvement part of the project, the results of the initial retrospective chart audit and findings of the literature review were analyzed. This analysis was conducted to guide the project's postoperative telephone calls and to develop the script to be used with the follow-up phone call.

This review of the literature resulted in a compilation of the most common complications of UKS surgery and the most common issues related to ureteral stents. It also resulted in a collection of studies revealing patient satisfaction with nurse-led telephone follow up and that nurses are qualified to answer patients' postoperative questions. Research shows that telephone follow up can replace face-to-face follow-up visits, but there was very little research found supporting nurse-led telephone calls to reduce ED visits postoperatively.

These studies imply that patients undergoing ureteroscopic stone surgery may benefit from telephone follow-ups to assess postoperative pain, lower urinary tract symptoms, and fever. Nurse-led postoperative telephone calls may reduce the use of additional healthcare resources and hospital readmissions. The literature also indicates that patients find nurse-led phone calls helpful, especially in the acute postoperative period (24 to 48 hours).

Improvement Interventions

After the analysis was performed and prior to the intervention phase of the project, a proposal was submitted to the Institutional Review Board (IRB) at the project site. The IRB considered the project exempt because it was considered quality improvement and not research. The intervention portion of the project ran from September 15, 2015, through December 12, 2015, and consisted of all English-speaking patients who had UKS surgery. This time of year was chosen because it was similar to the time of year chosen for the comparison group. During this time, the operative schedules of the surgeons in the practice were evaluated daily for all UKS surgeries performed. Once patients were identified, the nurse practitioner made the postoperative phone calls to them.

A script was created based upon the prior literature review and the most common reported complaints in prior chart audits. The script was used as part of the process to ensure that the same information was discussed with every patient. The script included asking the patient about pain, medications, lower urinary tract symptoms, fever, constipation, and hematuria, and allowed the patient to discuss any further concerns.

If patients were unavailable at the time of the phone call, patients were left a message to call the clinic back to speak with the nurse practitioner. If the patient did not return the phone call, three attempts were made to reach the patient to assess his or her condition postoperatively. Prior to the study, barriers identified included possibility of being unable to reach the patient by telephone, timing of symptoms, lack of time to call patients within the desired 24 to 48 hours postoperatively, difficulty communicating with patients, patient ability to comprehend educational instructions, and compliance with information provided in the intervention. During the project, the only issue was difficulty in reaching patients. Information from patient phone calls was documented in the patient's electronic medical chart. If patients discussed non-emergent concerns that needed a face-to-face assessment, they were brought into the clinic during clinic hours for evaluation by the nurse practitioner.

The intervention group's medical charts were retrospectively reviewed, and nominal data were collected, including if the patient called the advice line, went to an emergency department within the health system, the time and date of the advice line phone call or emergency department visit, the reason for the emergency department visit or advice line phone call, patients' demographics, and surgery information. This information was then compared to the same nominal data from patients who did not receive phone calls reported previously and collected from July 1, 2014, through December 31, 2014. Percentage and frequency analyses were used to compare the number of ED visits and nurse advice line calls within 30 days of UKS surgery between groups.

Results of intervention. The intervention group (N = 27) included 14 males and 13 females. The age range was 26 to 79 years, with a mean age of 54.8 years. The insurance for this group of patients consisted of commercial insurance (45%) and Medicare (48%). The comparison group (N = 54) included 32 males and 22 females. The age range was 24 to 82 years, with a mean age of 55.4 years. The majority of patients in this group (61%) had commercial insurance, while much fewer had Medicare (30%).

Only two of the 27 patients that received follow-up calls sought treatment in the ED, with one being admitted to the hospital. However, neither of these two patients returned to the ED for issues related to the UKS surgery connected to the project. One patient required ED evaluation for pain in the opposite kidney over concern that a non-obstructive stone in the contralateral kidney had moved. The other patient went back to the operating room three weeks after his first surgery for a second planned stone surgery. Following the second surgery, he developed fever and presented to the ED. This patient was not called after the second stone surgery as requested by his wife.

Of the group who did not receive phone calls, 10 patients returned to the ED. Three of these patients were also admitted to the hospital. The major reasons for ED visits were pain, hematuria, urinary retention, and urinary tract infection-like symptoms. Of the patients who presented with pain to the ED, three became symptomatic after stent removal.

Of the 27 patients in the intervention group, 12 called the nurse advice line. The calls were primarily for pain from the stent, urinary tract infection concerns, and pain after the stent was removed (see Table 1). The comparison group [N= 54) had 24 patients call the nurse advice line. The main reasons for these calls were pain, hematuria, and concerns about having a urinary tract infection (see Table 2).

The objectives of the project were to use postoperative phone calls to decrease the rate of ED visits and advice line calls within 30 days of UKS surgery. Results demonstrated an 11% decrease in patients returning to the ED in the intervention group. However, there was no difference in the percentage of people who called the nurse advice line between groups. These results show that postoperative phone calls were beneficial for decreasing ED visits but not nurse advice line calls within 30 days of UKS surgery.


This QI project demonstrated a significant decrease in postoperative visits to the ED following nurse initiated follow-up phone calls (assuming they did not go to another ED). This means that four people did not have to incur the costs associated with an ED visit. These patients were also spared the frustration of additional problems, such as transportation to the ED, childcare during the illness, missed time from work, and the emotional stress of being in the ED.

It is unknown why the advice line calls did not change. One theory is that patients were instructed to call back for questions or concerns. This may have made patients more comfortable with calling the advice line with questions. Anecdotal evidence, which may support patients being more comfortable calling, was that most of the patients stated they were happy they received the phone call and thanked the nurse practitioner for the call. None of the patients called had anything negative to say about the phone call. Several patients stated that it was reassuring to them that the symptoms they were experiencing were normal. Therefore, opening up the lines of communication may have resulted in patients calling the nurse advice line back when they had questions.

Based on these results, the control portion of the DMAIC model would be to change the current practice of not calling patients postoperatively after UKS surgery to making a standard follow-up call within 48 hours. Another issue that was recognized during the study is that patients called the nurse advice line for complaints of pain after the stent was removed. Based on this observation, another recommendation would be to have the nurse discuss pain management after the stent is removed. It is also recommended that there is a proposal for continued research using postoperative phone calls as an intervention after other types of urological surgeries. Lastly, it is recommended that larger studies showing the cost savings from using nurse-initiated post-operative phone calls to decrease ED visits in various populations be conducted.

Implications for Nursing

This study shows the importance of using nurses to call patients after UKS surgery. According to Fay (2015), an ED visit for someone with private insurance costs an estimated $933.00. If a nurse can decrease the rate of ED visits by simply making a phone call, this could be a significant cost savings to both patients and hospitals. By using the estimated cost of an ED visit as discussed by Fay (2015), this study would have saved at least $3,732. Additionally, if telephone calls can decrease ED visits, patients who do not have emergent needs can also be kept out of the ED. Thus, patients who have emergent needs can be seen sooner because the ED staff can focus on the emergent cases.


Postoperative complications hinder recovery and decrease patient satisfaction by creating unwanted stress and anxiety. The IOM (2001) acknowledges that current healthcare delivery needs to change. Healthcare reform is well underway to decrease unnecessary ED visits as well as readmissions to the hospital. Research supports the use of postoperative telephone calls to improve patient communication and to discuss concerns in a proactive fashion. The clinic did not see a change in calls from patients to the nurse advice lines, but the clinic was able to decrease ED visits after UKS surgery by 11%. These results support the routine use of postoperative nurse-initiated telephone calls following UKS surgery and support for it to become standard practice to improve cost-effective care in all areas of care.


Acknowledgements: The authors would like to thank Dr. Brian Whitley and Dr. Charles Scales for their support of this project. They would also like to thank Dr. Barbara Berg, Dr. Nancy Steele, and Dr. Jane Hokanson Hawks for their time and assistance with this article.


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Centers for Medicare and Medicaid Services (CMS). (2014). The hospital readmissions reduction program. Retrieved from https://www.cms. gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ Value-B as ed-Programs/HRRP/ Hospital-Readmission-ReductionProgram.html

D'Amore, J., Murray, J., Powers, H., & Johnson, C. (2011). Does telephone follow-up predict patient satisfaction and readmission? Population Health Management, 14, 249-255. doi:10. 1089/pop.2010.0045

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Inman, D., Maxson, P., Johnson, K., Myers, R., & Holland, D. (2011). The impact of follow-up educational telephone calls on patients after radical prostatectomy: Finding value in low-margin activities. Urologic Nursing, 31, 83-91.

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Pengfei, S., Yutao, L., Jie, Y., Wuran, W., Hao, Z., & Jia, W. (2011). The results of ureteral stenting after ureteroscopic lithotripsy for ureteral calculi: A systematic review and meta-analysis. The Journal of Urology, 186, 1904-1909.

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Helen M. Tackitt, DNP, RN, FNP-BC, NE-C, was a Nurse Practitioner, Duke University Medical Center, Division of Urologic Surgery, Raleigh, NC; and is currently a Director of APRN/PA Practice, the Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH.

Samuel H. Eaton, MD, is an Assistant Professor of Surgery, Duke University Medical Center, Division of Urologic Surgery, Raleigh, NC.

Aaron C. Lentz, MD, FACS, is an Associate Professor of Surgery Duke University Medical Center, Division of Urologic Surgery, Raleigh, NC.
Table 1.

Advice Lines Calls
(Intervention Group)

of Calls    Reasons for Calls

2           Stent pain
2           UTI symptoms
1           String detached from stent
1           Vaginal yeast infection
1           Fever
1           Post-op instructions
1           Medication question
1           Pain after stent removal

Table 2.

Advice Lines Calls
(Comparison Group)

of Calls    Reasons for Calls

11          Stent pain
4           UTI symptoms
1           Post-op instructions
1           Medications questions
5           Hematuria
1           Constipation
1           Bladder spasms
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Title Annotation:Quality/Performance Improvement Project
Author:Tackitt, Helen M.; Eaton, Samuel H.; Lentz, Aaron C.
Publication:Urologic Nursing
Article Type:Report
Date:Nov 1, 2016
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