PMID- 31444122
OWN - NLM
STAT- MEDLINE
DCOM- 20200924
LR  - 20200924
IS  - 1873-4898 (Electronic)
IS  - 1477-5131 (Linking)
VI  - 15
IP  - 5
DP  - 2019 Oct
TI  - Implementation of the accelerated care of torsion pathway: a quality improvement 
      initiative for testicular torsion.
PG  - 473-479
LID - S1477-5131(19)30223-2 [pii]
LID - 10.1016/j.jpurol.2019.07.011 [doi]
AB  - 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] 137-249 min) to 127 min (IQR 100-148 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 = 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.
CI  - Copyright (c) 2019 Journal of Pediatric Urology Company. Published by Elsevier Ltd. 
      All rights reserved.
FAU - Zee, R S
AU  - Zee RS
AD  - Children's National Medical Center Division of Urology, Washington, D.C, USA. 
      Electronic address: becca.zee@gmail.com.
FAU - Bayne, C E
AU  - Bayne CE
AD  - University of Florida Division of Pediatric Urology, Gainesville, FL, USA.
FAU - Gomella, P T
AU  - Gomella PT
AD  - George Washington University Department of Urology, Washington, D.C, USA.
FAU - Pohl, H G
AU  - Pohl HG
AD  - Children's National Medical Center Division of Urology, Washington, D.C, USA.
FAU - Rushton, H G
AU  - Rushton HG
AD  - Children's National Medical Center Division of Urology, Washington, D.C, USA.
FAU - Davis, T D
AU  - Davis TD
AD  - Children's National Medical Center Division of Urology, Washington, D.C, USA.
LA  - eng
PT  - Journal Article
DEP - 20190717
PL  - England
TA  - J Pediatr Urol
JT  - Journal of pediatric urology
JID - 101233150
SB  - IM
MH  - Acute Disease
MH  - Adolescent
MH  - Child
MH  - *Critical Pathways
MH  - Humans
MH  - Male
MH  - Orchiectomy/statistics & numerical data
MH  - *Quality Improvement
MH  - Retrospective Studies
MH  - Spermatic Cord Torsion/*surgery
MH  - Time Factors
MH  - Triage
MH  - Urologic Surgical Procedures, Male/methods/standards
OTO - NOTNLM
OT  - Acute scrotum
OT  - Orchiectomy
OT  - Quality improvement
OT  - Testicular torsion
OT  - Testis
EDAT- 2019/08/25 06:00
MHDA- 2020/09/25 06:00
CRDT- 2019/08/25 06:00
PHST- 2019/01/04 00:00 [received]
PHST- 2019/07/11 00:00 [accepted]
PHST- 2019/08/25 06:00 [pubmed]
PHST- 2020/09/25 06:00 [medline]
PHST- 2019/08/25 06:00 [entrez]
AID - S1477-5131(19)30223-2 [pii]
AID - 10.1016/j.jpurol.2019.07.011 [doi]
PST - ppublish
SO  - J Pediatr Urol. 2019 Oct;15(5):473-479. doi: 10.1016/j.jpurol.2019.07.011. Epub 
      2019 Jul 17.