031 - A quality improvement initiative to improve testicular torsion timeliness and outcomes in a pediatric hospital

Publication Number: 31.4020

Trevor D. Fachko, Eastern Virginia Medical School, Kill Devil Hills, NC, United States; Paul Mullan, Children's Hospital of the King's Daughters, Norfolk, VA, United States; Phillip J. Poppas, Eastern Virginia Medical School, Norfolk, VA, United States; Lauren McMichael, Children's Hospital of The King's Daughters, Norfolk, VA, United States; Malea Drummond, Children’s Hospital of the King’s Daughters, Norfolk, VA, United States; Benjamin Ilapit, Children's Hospital of The King's Daughters, Smithfield, VA, United States; Kathryn Outland, Children's Hospital of The King's Daughters, Chesapeake, VA, United States; Jasilyn Wray-Jordan, Children's Hospital of the King's Daughters, Norfolk, VA, United States; Miccah Seaman, Children’s Hospital of the King’s Daughters, Chesapeake, VA, United States; Janelle A. Fox, Eastern Virginia Medical School, Norfolk, VA, United States

Background: The US News and World Report (USNWR) hospital ranking metrics have recently included testicular torsion quality metrics . At our pediatric tertiary care center, we retrospectively found low testicular salvage rates (58%; national mean post USNWR = 70.9%) and we have previously reported on differences in outcomes based on equity.

Objective: To address these challenges, we started a quality improvement initiative to improve testicular torsion treatment times and outcomes at our facility.

Design/Methods: Our first Plan-Do-Study Act cycle (PDSA1: 6/1/2024 to current) was a new testicular torsion triage and transfer pathway involving early notification of urology attendings, rapid transfer from outside hospital (OSH) based on clinical findings without needing OSH ultrasounds, and transfer from OSH via private vehicle in lieu of ambulance (Fig.1). Our primary outcome is the time from our emergency department (ED) to operating room (OR) arrival (EDOR). Our primary aim is to improve our EDOR time by 25% within 6 months of implementing PDSA1, compared to our baseline period (11/1/2021 to 5/31/2024). Secondary aims include improving testicular salvage rates, time case booking to OR time, and time from OSH arrival to ED arrival. Two-sided t-tests were used to compare baseline and intervention data. Cases with EDOR of >720 minutes were excluded as known cases of intermittent torsion or nonacute pathology.

Results: There were 115 and 21 cases in our baseline (n=32 exclusions) and intervention periods (n=1 exclusions), respectively. The median EDOR significantly decreased from the baseline (160 minutes) to the intervention (121 minutes) (p=0.005) (Figure 2). There was no significant change in case booking to OR time or testicular salvage rates; however, there was a significant increase in time from OSH presentation to ED arrival from baseline (Table 1).

Conclusion(s): Adoption of our new PDSA1 pathway was associated with significant improvements in our primary aim. Future PDSA cycles will be designed to impact our secondary outcomes, including local pediatrician education (PDSA2) and local school outreach for adolescent health education (PDSA3).

Figure 1. Testicular Torsion Triage and Transfer Pathways
Testicular torsion triage and transfer pathways adopted at our facility, focusing on early notification of urology, outpatient transfer based on TWIST, and transfer via private vehicle.

Figure 2. Run Chart of Time from ED Arrival to OR Arrival
Run chart comparing pre-intervention and post-intervention time from ED arrival to OR arrival with USNWR quality standard benchmark.

Table 1. Comparison of Pre-Intervention and Post-Intervention Outcomes
Comparison of EDOR, time from case booking to OR arrival, time from OSH arrival to ED arrival, and testicular salvage rate between pre-and-post intervention groups.