Closing the Loop on Stone Prevention: A Two-Cycle Audit of Recurrence Prevention Counselling After Ureteric Stone...

Background National guidance requires that every patient presenting with a new or recurrent urinary stone receives documented dietary and fluid advice, and this is a measurable quality indicator rather than a discretionary extra. In our department, this advice appeared to be delivered inconsistently, particularly at acute presentation, but the reasons were unclear. We audited compliance against national standards and, unusually for an audit of this kind, surveyed the clinicians responsible for delivering the advice to establish why the standard was being missed before attempting to correct it. Methodology We conducted a two-cycle retrospective audit in a district general hospital urology department. Cycle one reviewed 59 consecutive patients presenting with ureteric stones between February and April 2026. Compliance was assessed against national guideline standards for emergency computed tomography within 24 hours, alpha-blocker therapy in distal ureteric stones smaller than 10 mm, metabolic evaluation, and documented dietary and fluid advice. An anonymous survey of eight clinicians examined guideline awareness, self-reported practice, documentation habits, perceived barriers, and confidence. Interventions followed: a standardised printed prevention leaflet across the emergency department and wards, an explicit prompt within discharge documentation, written clarification of who delivers advice at each point in the pathway, and departmental teaching. Cycle two re-audited 46 consecutive patients between June and July 2026 using an identical proforma. Results Cycle one revealed near-total failure of the prevention standard. Documented prevention advice and dietary advice were each present in 22.0% of patients, and hydration advice in 18.6%. Metabolic evaluation was arranged in 35.6%, and alpha-blocker therapy was prescribed to only five of 14 patients meeting the guideline indication. Imaging and follow-up performed well at 96.7% and 89.8%, respectively, indicating a deficit specific to prevention rather than a general failure of care. The survey proved decisive: every respondent reported rarely documenting advice, 87.5% identified unclear professional responsibility as the principal barrier, and mean self-rated confidence was 2.0 of 5. Cycle two showed improvement across every prevention measure. Documented prevention advice and dietary advice each rose to 89.1%, hydration advice to 100%, and metabolic evaluation to 89.1%. Alpha-blocker therapy was prescribed to 15 of 17 eligible patients, rising to 88.2%. Imaging reached 100% and follow-up 95.7%. The gap between acute and elective settings closed, with documented advice rising from 20.0% to 88.0% in emergency presentations and from 24.1% to 90.0% in elective patients. Conclusions Poor compliance here reflected system design rather than clinical knowledge or intent. Surveying staff before intervening identified diffuse responsibility and absent written resources as the operative barriers, and compliance subsequently improved by 53 to 81 percentage points across every prevention measure. We cannot demonstrate that the intervention package caused these changes, and the design does not permit attribution to any individual component. Audits reporting non-compliance without investigating its cause are of limited value; a brief staff survey is a proportionate, high-yield addition to the audit cycle.