Variation and Opportunities to Improve Testicular Torsion Care: The National Surgical Quality Improvement Program Pediatric Testicular Torsion Collaborative
Julia Finkelstein, MD1, Leslie McQuiston, MD2, Natalia Ballesteros, MD3, David Chalmers, MD4, Yvonne Chan, MD5, Suvro De, MD6, Anne Dudley, MD7, Emily Durkin, MD8, Nicolas Fernandez, MD9, Ernesto Figueroa, MD10, Gwen Grimsby, MD11, Ed Gong, MD12, Sarah Lambert, MD13, Mary Killan, MD14, Peter Metcalfe, MD15, Hans Pohl, MD16, Ethan Polsky, MD17, Kyle Rove, MD18, Megan Schober, MD19, Carmen Tong, MD20, Jill Whitehouse, MD21, Hsi-Yang Wu, MD PhD22, Anja Zann, MD23, Rebecca Zee, MD24, Jonathan S. Ellison, MD25.
1Boston Children's Hospital, Boston, MA, USA, 2Dell Children's Medical Center, Austin, TX, USA, 3St. Joseph's Childrens Hospital, Tampa, FL, USA, 4Maine Medical Center, Portland, ME, USA, 5Children's Medical Center, Dallas, TX, USA, 6Children's Healthcare of Atlanta, Atlanta, GA, USA, 7Connecticut Children's, Hartford, CT, USA, 8Helen DeVos Children's Hospital, Grand Rapids, MI, USA, 9Seattle Children's Hospital, Seattle, WA, USA, 10Nemours Children's Hospital Delaware, Wilmington, DE, USA, 11Phoenix Children's Hospital, Phoenix, AZ, USA, 12Lurie Children's Hospital, Chicago, IL, USA, 13Yale School of Medicine, New Haven, CT, USA, 14LeBoneur Children's Hospital, Memphis, TN, USA, 15Stollery Children's Hospital, Edmonton, AB, Canada, 16Children's National Hospital, Washington D.C., VA, USA, 17Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA, 18Children's Hospital of Colorado, Aurora, CO, USA, 19William Beaumont, Royal Oak, MI, USA, 20Children's of Alabama, Birmingham, AL, USA, 21Joe DiMaggio Hospital, Hollywood, FL, USA, 22Hasbro Children's Hospital, Providence, RI, USA, 23Children's Hospital and Medical Center, Omaha, NE, USA, 24Children's Hospital of Richmond, Richmond, VA, USA, 25Medical College of Wisconsin, Milwaukee, WI, USA.
BACKGROUND:Testicular torsion is a well-documented pediatric urological emergency that poses a time-sensitive risk to the testicle. Hospital-based efforts to improve the emergency department throughput and rapid access to specialty surgical services have been described. To date, however, best practices for testicular torsion protocols remain unclear. In 2020, the National Surgical Quality Improvement Program Pediatric (NSQIPP) initiated a voluntary pilot program assessing process measures related to time-sensitive surgical interventions including testicular torsion. We convened a collaborative comprised of institutions in this program to assess factors associated with favorable process metrics.
Methods:Data were accrued across 26 participating NSQIPP sites. Testicular torsion process measures capture site of initial presentation, times and dates of presentation, presence of NSQIPP facility ultrasound procedure time and date, and testicular salvage as indicated by orchiectomy billed at time of the procedure. These data exclude neonatal and intermittent torsion. Post-processed data available through NSQIPP for each participating site were compared. These data included site of initial presentation, median time from presentation to operating room (OR), median time from presentation to diagnosis, median time from diagnosis to OR, number of cases greater than the aggregate median, and mean orchiectomy rate. Additionally, hospital level data and other torsion-care related processes were collected from each participating site, and comparisons were made.
Results:From 10/1/2021 to 9/30/22, the NSQIPP collaborative data included a total of 890 testicular torsion patients, with a median of 31.5 (IQR 21.5-40.5) patients per institution. Overall median time from presentation to OR was 2.5 hours (IQR 2.1 – 2.7) and the mean orchiectomy rate was 18.0% (SD 11.0). Time to presentation was improved with both employing a standardized evaluation protocol, as measured by proportion of cases beneath NSQIPP benchmark (33.9 vs 61.8 %, p=0.011), and TWIST score use (0.7 vs 1.1 hours, p=0.038) as measured by median time duration. Free-standing children’s hospitals (p=0.003), compared to children’s centers within adult systems, and institutions with American College of Surgeons Children’s Surgical Verification (p=0.025) also demonstrated decreased time from presentation to diagnosis. For patients presenting to the NSQIPP facility, being a free-standing children’s hospital was additionally associated with decreased time from presentation to OR (p=0.043). Having an institutional guideline of 1 hour for time from case booking to OR was associated with increased orchiectomy rate (20.6 % vs 11.4%, p=0.041).
Conclusions:Our data show variability in testicular torsion processes and outcomes across a wide spectrum of hospitals within NSQIPP. We demonstrate that certain hospital torsion-related processes boost testicular torsion management times. These data suggest that we can learn from high performers and potentially establish best practices for management of testicular torsion and support participation in the process measure data collection. We also found that hospital level factors are associated with differences in process metrics. Lastly, orchiectomy rate was not
associated with most measured care processes and may be linked to external factors not captured in the current study. These findings warrant further evaluation to determine how we can most effectively improve testicular torsion outcomes.
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