These guidelines standardise ED referrals for confirmed kidney/ureteric stones to the urology teams at FPH and WPH. By using the Epic Stone Pathway, we aim to:

• Reduce unnecessary referrals and clinic wait times.

• Expedite treatment for eligible patients (e.g., urgent ESWL booking).

• Lower ED reattendance rates by ensuring timely follow-up.

For any patients fit for discharge, please only use the Epic Stone Pathway. No routine referral to urology team / clinic.

• Assess Patient:

  • Clinical Features: Loin pain, dipstick haematuria, nausea/vomiting

  • Adverse Features:

    • Uncontrolled symptoms i.e. pain / vomiting

    • Evidence of infection – elevated inflammatory markers, pyrexia, haemodynamic compromise

    • Deranged Renal Function (AKI or CKD 3 / 4)

    • Known renal tract abnormality

  • If any adverse features present, refer to Urology for assessment and further investigation and management

  • Rule out other pathology

    • THINK AORTA: in anyone >55 yrs

    • Ectopic pregnancy: urine HCG to rule out

• Baseline Labs: FBC, U&E, bone profile, Uric acid (for all suspected cases).

• Urine tests: dipstick, HCG

• Medications:

  • Analgesia:

First line: PR diclofenac 75-150mg in 2-3 divided doses, alternatively 100mg OD.

Second line: Naproxen 500mg BD, consider gastro protection with PPI

Codeine/morphine liquid if required, consider laxative in addition.

• Antiemetics (e.g. Ondansetron 4-8mg TDS)

• Antibiotics: if signs of sepsis / infection prescribe as per Microbiology EOLAS Guidelines

• Imaging: Non-contrast CT KUB (confirmatory for stones).

  • In hours 0800-2100 – request and liaise with Radiology

  • Out of hours 2100 – 0800

    • Discharge patient and complete discharge note

    • TTOs – PR diclofenac/naproxen, codeine/morphine, antiemetic

    • Book patient in ED Snapboard to return to ED next day at 0930 onwards (please see Appendix 1 for Epic Guidance)

    • Book CTKUB with appropriate clinical details. CT request automatically marked as ‘Ambulatory’

Patients Returning to ED for CTKUB

• Nurse and Physician in Charge of Majors A to review Snapboard at 0800 for expected CTKUB patients

• CTKUBs ordered overnight will be vetted by the Hot Seat Radiologist at 0900

• Patients should return to ED at 0930 and book in at reception

• CT Radiographer will call Nurse in Charge of Majors A once they are ready for the patient to go to CT

• Once the patient has had the scan they should return to ED and be transferred to ED Short Stay, where the scan and the patient will be reviewed by the Physician in Charge of Majors A

3.1 Admit & Discuss with Urology (Immediate Referral)

Patients requiring hospital admission or with any of the following:

• Bilateral ureteric stones

• Ureteric stone >10mm

• Signs of sepsis (fever, tachycardia, elevated WCC/CRP)

• New/worsening AKI (↑Cr, oliguria)

• Pregnancy

• Re-presentation within 1 month of prior stone diagnosis

• Recent urological intervention (e.g., stent, surgery)

• Contact Urology for discussion of complex cases

(Please see Appendix 2 for Epic Stone Pathway)

If stable for discharge and NO red flags above, proceed as follows:

4.1 Epic Stone Pathway Referral Process

1. Confirm stone on CT KUB (no referral if negative).

2. If stone passed to bladder → No follow-up required unless patient has additional kidney stones (then use pathway).

3. Kidney stones

   • ≤4mm → Discharge to GP (no routine urology follow-up).

• Spontaneous passage rate: 17-46% (1st year).

• Intervention rate: 17-29% (long-term).

• Rate of progression: <30%

• 5-10mm → Routine ESWL Referral or Urgent F2F Stone Clinic Referral if ESWL contraindications

• >10mm → Stone Clinic (Urgent Referral)

4. Ureteric Stones

   • ≤ 5mm → OP CTKUB and Virtual Stone Clinic

   • >5mm → Urgent ESWL Referral or Urgent F2F Stone Clinic Referral if ESWL contraindications

4.2.1 Contraindications for ESWL

• Anticoagulants/bleeding disorders

• Pregnancy

• Active UTI/sepsis history

• Abdominal aortic aneurysm

• Uncontrolled HTN

• Prior failed ESWL

4.2.2 Patients suitable for ESWL candidates:

• Booked within 3 working days if no contraindications.

• Print AVS (includes ESWL info leaflet).

4.2.3 Management for Patients Not Suitable for ESWL

If the patient is not a candidate for ESWL (due to contraindications or other factors):

• Follow the Epic Stone Pathway for automated scheduling.

• The pathway will arrange:

  • Urology clinic follow-up (if required), and/or

  • Follow-up CT scan (as clinically indicated).

• No additional manual referral is needed—the Epic system coordinates these steps.

• Print AVS

Do NOT refer if:

• CT KUB negative for stones.

• Stone already passed to bladder (unless residual stones).

• Asymptomatic ≤4mm stones (discharge to GP).

Epic pathway = definitive referral (no duplicate urology consults).

Provide AVS to patients (explains next steps).

• Faster access to ESWL/clinics for appropriate patients.

• Fewer ED reattendances due to delayed care.

• Improved patient education via structured discharge info.

National Institute for Health and Care Excellence [NICE] (2020) Renal and ureteric stones. QS195. Available at: https://www.nice.org.uk/guidance/qs195 (Accessed: 13 May 2025).

BMJ Best Practice (2024) ‘Nephrolithiasis’, in BMJ Best Practice. London: BMJ Best Practice. Available at: https://bestpractice.bmj.com/topics/en-gb/3000101

© Epic Systems Corporation

Upon discharging a patient from the ED, the clinician will go to the Dispo activity.

1. Open the Disposal section.

2. Select a discharge disposition, generally either ‘Discharge: No GP follow up’ or ‘Discharge: GP follow up’.

3. From the Follow Up section, select Kidney/Ureteric Stone Pathway.

By clicking this, it opens a set of orders specific to kidney/ureteric stones which they can choose from.

It has a short piece of information giving instructions about making sure to discuss with the urology on call for certain things, to make sure the Authorising Clinician is set to the correct one when placing the orders (all orders should go to the urology doctors not the ED doctors). Make sure one of the appropriate documents is added onto the After Visit Summary (AVS).

There are two orders in the Prescriptions & Orders section, select the appropriate one:

• Kidney Stone (If <=4mm, discharge with GP follow up)

• Ureteric Stone.

Kidney Stone

(If <=4mm, discharge with GP follow up).

1. If <=4mm.

2. From the Disposal section, select Discharge with GP follow up.

3. From the Instructions section, select appropriate attachment to add to the After Visit Summary (AVS).

4. Continue with discharge paperwork as normal.

5. If larger than 4mm, click Kidney Stone.

6. From the pathway pop-up, select the appropriate option, depending on the size of the stone.

7. 5-10mm

• Select one of the options:

ESWL contraindications.

• Appointment request Face to Face will be ordered automatically.

No ESWL contraindications.

• Select the appropriate ultrasound to order.

• From the order pop-up, everything that can be automatically filled out has been, the only piece of information needed to be completed is ‘Is the patient on anticoagulation?’

• Once completed, Accept and Sign the order.

2. >10mm

• Generates a Face to Face appointment order.

• Accept and Sign the order.

Ureteric Stone.

From the pathway pop-up, select the appropriate option, depending on the size of the stone.

a. <=5mm

• Generates two orders:

• CT Kidney Ureters Bladder KUB order – this is auto completed.

• Virtual Stone Clinic order – this is auto completed.

• Accept and Sign orders.

b. >5mm

• Select one of the options.

ESWL Contraindications.

• Appointment request Face to Face will be ordered automatically.

No ESWL Contraindications.

• Select the appropriate ultrasound to order.

• From the order pop-up, everything that can be automatically filled out has been, the only piece of information needed to be completed is ‘Is the patient on anticoagulation?’

• Once completed, Accept and Sign the order.

1. From the Instructions section, select appropriate attachment to add to the After Visit Summary (AVS).

Will appear on the patient’s After Visit Summary as so:

2. The clinician will continue with the discharge paperwork as normal.

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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