Standardized process to improve patient flow from the Emergency Room to the Operating Room for pediatric patients with testicular torsion

Summary Background Testicular torsion (TT) remains one of the most common urological emergencies. The length of time from onset of symptoms to detorsion and degree of spermatic cord twisting are usually the most important factors for testicular damage. Therefore early presentation, accurate diagnosis, and prompt treatment are important factors for optimizing the testicular salvage rate. While delay in seeking medical attention is a common cause of testicular loss in pediatric patients with testicular torsion, delays in diagnosis and treatment can be preventable causes of testicular loss. Objective In this study, we aimed to develop a standardized process to improve the patient flow from the Emergency Room (ER) to Operating Room (OR) for TT patients in an academic children's hospital. Study design Thirty consecutive pediatric patients with acute testicular torsion between November 2013 and July 2014 served as the control group. A scrotal pain checklist was implemented in July 2014, and 30 consecutive patients from July 2014 until April 2015 served as the study group. Perioperative parameters including times, ultrasound (US) findings, and surgical results were reviewed. Results The mean ages of the control group and the study group were similar (12.3 ± 4.9 years and 11.5 ± 5 years, respectively) ( p = 0.575). ER arrival to OR time, triage completion to OR time, and scrotal US to OR time were significantly decreased in the study group ( p p = 0.071, p = 0.112, respectively). Discussion Utilizing scoring tools during the triage of patients with scrotal pain can help identify high-risk patients earlier and prevent unnecessary use of resources in an ER serving a large pediatric population. Limitations of this pilot study include the limited number of patients and the potential for the Hawthorne effect (staff awareness of the study). Additionally, we did not examine scrotal pain checklist scores for other acute scrotal diseases. This study focused on a quality improvement process for TT patients, in order to reduce ER to OR times. Conclusion A standardized process with use of a scrotal pain checklist and prompt communication between the ER, Urology, and Radiology teams led to significantly reduced times from the ER to the OR. Standardized processes for pediatric patients with testicular torsion may help to improve testicular survival rates. Table . Patient demographics and time flow. Control group, mean ± SD (min–max) Study group, mean ± SD (min–max) * p Age (years) 12.3 ± 4.9 (0.1–17.9) 11.5 ± 5 (0.1–18) 0.575 Triage time (h:min) 0:14 ± 0:12 (0:02–0:55) 0:09 ± 0:07 (0:03–0:29) 0.071 ER arrival to OR Time (h:min) 3:18 ± 1:16 (1:03–7:23) 2:05 ± 0:45 (0:55–3:26) 0.001 Triage completion to OR time (h:min) 3:03 ± 1:16 (0:55–7:18) 1:55 ± 0:43 (0:50–3:12) 0.001 ER arrival to Scrotal Doppler US Time (h:min) 0:52 ± 0:36 (0:11–2:44) 0:39 ± 0:20 (0:13–1:33) 0.112 Scrotal Doppler US to OR time (h:min) 2:26 ± 1:04 (0:36–5:54) 1:26 ± 0:39 (0:19–3:01) 0.001 ER = Emergency Room; OR = Operating Room; US = ultrasonography. *Student t test. The bold p values are the statistically significant ones (