- Email: [email protected]
Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion
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Journal of Pediatric Urology (xxxx) xxx xxx
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Children’s National Medical Center Division of Urology, Washington, D.C, USA
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University of Florida Division of Pediatric Urology, Gainesville, FL, USA
Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion R.S. Zee a,*, C.E. Bayne b, P.T. Gomella c, H.G. Pohl a, H.G. Rushton a, T.D. Davis a Summary
c
George Washington University Department of Urology, Washington, D.C, USA * Corresponding author. Children’s National Medical Center, 111 Michigan Avenue NW, Washington, D.C, 20010, USA. [email protected] (R.S. Zee) Keywords Testicular torsion; Quality improvement; Testis; Orchiectomy; Acute scrotum
Abbreviations ACT, Accelerated Care of Torsion; ED, Emergency Department; IQR, Interquartile Range; OR, Operating Room; TTO, Time to Operating Room; USNWR, United States News and World Report; US, Ultrasound; QI, Quality Improvement Received 4 January 2019 Accepted 11 July 2019 Available online xxx
Background Timely diagnosis and management of testicular torsion is of paramount importance. Furthermore, time to surgical intervention is a benchmark for the quality of care provided by pediatric urologists included in US News and World Report (USNWR) methodology. Objective We sought to optimize management of acute testicular torsion at a single institution by decreasing time from presentation to definitive management through the creation and implementation of a clinical care pathway (accelerated care of torsion or ACT) for acute testicular torsion in a 2-year period. Study design Multidisciplinary process mapping involving the emergency department (ED), radiology, anesthesiology, peri-operative services, and operating room (OR) teams resulted in development of the ACT pathway with the goal of achieving surgical intervention within 4 h of arrival at our institution. The accelerated care of torsion pathway was implemented in April 2016. Thirty-eight consecutive acute torsion cases were then prospectively evaluated from April 2016 to April 2018. For process measures, we recorded triage to OR times and mode of presentation. For outcome measures, we examined orchiectomy rates. We retrospectively reviewed 97
cases of acute torsion from 2004 to 2016 as a control. Results Time from ED triage to OR start decreased from a median 196 min (interquartile range [IQR] 137e249 min) to 127 min (IQR 100e148 min; P < 0.0001) for all cases of acute torsion. 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 min time frame. Orchiectomy rates were performed in 24% of control cases vs 30% after ACT implementation (P Z NS). Survival curve analysis demonstrated no significant difference in probability of testis salvage before or after implementation of the ACT pathway. Discussion In agreement with similar studies, despite a significant reduction in triage to OR times, the orchiectomy rate approached 30%. This outcome did not significantly improve after implementation of the ACT pathway. Overall ischemia time was a more important determinant of testis salvage. Study limitations include limited patient follow-up to assess testis atrophy. 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 rate was not significantly affected.
https://doi.org/10.1016/j.jpurol.2019.07.011 1477-5131/ª 2019 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article as: Zee RS et al., Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion, Journal of Pediatric Urology, https://doi.org/10.1016/j.jpurol.2019.07.011
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Introduction Pediatric testicular torsion is a common surgical emergency which affects an estimated 3.8 to 5 in 100,000 males aged below 18 years [1,2]. Ischemia time as well as the degree of torsion determines survival of the affected testis. These patients must be diagnosed and brought to the operating room (OR) expediently, as loss of germ cells and subsequent fibrosis can impact future fertility potential with reported oligospermia in 30% of men with a history of unilateral testicular torsion [3]. Several clinical departments must be coordinated to achieve timely diagnosis and surgical management of acute torsion. Given the potential impact on patient outcomes, as well as the US News and World Report (USNWR) scores (presentation to OR < 4 h), we sought to implement a quality improvement (QI) initiative to address time to operating room (TTO) for patients presenting to our institution, referred to as the accelerated care of torsion (ACT). The pathway was designed to standardize multidisciplinary communication and streamline tasks required to achieve surgical intervention in a timely fashion. As such, the project focused specifically on the timeline of events that occurred between patient arrival in the emergency department (ED) and entry into the OR. The aim of this QI project was to implement the ACT pathway in all acute testicular torsion patients presenting to our institution between April 2016 and April 2018. Process measures included triage to OR times and mode of presentation (referrals vs direct presentation to our institution). We speculated that improved TTO would decrease orchiectomy rates in our patient population. Therefore, the outcome measure examined orchiectomy rates before and after implementation of the pathway.
Methods Data collection For the control group, we retrospectively reviewed acute torsion cases for males younger than 18 years of age who were taken to the OR between April 2004 and March 2016 based on current procedural terminology (CPT) codes (54600 and/or 54620) in the electronic medical records database. Each case was individually reviewed and confirmed to be acute torsion before inclusion. For the intervention group, we prospectively recorded all cases that presented as acute torsion after implementation of the ACT pathway between April 2016 and April 2018 were prospectively recorded. All patients who had acute torsion with duration of symptoms <24 h resulted in activation of the ACT pathway. Patients with late phase torsion who presented greater than 24 h after onset of symptoms, neonatal torsion, intermittent torsion, and patients who were explored but did not have torsion were all excluded from the final cohort. For process measures, ED triage to ultrasound (US) (if applicable) and OR time, as well as mode of presentation were recorded. Orchiectomy rates were evaluated as an outcome measure. This is a project undertaken as a QI Initiative at our institution and, based on IRB review, their opinion was that it did not constitute
R.S. Zee et al. human subjects research. As such, the project did not require further oversight by the Institutional Review Board. Eight surgeons were included in the QI project. Intraoperative decision-making with regard to orchiopexy vs orchiectomy was left at the discretion of the surgeon. The individual surgeon criteria for salvage or orchiectomy did not change throughout the duration of the study. Follow-up appointment timing was also left to individual surgeon preference. Postoperative imaging was not routinely obtained.
Process mapping Process mapping was performed by an interdisciplinary panel comprised of urology, the ED, radiology, anesthesiology, peri-operative services, and the OR (Supplemental Figure). The same multidisciplinary team then created an optimized workflow for both direct presentations of testis torsion to the ED as well as testis torsion transfers to the ED from primary care offices, outside EDs, or urgent care centers. Duration of time elapsed between locations within the institution was determined based on time stamps recorded in the electronic medical record. Locations included referring provider, ED triage, radiology, and the OR. At this institution, referrals from outside institutions for acute torsion are transferred directly to the ED before transfer to the OR. The time stamp utilized for the OR was patient time of arrival in the OR. The primary goal of process mapping was to optimize the length of time between triage and arrival in the OR. Each department leader performed discipline-specific teaching for the pathway before implementation in April 2014.
Key drivers and implementation of the pathway After detailed review of the process map, several key drivers were identified for intervention (Fig. 1: Key Driver diagram). Department-specific education was performed to improve care team awareness of the ACT pathway and promote multidisciplinary coordination of care. Another key driver of the pathway involved early notification of the urology team whenever a patient presented to the ED with a suspected testicular torsion or was being transferred from an outside institution for management of known or suspected testis torsion. An additional key driver was efficient transfer of the patient between the ED and OR areas. The intervention involved relying on the urology team to transfer the patient from the ED to the preoperative area rather than waiting for hospital transport to arrive. Finally, completion of a preoperative safety checklist required for all patients having non-emergent surgery at our institution was formally eliminated from the ED workflow. Implementation and prospective monitoring of the ACT pathway is ongoing. Each new case of acute testicular torsion is audited by a multidisciplinary team for pathway deviations, delays, and possible new pathway improvements. There is no specific time interval that defined a delay. Instead, any subjective delay in any component of the pathway is reviewed during the audit. Deviation from
Please cite this article as: Zee RS et al., Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion, Journal of Pediatric Urology, https://doi.org/10.1016/j.jpurol.2019.07.011
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Figure 1 Key driver diagram illustrating interventions that decreased TTO in the target population. TTO, time to operating room; ACT, accelerated care of torsion; ED, emergency department; OR, overall survival.
the protocol that has the potential to result in a delay in TTO results in multidisciplinary discussion and intervention, most commonly in the form of ongoing education of involved care providers. Challenges with development of the pathway included consensus on the pathway itself due to the involvement of multiple disciplines and institutional resistance to change. The primary barrier in adherence to the pathway was lack of provider knowledge of the specifics of ACT pathway, related to both timely initial education and on-going education on the pathway. This was particularly problematic in larger departments with high turnover in faculty, residents, nursing, technicians, and/or support staff. Therefore, provider education and re-education has been a high priority intervention in implementation of the pathway.
Statistical analysis Statistical analysis was performed by one-way analysis of variance, Fisher’s exact test, or log-rank test where appropriate. Kaplan-Meier curves were analyzed using Graphpad Prism 8 software. Significance of the survival
curve was calculated using Mantel-Cox test. A P-value less than 0.05 was considered statistically significant.
Results For the control group, a total of 207 patients presented to the institution between April 2004 and March 2016 and underwent scrotal exploration for suspected acute testicular torsion. After excluding for neonatal torsion, intermittent torsion, and delayed torsion, 97 (46.8%) patients met inclusion criteria for acute testicular torsion. Roughly one-third (n Z 34; 35%) of these patients were referred from other institutions or community providers. The remaining 63 (65%) presented directly to our institution. The ACT pathway was implemented in April 2014 after each department had completed training for their respective roles. Ninety-seven patients presented to our institution with a diagnosis of testicular torsion during the 2 years following implementation of ACT. After applying exclusion criteria, 38 patients (39%) met inclusion criteria for acute torsion. Eighteen (47%) patients were referred from other institutions, whereas the remaining 20 (53%) presented
Please cite this article as: Zee RS et al., Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion, Journal of Pediatric Urology, https://doi.org/10.1016/j.jpurol.2019.07.011
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directly to the ED. Demographics were analyzed and shown in Table 1. Median age of the control group was 13 years (interquartile range [IQR] 12e15) compared with 14 years (IQR 12e15) in the ACT group (P Z 0.33). In the control group, 67 (69%) of patients and 35 patients (97%) in the ACT group had US with timestamps available for review. Time from ED triage to US start decreased from a median 48.5 min (IQR 30e97) to 18 min (IQR 12e33; P < 0.0001). There was no significant difference in the time it took to complete an US which was 12.5 min (IQR 9e21) in the control group vs 13 min (IQR 9e18) in the ACT group. Overall, after implementation of ACT, median time from ED triage to completion of a scrotal US decreased from 72 min (IQR 47e110) to 31 min (IQR 22e53; P < 0.0001). After ACT implementation, median time from ED triage to the OR decreased from 196 min (IQR 137e249) to 127 min (IQR 100e148; P < 0.0001; Table 2). Patients who presented directly to the institution experienced an improvement from a median of 201 min (IQR 159e270) to 143 min (IQR 130e159; P Z 0.006). Patients referred from other institutions experienced a decrease in time from ED triage to OR from 170 min (IQR 97e208) to 100 min (IQR 63e122; P < 0.01). The ACT pathway increased the percentage of patients who reached the OR from ED triage within 240 min from 72% to 100% (P < 0.0001; Table 2). In the group who presented directly to our institution, the proportion of patients who reached the OR within 240 min increased from 63% to 100% (P < 0.001). For referred patients, the number of patients achieving surgical intervention within 240 min increased from 88% to 100% (P Z 0.28). After implementation of the ACT pathway, the most common reason for deviation from the pathway involved delays in interdisciplinary communication. In four (10%) cases, there were either difficulties or delays in communication. In these cases, the median TTO was 150 min (IQR 143e182). In two patients (5%), there was a delay because the ED nurse completed the preoperative checklist, an item which was eliminated from the workflow as it was deemed unnecessary. Median TTO for these patients was 133 min (IQR 123e143). For both of these issues, the median TTO was not significantly different when compared with the overall cohort. However, pathway re-education was undertaken in all cases to prevent significant delays in the future. For the study outcome measure of orchiectomy rates, 27 (30%) patients underwent orchiectomy before implementation of the pathway whereas 10 (24%) underwent orchiectomy after ACT implementation (P Z NS; Table 2). Table 1
Demographics of patients included in the study.
Characteristic
Control (n Z 97) ACT (n Z 38) P-value
Age, median (IQR) Race Caucasian African-American Latino Asian Other
13 (12e15)
14 (12e15)
7 (7%) 56 (58%) 21 (22%) 1 (1%) 12 (12%)
2 (6%) 25 (67%) 2 (6%) 0 8 (21%)
0.33
IQR, interquartile range; ACT, accelerated care of torsion.
When investigating overall ischemia times based on patient-reported onset of symptoms, we found no significant difference in ischemia times before or after implementation of the ACT pathway (Table 3). Patients in the control group had a median ischemia time of 476 min (IQR 377e667) in comparison to 409 min (302e722) in the ACT group (P Z 0.99). In the control group, there was a significant difference in ischemia times between patients who underwent salvage or orchiectomy (451 min vs 799 min; P < 0.0001). After implementation of ACT, the mean ischemia time in patients undergoing salvage was less than for orchiectomy, but the difference was not statistically significant (346 min [IQR 298e642 min] vs 711 min [IQR 453e1347 min]; P Z 0.14). A Kaplan-Meier curve was calculated based on overall ischemia time (Fig. 2). Survival probabilities were comparable. In the control cohort, 100% survival threshold was 6 h 35 min, whereas in the ACT group, this threshold was 4 h 25 min. The median time to reach a 50% probability of testis survival was 15 h 25 min vs 22 h 4 min after ACT implementation. The curves were not significantly different suggesting that overall warm ischemia times did not change before or after implementation of the pathway. Follow-up rates were examined for patients included in the ACT pathway. Overall, 23 of 38 (60%) patients had follow-up at a median 31 days following surgery. Testis size at follow-up was not routinely documented in the EMR. Ultrasound at follow-up was not routinely performed as patients typically only returned for a single postoperative visit for a wound check.
Discussion In this manuscript, we describe a QI initiative for our institution that sought to decrease TTO for patients presenting with acute testicular torsion utilizing process mapping. We were able to significantly reduce the time from presentation to the ED to OR in patients following development and implementation of the ACT pathway. US News and World Report evaluates TTO for acute testicular torsion as a criterion for ranking pediatric urology programs. If greater than 90% of patients achieve operative intervention within 240 min of presentation then the maximum score of 2 points is awarded to the program. The program is given 1 point if 50e90% of patients reach that benchmark [4]. By initiating a multidisciplinary panel for process improvement, we were able to decrease the TTO to less than 240 min for 100% of patients who presented with acute testicular torsion after implementation of the pathway, which is the benchmark for quality care as defined by USNWR [4]. Others have been implementing similar pathways to decrease TTO with good success [5e7]. The development and implementation of the ACT pathway was not without challenges. Interdisciplinary creation of a process map requires that all departments agree on a single pathway for torsion patients as they move through the institution. In some cases, this required the addition of tasks to already busy services that were resistant to changing the status quo. After implementation, the most common reason for deviation in the pathway was lack of awareness of elements of the
Please cite this article as: Zee RS et al., Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion, Journal of Pediatric Urology, https://doi.org/10.1016/j.jpurol.2019.07.011
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Table 2 Total duration of time elapsed between triage and treatment before and after implementation of ACT. There was a significant decrease in TTO for both direct and referred cases of torsion. There was a significant increase in the proportion of patients who reached intervention within the goal time of 240 min. Values are expressed as median in minutes with interquartile range. P-values were determined by one-way ANOVA. P-value
Direct torsion
TTO median min (IQR) Intervention <240 min (%) Orchiectomy rate (%)
Control
ACT
201 (159e270) 63
144 (131e160) 100
29
20
Referred torsion Control
ACT
< 0.001
170 (97e208) 88
100 (63e122) 100
0.56
26
38
0.006
P-value
P-value
Combined Control
ACT 127 (100e148) 100%
<0.0001
0.28
196 (137e249) 72%
0.36
28
30
> 0.99
0.01
< 0.0001
TTO, time to operating room; ACT, accelerated care of torsion; ANOVA, analysis of variance; IQR, interquartile range.
Table 3 Total ischemia time was calculated before and after implementation of ACT. Even when accounting for direct or referred presentations, there was no significant different in mean ischemia times. Data are expressed as median value in minutes with interquartile range. P-values were determined by one-way ANOVA. Direct torsion
Ischemia time, median min (IQR) Salvaged testes, median min (IQR) Orchiectomy, median, min (IQR)
P-value Referred torsion
P-value Combined
P-value
Control
ACT
Control
ACT
Control
ACT
465 (364e641) 339 (238e438) 1034 (577e1448)
518 >0.99 (305e736) 374 >0.99 (299e714) 1034 >0.99 (577e1448)
491 (367e668) 460 (273e605) 799 (441e1331)
382 0.99 (294e634) 320 0.99 (274e491) 626 0.94 (340e1172)
476 (377e667) 451 (335e577) 799 (466e1117)
409 0.99 (302e722) 346 >0.99 (298e642) 711 0.97 (453e1347)
ACT, accelerated care of torsion; ANOVA, analysis of variance; IQR, interquartile range.
pathway. All urology residents rotating through the service are given an orientation to the pathway at the start of their rotation. However, performing initial and ongoing education in larger departments with high turnover in support staff and healthcare providers proved to be
Figure 2 A survival curve was calculated based on total ischemia time in hours. There was no significant difference in the probability of salvage before or after implementation of the ACT pathway. Median survival in the control group was 15.42 h and 22 h in the ACT group. P Z 0.95. ACT, accelerated care of torsion.
extremely challenging. Ongoing educational efforts are underway and performed after each case of acute torsion is reviewed, and the opportunity for pathway modification and improvement is continually assessed in a multidisciplinary fashion. We found that despite identifying deviations from the pathway with resulting delays, the TTO was not significantly greater for these patients compared with the overall cohort. Despite these challenges, we were able to streamline the process of taking an acute testis torsion patient from the ED to the OR, and TTO in our institution was significantly decreased. The creation and implementation of the pathway served to re-educate and heighten awareness of the time sensitive nature of testis torsion in the institution as a whole, which we believe played a large role in shorter times in all phases care in the management and treatment of this condition. Interestingly, despite decreasing time from ED triage to the OR, we did not significantly impact orchiectomy rates (30% in the control group vs 24% in the intervention group). This aligns with orchiectomy rates ranging from 31 to 32% in recent publications of patients presenting with acute torsion [2,8]. Similar to the study findings, Arevalo et al. recently demonstrated that significantly decreasing TTO by taking referred patients directly to the OR upon arrival had no significant impact on orchiectomy rates. In this publication, the authors successfully decreased median TTO in the intervention group by 40 min without a discernible impact on orchiectomy rate. In contrast, Afsarlar et al. previously reported an improvement in orchiectomy rates
Please cite this article as: Zee RS et al., Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion, Journal of Pediatric Urology, https://doi.org/10.1016/j.jpurol.2019.07.011
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1.e6 from 58.6% to 41.4% after enacting a standardized checklist meant to identify acute testicular torsion patients in the ED that decreased TTO from a mean 3.3 he2.1 h [7]. Acute testicular torsion patients should ideally be diagnosed and treated within 6e8 h of ischemia time to avoid testis loss [9e12]. In the study data set, both the control and ACT cohort demonstrated excellent salvage rates when warm ischemia was less than 6 h. The implementation of ACT did not significantly decrease the overall ischemia time between the two groups suggesting that decreasing TTO in torsion patients was not the most important factor dictating salvage. Rather, the delay in presentation is more likely to determine the probability of salvage. A previous publication reported that after an ischemic time of 6 h, the risk of orchiectomy increased 22-fold [13]. In the study cohort, testicular salvage was 92% with a warm ischemia time of up to 7 h 45 min. It has been previously reported that factors that contribute to a delay in presentation is determined by factors beyond the physician’s control, such as patient age, insurance status, developmental delay, distance from the hospital, hospital transfer, and socio-economic status [2,8,14,15]. Certainly, public knowledge of testis torsion and its implications is poor with only 34% of parents having knowledge of torsion [16,17]. In a survey of adolescent males, 64% of respondents knew to seek medical attention for acute scrotal pain [16,17]. A limitation of this study is lack of long-term follow-up with regard to assessment of testis atrophy. Follow-up rates for these patients are poor despite scheduling appointments for all of them. We also do not routinely perform scrotal US postoperatively on patients who have undergone orchiopexy for acute testicular torsion and therefore are not able to objectively measure the degree of atrophy in the testis after surgery. Furthermore, documentation of testis size at follow-up was inconsistent between providers, and with an average follow up time of approximately 1 month, this is likely too soon to identify all cases of atrophy on exam. Future follow-up will be standardized to include longer term follow-up at 6 months to monitor for testicular atrophy. Another limitation of the study is that we relied on patient report for time of onset of symptoms, as documented in the electronic medical record, which is subject to recall bias or inaccuracies in documentation. However, there is no other way to document this parameter. Finally, the ultimate decision to perform orchiectomy is subjective and thus creates a selection bias that may impact the rate of testicular salvage with eight surgeons involved in this study.
Conclusion The implementation of a QI initiative to expedite surgical intervention in patients presenting with acute torsion was effective in significantly reducing the time from presentation to the ED to OR and brought 100% of patients to the OR within the USNWR goal time frame of 4 h of presentation. However, this did not translate to improved orchiectomy rates because of the limited impact on overall ischemia time. If delay in presentation has a greater impact on testis salvage rates than TTO in torsion patients, public health
R.S. Zee et al. initiatives educating the general public the importance of timely evaluation and treatment of testis torsion are a crucial next step in reducing orchiectomy rates in cases of testis torsion.
Author statements Ethical approval None required.
Funding There are no funding sources to report.
Competing interests There are no conflicts of interests to report.
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Quality improvement initiative for testicular torsion [12] Tryfonas G, Violaki A, Tsikopoulos G, Avtzoglou P, Zioutis J, Limas C, et al. Late postoperative results in males treated for testicular torsion during childhood. J Pediatr Surg 1994;29:553e6. https: //doi.org/10.1016/0022-3468(94)90090-6. [13] Ramachandra P, Palazzi K, Holmes N, Marietti S. Factors influencing rate of testicular salvage in acute testicular torsion at a tertiary pediatric center. West J Emerg Med 2015;16: 190e4. https://doi.org/10.5811/westjem.2014.11.22495. [14] Bayne AP, Madden-Fuentes RJ, Jones EA, Cisek LJ, Gonzales ET, Reavis KM, et al. Factors associated with delayed treatment of acute testicular torsionddo Demographics or interhospital transfer matter? J Urol 2010;184:1743e7. https: //doi.org/10.1016/J.JURO.2010.03.073. [15] Bayne CE, Villanueva J, Davis TD, Pohl HG, Rushton HG. Factors associated with delayed presentation and misdiagnosis of
1.e7 testicular torsion: a case-control study. J Pediatr 2017;186: 200e4. https://doi.org/10.1016/J.JPEDS.2017.03.037. [16] Cohen A, Friedman AA, Ahmed H, Gitlin JS, Palmer LS. Standardized education and parental awareness are lacking for testicular torsion. 2016. https: //doi.org/10.1016/j.jpurol.2016.01.008. [17] Nasrallah P, Nair G, Congeni J, Bennett CL, McMahon D. Testicular health awareness in pubertal males. J Urol 2000;164: 1115e7. https://doi.org/10.1016/S0022-5347(05)67265-5.
Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.jpurol.2019.07.011.
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Journal of Pediatric Urology (xxxx) xxx xxx
a
Children’s National Medical Center Division of Urology, Washington, D.C, USA
b
University of Florida Division of Pediatric Urology, Gainesville, FL, USA
Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion R.S. Zee a,*, C.E. Bayne b, P.T. Gomella c, H.G. Pohl a, H.G. Rushton a, T.D. Davis a Summary
c
George Washington University Department of Urology, Washington, D.C, USA * Corresponding author. Children’s National Medical Center, 111 Michigan Avenue NW, Washington, D.C, 20010, USA. [email protected] (R.S. Zee) Keywords Testicular torsion; Quality improvement; Testis; Orchiectomy; Acute scrotum
Abbreviations ACT, Accelerated Care of Torsion; ED, Emergency Department; IQR, Interquartile Range; OR, Operating Room; TTO, Time to Operating Room; USNWR, United States News and World Report; US, Ultrasound; QI, Quality Improvement Received 4 January 2019 Accepted 11 July 2019 Available online xxx
Background Timely diagnosis and management of testicular torsion is of paramount importance. Furthermore, time to surgical intervention is a benchmark for the quality of care provided by pediatric urologists included in US News and World Report (USNWR) methodology. Objective We sought to optimize management of acute testicular torsion at a single institution by decreasing time from presentation to definitive management through the creation and implementation of a clinical care pathway (accelerated care of torsion or ACT) for acute testicular torsion in a 2-year period. Study design Multidisciplinary process mapping involving the emergency department (ED), radiology, anesthesiology, peri-operative services, and operating room (OR) teams resulted in development of the ACT pathway with the goal of achieving surgical intervention within 4 h of arrival at our institution. The accelerated care of torsion pathway was implemented in April 2016. Thirty-eight consecutive acute torsion cases were then prospectively evaluated from April 2016 to April 2018. For process measures, we recorded triage to OR times and mode of presentation. For outcome measures, we examined orchiectomy rates. We retrospectively reviewed 97
cases of acute torsion from 2004 to 2016 as a control. Results Time from ED triage to OR start decreased from a median 196 min (interquartile range [IQR] 137e249 min) to 127 min (IQR 100e148 min; P < 0.0001) for all cases of acute torsion. 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 min time frame. Orchiectomy rates were performed in 24% of control cases vs 30% after ACT implementation (P Z NS). Survival curve analysis demonstrated no significant difference in probability of testis salvage before or after implementation of the ACT pathway. Discussion In agreement with similar studies, despite a significant reduction in triage to OR times, the orchiectomy rate approached 30%. This outcome did not significantly improve after implementation of the ACT pathway. Overall ischemia time was a more important determinant of testis salvage. Study limitations include limited patient follow-up to assess testis atrophy. 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 rate was not significantly affected.
https://doi.org/10.1016/j.jpurol.2019.07.011 1477-5131/ª 2019 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article as: Zee RS et al., Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion, Journal of Pediatric Urology, https://doi.org/10.1016/j.jpurol.2019.07.011
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Introduction Pediatric testicular torsion is a common surgical emergency which affects an estimated 3.8 to 5 in 100,000 males aged below 18 years [1,2]. Ischemia time as well as the degree of torsion determines survival of the affected testis. These patients must be diagnosed and brought to the operating room (OR) expediently, as loss of germ cells and subsequent fibrosis can impact future fertility potential with reported oligospermia in 30% of men with a history of unilateral testicular torsion [3]. Several clinical departments must be coordinated to achieve timely diagnosis and surgical management of acute torsion. Given the potential impact on patient outcomes, as well as the US News and World Report (USNWR) scores (presentation to OR < 4 h), we sought to implement a quality improvement (QI) initiative to address time to operating room (TTO) for patients presenting to our institution, referred to as the accelerated care of torsion (ACT). The pathway was designed to standardize multidisciplinary communication and streamline tasks required to achieve surgical intervention in a timely fashion. As such, the project focused specifically on the timeline of events that occurred between patient arrival in the emergency department (ED) and entry into the OR. The aim of this QI project was to implement the ACT pathway in all acute testicular torsion patients presenting to our institution between April 2016 and April 2018. Process measures included triage to OR times and mode of presentation (referrals vs direct presentation to our institution). We speculated that improved TTO would decrease orchiectomy rates in our patient population. Therefore, the outcome measure examined orchiectomy rates before and after implementation of the pathway.
Methods Data collection For the control group, we retrospectively reviewed acute torsion cases for males younger than 18 years of age who were taken to the OR between April 2004 and March 2016 based on current procedural terminology (CPT) codes (54600 and/or 54620) in the electronic medical records database. Each case was individually reviewed and confirmed to be acute torsion before inclusion. For the intervention group, we prospectively recorded all cases that presented as acute torsion after implementation of the ACT pathway between April 2016 and April 2018 were prospectively recorded. All patients who had acute torsion with duration of symptoms <24 h resulted in activation of the ACT pathway. Patients with late phase torsion who presented greater than 24 h after onset of symptoms, neonatal torsion, intermittent torsion, and patients who were explored but did not have torsion were all excluded from the final cohort. For process measures, ED triage to ultrasound (US) (if applicable) and OR time, as well as mode of presentation were recorded. Orchiectomy rates were evaluated as an outcome measure. This is a project undertaken as a QI Initiative at our institution and, based on IRB review, their opinion was that it did not constitute
R.S. Zee et al. human subjects research. As such, the project did not require further oversight by the Institutional Review Board. Eight surgeons were included in the QI project. Intraoperative decision-making with regard to orchiopexy vs orchiectomy was left at the discretion of the surgeon. The individual surgeon criteria for salvage or orchiectomy did not change throughout the duration of the study. Follow-up appointment timing was also left to individual surgeon preference. Postoperative imaging was not routinely obtained.
Process mapping Process mapping was performed by an interdisciplinary panel comprised of urology, the ED, radiology, anesthesiology, peri-operative services, and the OR (Supplemental Figure). The same multidisciplinary team then created an optimized workflow for both direct presentations of testis torsion to the ED as well as testis torsion transfers to the ED from primary care offices, outside EDs, or urgent care centers. Duration of time elapsed between locations within the institution was determined based on time stamps recorded in the electronic medical record. Locations included referring provider, ED triage, radiology, and the OR. At this institution, referrals from outside institutions for acute torsion are transferred directly to the ED before transfer to the OR. The time stamp utilized for the OR was patient time of arrival in the OR. The primary goal of process mapping was to optimize the length of time between triage and arrival in the OR. Each department leader performed discipline-specific teaching for the pathway before implementation in April 2014.
Key drivers and implementation of the pathway After detailed review of the process map, several key drivers were identified for intervention (Fig. 1: Key Driver diagram). Department-specific education was performed to improve care team awareness of the ACT pathway and promote multidisciplinary coordination of care. Another key driver of the pathway involved early notification of the urology team whenever a patient presented to the ED with a suspected testicular torsion or was being transferred from an outside institution for management of known or suspected testis torsion. An additional key driver was efficient transfer of the patient between the ED and OR areas. The intervention involved relying on the urology team to transfer the patient from the ED to the preoperative area rather than waiting for hospital transport to arrive. Finally, completion of a preoperative safety checklist required for all patients having non-emergent surgery at our institution was formally eliminated from the ED workflow. Implementation and prospective monitoring of the ACT pathway is ongoing. Each new case of acute testicular torsion is audited by a multidisciplinary team for pathway deviations, delays, and possible new pathway improvements. There is no specific time interval that defined a delay. Instead, any subjective delay in any component of the pathway is reviewed during the audit. Deviation from
Please cite this article as: Zee RS et al., Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion, Journal of Pediatric Urology, https://doi.org/10.1016/j.jpurol.2019.07.011
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Figure 1 Key driver diagram illustrating interventions that decreased TTO in the target population. TTO, time to operating room; ACT, accelerated care of torsion; ED, emergency department; OR, overall survival.
the protocol that has the potential to result in a delay in TTO results in multidisciplinary discussion and intervention, most commonly in the form of ongoing education of involved care providers. Challenges with development of the pathway included consensus on the pathway itself due to the involvement of multiple disciplines and institutional resistance to change. The primary barrier in adherence to the pathway was lack of provider knowledge of the specifics of ACT pathway, related to both timely initial education and on-going education on the pathway. This was particularly problematic in larger departments with high turnover in faculty, residents, nursing, technicians, and/or support staff. Therefore, provider education and re-education has been a high priority intervention in implementation of the pathway.
Statistical analysis Statistical analysis was performed by one-way analysis of variance, Fisher’s exact test, or log-rank test where appropriate. Kaplan-Meier curves were analyzed using Graphpad Prism 8 software. Significance of the survival
curve was calculated using Mantel-Cox test. A P-value less than 0.05 was considered statistically significant.
Results For the control group, a total of 207 patients presented to the institution between April 2004 and March 2016 and underwent scrotal exploration for suspected acute testicular torsion. After excluding for neonatal torsion, intermittent torsion, and delayed torsion, 97 (46.8%) patients met inclusion criteria for acute testicular torsion. Roughly one-third (n Z 34; 35%) of these patients were referred from other institutions or community providers. The remaining 63 (65%) presented directly to our institution. The ACT pathway was implemented in April 2014 after each department had completed training for their respective roles. Ninety-seven patients presented to our institution with a diagnosis of testicular torsion during the 2 years following implementation of ACT. After applying exclusion criteria, 38 patients (39%) met inclusion criteria for acute torsion. Eighteen (47%) patients were referred from other institutions, whereas the remaining 20 (53%) presented
Please cite this article as: Zee RS et al., Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion, Journal of Pediatric Urology, https://doi.org/10.1016/j.jpurol.2019.07.011
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directly to the ED. Demographics were analyzed and shown in Table 1. Median age of the control group was 13 years (interquartile range [IQR] 12e15) compared with 14 years (IQR 12e15) in the ACT group (P Z 0.33). In the control group, 67 (69%) of patients and 35 patients (97%) in the ACT group had US with timestamps available for review. Time from ED triage to US start decreased from a median 48.5 min (IQR 30e97) to 18 min (IQR 12e33; P < 0.0001). There was no significant difference in the time it took to complete an US which was 12.5 min (IQR 9e21) in the control group vs 13 min (IQR 9e18) in the ACT group. Overall, after implementation of ACT, median time from ED triage to completion of a scrotal US decreased from 72 min (IQR 47e110) to 31 min (IQR 22e53; P < 0.0001). After ACT implementation, median time from ED triage to the OR decreased from 196 min (IQR 137e249) to 127 min (IQR 100e148; P < 0.0001; Table 2). Patients who presented directly to the institution experienced an improvement from a median of 201 min (IQR 159e270) to 143 min (IQR 130e159; P Z 0.006). Patients referred from other institutions experienced a decrease in time from ED triage to OR from 170 min (IQR 97e208) to 100 min (IQR 63e122; P < 0.01). The ACT pathway increased the percentage of patients who reached the OR from ED triage within 240 min from 72% to 100% (P < 0.0001; Table 2). In the group who presented directly to our institution, the proportion of patients who reached the OR within 240 min increased from 63% to 100% (P < 0.001). For referred patients, the number of patients achieving surgical intervention within 240 min increased from 88% to 100% (P Z 0.28). After implementation of the ACT pathway, the most common reason for deviation from the pathway involved delays in interdisciplinary communication. In four (10%) cases, there were either difficulties or delays in communication. In these cases, the median TTO was 150 min (IQR 143e182). In two patients (5%), there was a delay because the ED nurse completed the preoperative checklist, an item which was eliminated from the workflow as it was deemed unnecessary. Median TTO for these patients was 133 min (IQR 123e143). For both of these issues, the median TTO was not significantly different when compared with the overall cohort. However, pathway re-education was undertaken in all cases to prevent significant delays in the future. For the study outcome measure of orchiectomy rates, 27 (30%) patients underwent orchiectomy before implementation of the pathway whereas 10 (24%) underwent orchiectomy after ACT implementation (P Z NS; Table 2). Table 1
Demographics of patients included in the study.
Characteristic
Control (n Z 97) ACT (n Z 38) P-value
Age, median (IQR) Race Caucasian African-American Latino Asian Other
13 (12e15)
14 (12e15)
7 (7%) 56 (58%) 21 (22%) 1 (1%) 12 (12%)
2 (6%) 25 (67%) 2 (6%) 0 8 (21%)
0.33
IQR, interquartile range; ACT, accelerated care of torsion.
When investigating overall ischemia times based on patient-reported onset of symptoms, we found no significant difference in ischemia times before or after implementation of the ACT pathway (Table 3). Patients in the control group had a median ischemia time of 476 min (IQR 377e667) in comparison to 409 min (302e722) in the ACT group (P Z 0.99). In the control group, there was a significant difference in ischemia times between patients who underwent salvage or orchiectomy (451 min vs 799 min; P < 0.0001). After implementation of ACT, the mean ischemia time in patients undergoing salvage was less than for orchiectomy, but the difference was not statistically significant (346 min [IQR 298e642 min] vs 711 min [IQR 453e1347 min]; P Z 0.14). A Kaplan-Meier curve was calculated based on overall ischemia time (Fig. 2). Survival probabilities were comparable. In the control cohort, 100% survival threshold was 6 h 35 min, whereas in the ACT group, this threshold was 4 h 25 min. The median time to reach a 50% probability of testis survival was 15 h 25 min vs 22 h 4 min after ACT implementation. The curves were not significantly different suggesting that overall warm ischemia times did not change before or after implementation of the pathway. Follow-up rates were examined for patients included in the ACT pathway. Overall, 23 of 38 (60%) patients had follow-up at a median 31 days following surgery. Testis size at follow-up was not routinely documented in the EMR. Ultrasound at follow-up was not routinely performed as patients typically only returned for a single postoperative visit for a wound check.
Discussion In this manuscript, we describe a QI initiative for our institution that sought to decrease TTO for patients presenting with acute testicular torsion utilizing process mapping. We were able to significantly reduce the time from presentation to the ED to OR in patients following development and implementation of the ACT pathway. US News and World Report evaluates TTO for acute testicular torsion as a criterion for ranking pediatric urology programs. If greater than 90% of patients achieve operative intervention within 240 min of presentation then the maximum score of 2 points is awarded to the program. The program is given 1 point if 50e90% of patients reach that benchmark [4]. By initiating a multidisciplinary panel for process improvement, we were able to decrease the TTO to less than 240 min for 100% of patients who presented with acute testicular torsion after implementation of the pathway, which is the benchmark for quality care as defined by USNWR [4]. Others have been implementing similar pathways to decrease TTO with good success [5e7]. The development and implementation of the ACT pathway was not without challenges. Interdisciplinary creation of a process map requires that all departments agree on a single pathway for torsion patients as they move through the institution. In some cases, this required the addition of tasks to already busy services that were resistant to changing the status quo. After implementation, the most common reason for deviation in the pathway was lack of awareness of elements of the
Please cite this article as: Zee RS et al., Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion, Journal of Pediatric Urology, https://doi.org/10.1016/j.jpurol.2019.07.011
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Table 2 Total duration of time elapsed between triage and treatment before and after implementation of ACT. There was a significant decrease in TTO for both direct and referred cases of torsion. There was a significant increase in the proportion of patients who reached intervention within the goal time of 240 min. Values are expressed as median in minutes with interquartile range. P-values were determined by one-way ANOVA. P-value
Direct torsion
TTO median min (IQR) Intervention <240 min (%) Orchiectomy rate (%)
Control
ACT
201 (159e270) 63
144 (131e160) 100
29
20
Referred torsion Control
ACT
< 0.001
170 (97e208) 88
100 (63e122) 100
0.56
26
38
0.006
P-value
P-value
Combined Control
ACT 127 (100e148) 100%
<0.0001
0.28
196 (137e249) 72%
0.36
28
30
> 0.99
0.01
< 0.0001
TTO, time to operating room; ACT, accelerated care of torsion; ANOVA, analysis of variance; IQR, interquartile range.
Table 3 Total ischemia time was calculated before and after implementation of ACT. Even when accounting for direct or referred presentations, there was no significant different in mean ischemia times. Data are expressed as median value in minutes with interquartile range. P-values were determined by one-way ANOVA. Direct torsion
Ischemia time, median min (IQR) Salvaged testes, median min (IQR) Orchiectomy, median, min (IQR)
P-value Referred torsion
P-value Combined
P-value
Control
ACT
Control
ACT
Control
ACT
465 (364e641) 339 (238e438) 1034 (577e1448)
518 >0.99 (305e736) 374 >0.99 (299e714) 1034 >0.99 (577e1448)
491 (367e668) 460 (273e605) 799 (441e1331)
382 0.99 (294e634) 320 0.99 (274e491) 626 0.94 (340e1172)
476 (377e667) 451 (335e577) 799 (466e1117)
409 0.99 (302e722) 346 >0.99 (298e642) 711 0.97 (453e1347)
ACT, accelerated care of torsion; ANOVA, analysis of variance; IQR, interquartile range.
pathway. All urology residents rotating through the service are given an orientation to the pathway at the start of their rotation. However, performing initial and ongoing education in larger departments with high turnover in support staff and healthcare providers proved to be
Figure 2 A survival curve was calculated based on total ischemia time in hours. There was no significant difference in the probability of salvage before or after implementation of the ACT pathway. Median survival in the control group was 15.42 h and 22 h in the ACT group. P Z 0.95. ACT, accelerated care of torsion.
extremely challenging. Ongoing educational efforts are underway and performed after each case of acute torsion is reviewed, and the opportunity for pathway modification and improvement is continually assessed in a multidisciplinary fashion. We found that despite identifying deviations from the pathway with resulting delays, the TTO was not significantly greater for these patients compared with the overall cohort. Despite these challenges, we were able to streamline the process of taking an acute testis torsion patient from the ED to the OR, and TTO in our institution was significantly decreased. The creation and implementation of the pathway served to re-educate and heighten awareness of the time sensitive nature of testis torsion in the institution as a whole, which we believe played a large role in shorter times in all phases care in the management and treatment of this condition. Interestingly, despite decreasing time from ED triage to the OR, we did not significantly impact orchiectomy rates (30% in the control group vs 24% in the intervention group). This aligns with orchiectomy rates ranging from 31 to 32% in recent publications of patients presenting with acute torsion [2,8]. Similar to the study findings, Arevalo et al. recently demonstrated that significantly decreasing TTO by taking referred patients directly to the OR upon arrival had no significant impact on orchiectomy rates. In this publication, the authors successfully decreased median TTO in the intervention group by 40 min without a discernible impact on orchiectomy rate. In contrast, Afsarlar et al. previously reported an improvement in orchiectomy rates
Please cite this article as: Zee RS et al., Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion, Journal of Pediatric Urology, https://doi.org/10.1016/j.jpurol.2019.07.011
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1.e6 from 58.6% to 41.4% after enacting a standardized checklist meant to identify acute testicular torsion patients in the ED that decreased TTO from a mean 3.3 he2.1 h [7]. Acute testicular torsion patients should ideally be diagnosed and treated within 6e8 h of ischemia time to avoid testis loss [9e12]. In the study data set, both the control and ACT cohort demonstrated excellent salvage rates when warm ischemia was less than 6 h. The implementation of ACT did not significantly decrease the overall ischemia time between the two groups suggesting that decreasing TTO in torsion patients was not the most important factor dictating salvage. Rather, the delay in presentation is more likely to determine the probability of salvage. A previous publication reported that after an ischemic time of 6 h, the risk of orchiectomy increased 22-fold [13]. In the study cohort, testicular salvage was 92% with a warm ischemia time of up to 7 h 45 min. It has been previously reported that factors that contribute to a delay in presentation is determined by factors beyond the physician’s control, such as patient age, insurance status, developmental delay, distance from the hospital, hospital transfer, and socio-economic status [2,8,14,15]. Certainly, public knowledge of testis torsion and its implications is poor with only 34% of parents having knowledge of torsion [16,17]. In a survey of adolescent males, 64% of respondents knew to seek medical attention for acute scrotal pain [16,17]. A limitation of this study is lack of long-term follow-up with regard to assessment of testis atrophy. Follow-up rates for these patients are poor despite scheduling appointments for all of them. We also do not routinely perform scrotal US postoperatively on patients who have undergone orchiopexy for acute testicular torsion and therefore are not able to objectively measure the degree of atrophy in the testis after surgery. Furthermore, documentation of testis size at follow-up was inconsistent between providers, and with an average follow up time of approximately 1 month, this is likely too soon to identify all cases of atrophy on exam. Future follow-up will be standardized to include longer term follow-up at 6 months to monitor for testicular atrophy. Another limitation of the study is that we relied on patient report for time of onset of symptoms, as documented in the electronic medical record, which is subject to recall bias or inaccuracies in documentation. However, there is no other way to document this parameter. Finally, the ultimate decision to perform orchiectomy is subjective and thus creates a selection bias that may impact the rate of testicular salvage with eight surgeons involved in this study.
Conclusion The implementation of a QI initiative to expedite surgical intervention in patients presenting with acute torsion was effective in significantly reducing the time from presentation to the ED to OR and brought 100% of patients to the OR within the USNWR goal time frame of 4 h of presentation. However, this did not translate to improved orchiectomy rates because of the limited impact on overall ischemia time. If delay in presentation has a greater impact on testis salvage rates than TTO in torsion patients, public health
R.S. Zee et al. initiatives educating the general public the importance of timely evaluation and treatment of testis torsion are a crucial next step in reducing orchiectomy rates in cases of testis torsion.
Author statements Ethical approval None required.
Funding There are no funding sources to report.
Competing interests There are no conflicts of interests to report.
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Quality improvement initiative for testicular torsion [12] Tryfonas G, Violaki A, Tsikopoulos G, Avtzoglou P, Zioutis J, Limas C, et al. Late postoperative results in males treated for testicular torsion during childhood. J Pediatr Surg 1994;29:553e6. https: //doi.org/10.1016/0022-3468(94)90090-6. [13] Ramachandra P, Palazzi K, Holmes N, Marietti S. Factors influencing rate of testicular salvage in acute testicular torsion at a tertiary pediatric center. West J Emerg Med 2015;16: 190e4. https://doi.org/10.5811/westjem.2014.11.22495. [14] Bayne AP, Madden-Fuentes RJ, Jones EA, Cisek LJ, Gonzales ET, Reavis KM, et al. Factors associated with delayed treatment of acute testicular torsionddo Demographics or interhospital transfer matter? J Urol 2010;184:1743e7. https: //doi.org/10.1016/J.JURO.2010.03.073. [15] Bayne CE, Villanueva J, Davis TD, Pohl HG, Rushton HG. Factors associated with delayed presentation and misdiagnosis of
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Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.jpurol.2019.07.011.
Please cite this article as: Zee RS et al., Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion, Journal of Pediatric Urology, https://doi.org/10.1016/j.jpurol.2019.07.011