Ultrasound is a safe, noninvasive and effective way to identify the presence of kidney stones (nephrolithiasis) in children. Quality measures put in place at The Children’s Hospital of Philadelphia over the past few years have enabled us to reach 100 percent utilization of ultrasound as the first imaging study for children with suspected kidney stones.

The American Urological Association and the European Society of Pediatric Radiology now recommend ultrasound as the initial diagnostic imaging study for children with suspected stones.

Despite these new recommendations, computed tomography (CT) is still widely used across the country as the initial diagnostic tool in kids with suspected kidney stones. According to a study published in 2014 in the journal Pediatrics, more than 60 percent of pediatric patients still received a CT as the first diagnostic test.

The Children’s Hospital of Philadelphia has proactively changed our policies and practices to meet these guidelines for utmost patient safety, and to provide the most effective and accurate diagnosis. Between 2000 and 2013, these changes allowed us to go from 0 percent to 100 percent utilization of ultrasound in the evaluation of children and adolescents with suspected kidney stones.

Several important events impacted our approach to care of children with suspected nephrolithiasis:

• 2007 — Image Gently, an initiative of the Alliance for Radiation Safety in Pediatric Imaging, was founded by a committee that included CHOP radiology leadership. The initiative is now an international movement dedicated to safe and effective imaging for children.
• 2009 — CHOP’s Emergency Department established an ED care pathway for the evaluation and treatment of kidney stones, standardizing ultrasound as the initial diagnostic study. This was an important step in shifting institutional focus to reduction of unnecessary radiation and standardizing care to improve outcomes for patients with kidney stones.
• 2011 — CHOP developed clinical decision support for a child with suspected stones. Ultrasound became the default order that would appear in Epic.
• 2013 — CHOP developed an outpatient pathway, further standardizing care guidelines for the evaluation and treatment of children with kidney stones.

Additional reading and resources

• A recent article published in the Journal of Urology shows that care pathways are associated with decreased inappropriate utilization of CT. Read more.