Implementation of the Accelerated Care of Torsion (ACT) pathway: a quality improvement initiative for testicular torsion
Rebecca S. Zee, M.D./Ph.D.1, Christopher E. Bayne, M.D.1, Patrick T. Gomella, M.D.2, Hans G. Pohl, M.D.1, Gil Rushton, M.D.1, Tanya D. Davis, M.D.1.
1Children's National Medical Center, Washington, DC, USA, 2George Washington University Department of Urology, Washington, DC, USA.
BACKGROUND: Timely diagnosis and management of testicular torsion is of paramount importance. Furthermore, time to surgical intervention has become a benchmark for the quality of care provided by pediatric urologists, and is included in US News and World Report (USNWR) methodology. We sought to optimize management of torsion at a single institution by decreasing time from presentation to definitive management through the creation of a clinical care pathway called Accelerated Care of Torsion (ACT). Reduction of orchiectomy rate in our patient population was a secondary aim of this quality improvement initiative. METHODS: Multidisciplinary process mapping involving the Emergency Department (ED), Radiology, Anesthesiology, Perioperative services and Operating Room (OR) teams resulted in development of the ACT pathway. We reviewed USNWR methodology which awards the maximum score of 2 points if >90% of patients achieve surgical intervention within 240 minutes of presentation. One point is given if this time frame is met for 50-90% of patients. ACT was implemented in April 2016. Thirty-eight consecutive acute torsion cases were then prospectively evaluated from April 2016 to April 2018. We recorded triage to OR times, mode of presentation, and orchiectomy rates. Neonatal torsion, intermittent torsion and late phase torsion defined as duration of symptoms >24 hours were excluded from the analysis. We retrospectively reviewed 97 cases of acute torsion from 2004-2016 as a control group. RESULTS: In the control group, 72% of cases met the USNWR criteria for acute treatment of torsion. After ACT implementation, 100% of cases reached the OR within the 240 minute time frame. Time from ED triage to OR start decreased from a mean 200 min (SD 86.9 min) to 124 min (SD 39.2 min; p<0.0001). For direct presentations to our hospital, time to the OR decreased from a mean of 216 min (SD 78 min) to 148 min (SD 29 min; p<0.0001). For referred cases from outside hospitals, time to the OR decreased from a mean of 170 min (SD 95.6 min) to 97 min (SD 31.3; p<0.01). Orchiectomy rates were performed in 28% of control cases versus 26% after ACT implementation (N.S.). CONCLUSIONS: The multidisciplinary creation and implementation of a clinical pathway for the care of acute testis torsion has significantly decreased the time from ED to OR in our institution, however, overall orchiectomy rates were not affected. All 38 cases reached the OR in <240 minutes, meeting the USNWR benchmark.
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