Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion

Implementation of a health system intervention to reduce time from presentation to surgical intervention for pediatric testicular torsion

PURPOSE

Testicular salvage rates for torsion are time-dependent1. Door to detorsion time has been identified as an independent testicular survival factor2. We describe an initiative to reduce door to incision (DTI) time for pediatric testicular torsion.

MATERIALS AND METHODS

An institutional multidisciplinary quality improvement initiative with a primary outcome of reducing DTI time for pediatric testicular torsion was developed with multidisciplinary stakeholders. Several process and balancing measures were used as secondary outcomes to help interpret and verify the observed change in DTI time. Interventions were implemented in cycles. Initial interventions standardized assessment of suspected torsion by Emergency Medicine utilizing a validated scoring system. A threshold Testicular Workup for Ischemia and Suspected Torsion (TWIST) score led to parallel notification of essential services for rapid assessment and case prioritization3. Subsequently, bedside ultrasound in the Emergency Department was implemented. Progress was tracked in a live dashboard and analyzed with X-mR process control charts and Nelson rules. These tools are used in quality improvement and process control to demonstrate the significance of changes as they are being implemented, prior to when traditional hypothesis testing would be able to do so. We aimed to increase the proportion of cases with DTI times under 4 h from 64% to >90% within one year.

RESULTS

We observed 22 torsion cases prior to and 62 following initial implementation. The percentage of cases with DTI times under 4 h improved from 64% to 95%. At week 29, a shift identified a significant change on the X chart, with reduction in mean DTI time from 221 to 147 min. At the same time, a shift on the mR chart identified reduction in patient-to-patient variation. Mean time from arrival to Urology evaluation decreased from 140 to 56 min, mean time from arrival to scrotal ultrasound decreased from 70 to 36 min, and mean time from scrotal ultrasound to surgical incision decreased from 128 to 80 min. These improvements highlight the two key successes of our project: application of the TWIST score and bedside ultrasound for rapid assessment of suspected testicular torsions, and parallel processing of the evaluation and management.

CONCLUSIONS

Implementation of a protocol for pediatric testicular torsion increased the proportion of cases with DTI time <4 h to 95%, decreased mean DTI time, and decreased variation. Our protocol provides a model to improve timeliness of care in treating pediatric testicular torsion.

Atypical Presentation Delays Treatment of Pediatric Testicular Torsion

OBJECTIVE

The aim of the study is to identify patient- and care-related factors associated with time to treatment for acute testicular torsion and the likelihood of testicular loss.

METHODS

Data were retrospectively collected for patients 18 years and younger who had surgery for acute testicular torsion between April 1, 2005, and September 1, 2021. Atypical symptoms and history were defined as having abdominal, leg, or flank pain, dysuria, urinary frequency, local trauma, or not having testicular pain. The primary outcome was testicular loss. The primary process measure was time from emergency department (ED) triage to surgery.

RESULTS

One hundred eleven patients were included in descriptive analysis. The rate of testicular loss was 35%. Forty-one percent of all patients reported atypical symptoms or history. Eighty-four patients had adequate data to calculate time from symptom onset to surgery and time from triage to surgery and were included in analyses of factors affecting risk of testicular loss. Sixty-eight patients had adequate data to evaluate all care-related time points and were included in analyses to determine factors affecting time from ED triage to surgery. On multivariable regression analyses, increased risk of testicular loss was associated with younger age and longer time from symptom onset to ED triage, while longer time from triage to surgery was associated with reporting atypical symptoms or history.The most frequently reported atypical symptom was abdominal pain, in 26% of patients. These patients were more likely to have nausea and/or vomiting and abdominal tenderness but equally likely to report testicular pain and swelling and have testicular findings on examination.

CONCLUSIONS

Patients presenting to the ED with acute testicular torsion reporting atypical symptoms or history experience slower transit from arrival in the ED to operative management and may be at greater risk of testicular loss. Increased awareness of atypical presentations of pediatric acute testicular torsion may improve time to treatment.

Sex-based Disparities in the Management of Pediatric Gonadal Torsion

INTRODUCTION

In 2015, the U.S. News and World Report (USNWR) implemented a quality metric to expedite surgery for testicular torsion (TT), but not ovarian torsion (OT). This study examined OR timing among children with suspected TT and OT before and after this metric.

METHODS

A single-center retrospective cohort study of children (1-18yr) who underwent surgery for suspected gonadal torsion was performed. Time to OR (TTOR) from hospital presentation to surgery start was calculated. An interrupted time series analysis identified changes in TTOR for suspected TT versus OT after the 2015 USNWR quality metric.

RESULTS

Overall, 216 patients presented with TT and 120 with OT. Median TTOR for TT was 147 min (IQR:99-198) versus 462 min (IQR:308-606) for OT. Post-quality metric, children with TT experienced a 27.8 min decrease (95% CI:-51.7,-3.9, p = 0.05) in annual median TTOR. No significant decrease was observed for children with OT (p = 0.22). Children with history of a known ovarian mass (N = 62) experienced a shorter TTOR compared to those without (422 vs 499min; p = 0.04).

CONCLUSION

Implementation of a national quality metric for TT expedited surgical care for children with TT, but not children with OT. These findings highlight the need for equitable quality metrics for children presenting with suspected gonadal torsion.

LEVEL OF EVIDENCE

III.

TYPE OF STUDY

Retrospective Comparative Study, Observational Cohort Study.

Assessing timeline delays associated with utilization of ultrasound diagnostics in paediatric acute scrotum, pre and per COVID-19 pandemic

INTRODUCTION

Acute scrotum is a common presentation in the pediatric population and can indicate serious conditions such as testicular torsion, in which quick diagnosis and treatment is crucial for increasing the chances of a favorable outcome. During the COVID-19 pandemic, even patients with serious conditions, had delayed presentations and in-hospital management, resulting in worse outcomes.

OBJECTIVE

The aim of the study was to evaluate the safety of ultrasound in diagnosing pediatric acute scrotum and to identify delays from onset of symptoms until surgical exploration. Additionally, we wanted to gauge the impact of COVID-19 pandemic on delay and outcome.

METHODS

Medical records of patients aged 1-16 years seen with acute scrotum at the authors' University Hospital from 2017 to 2020 were reviewed, and 438 patients in 467 individual visits were included. Information on demographics, symptoms, ultrasound results, outcome, and time courses were retrieved and analyzed with regards to outcome and the presence COVID-19.

RESULTS

We did not find the use of ultrasound to increase the risk of orchiectomy (OR 2.259 (0.387-13.195)), however patients undergoing ultrasound had a significantly longer pre-hospital ischemia time, and therefore an increased orchiectomy rate. Delay between referral and presentation was the greatest predictor of orchiectomy in testicular torsion (OR 1.031 (1.003-1.060)), while in-hospital delay did not increase the risk of orchiectomy (OR 0.998 (0.992-1.004)). Time courses and outcome did not significantly differ before- and during the COVID-19 pandemic.

DISCUSSION

The primary contributor to ischemic time in testicular torsion was pre-hospital delay, and neither in-hospital delay nor the delay incurred by use of ultrasound affected the outcome. This might be explained by timely in-hospital management and ultrasound only being used selectively in patients with a lower clinical suspicion of testicular torsion and in those with prolonged symptom duration. During the COVID-19 pandemic, pre- and in-hospital delay as well as outcome did not differ significantly from pre-pandemic measures, which indicates that parents felt safe approaching the healthcare system, and resources were sufficient to handle this patient group in spite of an ongoing pandemic. The current study is limited by its retrospective design, and relatively small group of testicular torsion patients.

CONCLUSION

We found ultrasound to be safe in diagnosing pediatric acute scrotum. Furthermore, it can be inferred that measures aimed at reducing pre-hospital delay could potentially increase the salvage rate in testicular torsion. We did not find COVID-19 to affect either outcome or time to treatment in testicular torsion.

High risk and low prevalence diseases: Testicular torsion

INTRODUCTION

Testicular torsion is a serious condition that carries with it a high rate of morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of testicular torsion, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Testicular torsion is a urological emergency that occurs with rotation of the testicle along its supporting ligaments leading to obstruction of vascular flow. A key risk factor is the presence of a bell-clapper deformity. The most common population affected includes children in a bimodal distribution with the most cases occurring in the first year of life and between 12 and 18 years, although cases do occur in adults. Acute, severe, unilateral scrotal pain is the most common presenting symptom. Nausea and vomiting are common, but the presence or absence of a cremasteric reflex is not a reliable indicator of disease. The TWIST score may assist with clinical decision making in patients presenting with acute testicular pain but should not be used in isolation. If torsion is suspected or confirmed, consultation with the urology specialist should not be delayed, as outcomes are time sensitive. Ultrasound can be used for diagnosis, but a normal ultrasound examination cannot exclude the diagnosis. Treatment includes emergent urology consultation for surgical exploration and detorsion, as well as symptomatic therapy in the ED. Manual detorsion can be attempted in the ED while awaiting transfer or consultation.

CONCLUSIONS

An understanding of testicular torsion can assist emergency clinicians in diagnosing and managing this disease.

Testicular torsion during the COVID-19 pandemic: Results of a multicenter study in northern Italy

INTRODUCTION

The literature reported an increased avoidance of the Emergency Department (ED) during COrona VIrus Disease 19 (COVID-19) pandemic, causing a subsequent increase of morbidity and mortality for acute conditions. Testicular torsion is a surgical emergency, which can lead to the loss of the affected testicle if a delayed treatment occurs. As testicular loss is time-related, outcome was hypothesized to be negatively affected by the pandemic.

OBJECTIVE

The aim is to investigate whether presentation, treatment and outcomes of children with testicular torsion were delayed during COVID-19.

STUDY DESIGN

Medical records of pediatric patients operated for testicular torsion of six Paediatric Surgical Units in Northern Italy between January 2019 and December 2020 were retrospectively reviewed. Patients were divided as for ones treated during (dC) or before the pandemic (pC). To reflect possible seasonality, related to lockdown restrictions, winter and summer calendar blocks were also analysed. For all cohorts, demographic data, pre-operative evaluation, operative notes and post-operative outcomes were reviewed. Primary outcomes were referral time, time from diagnosis to surgery and ischemic time, while secondary outcomes were orchiectomy and atrophy rates. Statistic was conducted as appropriate.

RESULTS

A total of 188 patients with acute testicular torsion were included in the study period, 89 in the pre-COVID-19 (pC) period and 99 during COVID-19 (dC). Time from symptom onset to the access to the Emergency Department (T1) was not different among the two populations (pC: 5,5 h, dC: 6 h, p 0.374), and similarly time from diagnosis to surgery (pC: 2,5 h, dC: 2,5 h, p 0.970) and ischemic time (pC: 8,2 h, dC: 10 h, p 0.655). T1 was <6 h in 46/99 patients (46%) pC and 45/89 patients (51%) dC (p = 0.88, Fisher's exact test). Subgroup analysis accounting for different lockdown measures, confirm the absence of any difference. Orchiectomies rate was 23% (23/99) dC and 21% (19/89) pC (p = 0.861, Fisher's exact test) and rate of post-operative atrophy was 9% dC (7/76) and 14% pC (10/70), p = 0,44, Fisher's exact test.

DISCUSSION

Despite worldwide pediatric ED accesses reduction, we reported that neither ischemic time nor the long-term outcomes in children with testicular torsion increased during the COVID-19 pandemic. In the available literature, few studies investigated the topic and are controversial on the results. Similarly to our findings, some studies found that timing and orchiectomy rates were not significantly different during the pandemic, while others reported a correlation to pandemic seasonality. Furthermore, in the recent pediatric literature it has been reported a delayed testicular torsion diagnosis due to shame in informing parents. Strengths of this study are the large numerosity, its multicentric design and a long study period. Its main limitation is being retrospective.

CONCLUSIONS

We reported our large cohort from one of the most heavily COVID-19-affected regions, finding that referral, intra-hospital protocols and ischemic time in testicular torsion were not increased during to the pandemic, as well as orchiectomy rate and atrophy.

Quality Improvement Project to Improve the Timeliness of Care for Children With Testicular Torsion in the Emergency Department

Introduction

Testicular torsion (TT) is a urologic emergency that requires timely diagnosis and surgery. We noted variation in the door-to-detorsion times for patients with TT at our institution and our orchiectomy rate was 25.8%. We aimed to decrease the mean door-to-detorsion time from 124.6 to 114.6 minutes or less over 12 months.

Methods

A multidisciplinary team of pediatric emergency medicine, radiology, urology physicians, and nurses, was formed. Our key drivers were use of Testicular Workup for Ischemia and Suspected Torsion (TWIST) score, prompt urology consultation, and efficient transfer from emergency department (ED) to operating room. Our process measures were TWIST score documentation rate and early urology consultation rate, outcome measures were door-to-detorsion time and orchiectomy rate, and balancing measure was ultrasound utilization rate. Early urology consultation occurred when the ED provider documented telephone communication with urology, immediately after placing a testicular doppler ultrasound (TDUS) order and before TDUS result.

Results

Over 2 years, 45 cases of TT were diagnosed. TWIST score documentation was implemented and was sustained at 78%. This improved early urology consultations from 40% to 60%. The mean door-to-detorsion time improved from 124.6 to 114.2 minutes. There was no reduction in the orchiectomy rate or TDUS utilization rate.

Conclusions

A quality improvement project to improve the timeliness of care for children with TT resulted in expedited ED care but did not impact the orchiectomy rate.

Do healthcare disparities play a role in pediatric testicular torsion? - Analysis of a single large pediatric center

INTRODUCTION

Healthcare disparities have been shown to impact outcomes of various acute pediatric conditions. We sought to examine the impact of race, ethnicity and insurance status on the presentation, management and outcome of testicular torsion.

MATERIALS AND METHODS

A retrospective review of a prospectively maintained testicular torsion database was performed. Patients ≤18 years of age evaluated in our pediatric institution's emergency room between April 2016-April 2020 with US diagnosed and OR confirmed testicular torsion were included. Basic demographics, timing of presentation, referral rate, time to OR and orchiectomy rate were extracted and compared. P < 0.05 was considered statistically significant.

RESULTS

A total of 206 patients were included. 114 (56.2%) were Black or African American (Black/AA), 43 were (21.2%) Hispanic/Latino, 22 (10.8%) were Caucasian, and 24 (11.8%) were designated as Other races. Ninety-eight (48.3%) patients had Medicaid, 90 (44.3%) had private insurance, and 15 (7.4%) patients were uninsured. Sixty-eight (33.0%) presented in a delayed fashion (>24 h). Compared to the Caucasian patients, Black/AA patients were 2.1 years (95% CI: 0.5, 3.8; P = 0.010) older at the time of presentation. When compared to those with Medicaid insurance, uninsured patients had 6.26 times (95% CI: 1.58, 41.88; P = 0.021) higher odds to be referred from an outside hospital for management. In those patients presenting acutely (<24 h, N = 138), there were no significant differences in the odds of orchiectomy for Black/AA or Hispanic/Latino patients when compared to Caucasian patients, however, the odds of orchiectomy in Other races (non-Caucasian, non-Black/AA, non-Hispanic/Latino) was significantly higher (OR: 10.38; 95% CI: 1.13, 246.96; P = 0.049). While the mean time in minutes from ED to OR was longer in those with Medicaid insurance (141 vs 125.4 private vs 115 uninsured, p = 0.042), this did not impact orchiectomy rate (39.8% vs 40.9% vs 46.7%, p = 0.88).

CONCLUSIONS

We found no differences in the orchiectomy rates by race with the exception of a higher rate in the diverse and heterogeneous Other race (non-Caucasian, non-Black/AA, non-Hispanic/Latino) group. Those uninsured had a higher referral rate highlighting the potential existence of disparities for those uninsured and the need for further investigation.

Children's hospital quality ratings: where are we and can we do better?

Hospital quality ratings are intended to guide patients and payers to the highest quality hospitals. Their success in achieving this goal has been limited by inconsistencies between ratings and questionable data collection methods. Despite these shortcomings, their popularity and their importance are increasing. There is little published on how these quality rankings pertain to children's hospitals. The majority of what is available analyzes the US News and World Report's Best Children's Hospitals Survey and the Leapfrog Group's Pediatric Care survey. We provide a narrative review of the literature and our interpretation of the relative strengths and weaknesses of these tools, including a letter grade comparison. Based on our analysis, we provide potential improvements to these rating systems that may benefit both the patient, payer, and the hospital.

Access to emergency paediatric surgery for testicular torsion or intestinal volvulus in New Zealand: A system perspective

AIM

The risk of organ loss is increased in children with testicular torsion or intestinal volvulus if surgical management is not expedient. The current retrospective study aims to review the time-course from first symptom to 'knife to skin' in these conditions, to determine where delays occur and facilitate a systems approach to better manage these children.

METHODS

One hundred consecutive paediatric cases of scrotal exploration for presumed testicular torsion, and 100 neonatal cases presenting with possible malrotation/volvulus were analysed to evaluate the exact time-course of events from admission to surgery.

RESULTS

(i) Scrotal exploration: the median time from onset of symptoms to presentation was 12 h (interquartile range (IQR): 5-48 h). In children over 5 years of age, 36% (33/93) were transferred from an external district service area. (ii) Malrotation/volvulus: the median duration of symptoms prior to arrival/assessment was 12 h (IQR: 4-24 h). The median cumulative in-hospital time was over 6 h (368 min, IQR: 247-634 min).

CONCLUSIONS

Time to presentation contributes significantly to testicular ischaemic time. This delay to timely surgical intervention is multi-factorial, and must be addressed at a public health level. Support and training in the management of testicular torsion should be provided to all adult surgeons/trainees that may care for these children. In general, this condition is best managed at the presenting hospital whenever appropriate expertise is available. Novel pathways that streamline care may improve efficiency at an institutional level. Addressing issues of access to specialised neonatal surgery is more vexed on account of the tyranny of distance, and the pre-requisite level of surgical expertise required.

Rare case of a patient with testicular torsion complicated by acute pneumonia, requiring emergency surgery, during the COVID‐19 pandemic

Introduction

Case presentation

Conclusion

Adjuvant pharmacological and surgical therapy for testicular torsion: Current state of the art

INTRODUCTION

Although the consequences of testicular torsion (TT) have been recognized for centuries, little progress has been made to improve outcomes beyond those seen with timely scrotal exploration. Even with testicular salvage, ischemia/reperfusion injury cause significant atrophy and functional impairment. Recent efforts have sought to identify adjuvant pharmacological or surgical interventions that may attenuate these consequences. In this review, we assess the evidence supporting clinical use of these nascent interventions.

METHODS

We conducted a review of the literature published from 2000 to 2020, using the search terms "torsion", "testicular", "reperfusion", "ischemia", and "injury". Clinical and laboratory research focused on adjuvant pharmacological and surgical techniques mitigating torsion-associated injury in animal models and humans were identified. We recorded intervention timing/dose/route, and outcome timing/category through biomarkers of reperfusion injury, histology, and hormonal/reproductive function.

RESULTS

Fifty-four FDA-approved agents, plus 52 herbal/investigational drugs, were reported in animal TT models. In every study, the investigated agents showed beneficial effects on measured endpoints compared to controls. Despite these universally promising animal findings, no pharmacological trials in humans were reported. Surgical techniques studied in animal models included decompression (tunica albuginea incision, TAI), "ischemic conditioning", and hypothermia. Only three human studies on surgical adjuvant maneuvers have been reported, all involving TAI; these showed potential benefit, but the level of evidence is low.

CONCLUSION

There is preliminary evidence that adjuvant treatments may mitigate the effects of ischemia/reperfusion injury. However, the pool of investigated pharmacological agents is wide, yet remarkably shallow; most compounds have been reported in a single animal study. To advance this field, a mechanism-based approach should be used to select promising agents that can be tested systematically. This will determine treatment parameters that maximize safety, efficacy, and tolerability. Only then is it possible to move toward human trials. Adjuvant surgical methods such as TAI show promise in humans but require more robust clinical evaluation.

Timing and outcomes of testicular torsion during the COVID-19 crisis

BACKGROUND

During the COVID-19 crisis, there has been widespread reporting that non-COVID-19-related medical care has been delayed, even for emergent conditions. Testicular torsion is an emergent condition with higher risk of testicular loss with longer ischemic times. We sought to investigate whether patients with testicular torsion had longer time from symptom onset to initial presentation, longer total ischemic time, and higher rate of orchiectomy during the pandemic.

MATERIALS AND METHODS

Using billing data, we identified all patients age >1yo seen in our hospital from 1/1/2018 through 5/31/2020 who underwent emergent scrotal exploration for confirmed testicular torsion, comparing the COVID-19 crisis (3/1/2020-5/31/20) to the pre-COVID-19 period (1/1/2018-2/29/20). The primary outcome was time from symptom onset to initial presentation and secondary outcomes were ischemic time (time from symptom onset to entry of the OR) and orchiectomy rate. Parameters were compared with Mann-Whitney U and Fisher's exact tests; Poisson regression compared rates of torsion.

RESULTS

Of 94 total cases, 77 occurred during the pre-COVID-19 period and 17 during the COVID-19 crisis. Median time from symptom onset to initial presentation was not significantly different (2.4 h [IQR 1.1 h-38.9] during COVID-19 vs. 5.6 h [IQR 1.6-16.9] during pre-COVID-19 period, p = 0.476). Time to presentation was >12 h in 5/17 patients (29%) during COVID-19 and 24/77 patients (31%) during pre-COVID-19 period (p = 1.00). Median ischemic time during COVID-19 was 7.5 h (IQR 4.7 h-45.5 h) compared to 9.4 h (IQR 5.4 h-22.5 h) during pre-COVID-19 period (p = 0.694). Incidence of orchiectomy in our center was 29% (5/17) during COVID-19 and 17% (13/77) during pre-COVID-19 period (p = 0.397). About half of patients were seen initially at outside facilities prior to arrival (47% [8/17] during COVID-19 vs. 49% [38/77] during pre-COVID-19 period, p = 1.00). The number of torsion case presentations per week to our facility increased from 0.7 cases/week in the pre-COVID-19 period to 1.3 cases/week during COVID-19 (p = 0.015); when comparing only the March 1 to May 31 calendar period, there were 0.6 cases/week during the pre-COVID-19 period and 1.3 cases/week during COVID-19 (p = 0.021).

CONCLUSION

Time to presentation, ischemic times, and orchiectomy rates for testicular torsion at our center were not significantly different during the COVID-19 period compared to the preceding 2 year period. The number of torsion case per week presenting to our facility increased significantly.