417 - Decreasing Time to Ultrasound Completion in Children and Adolescents with Suspected Adnexal Torsion: A Quality Improvement Project

Publication Number: 4408.417

Haley D. Kittle, Nemours Children's Hospital, Wilmingotn, DE, United States; Beth I. Schwartz, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States; Loren Berman, Nemours Children's Hospital, wilmington, DE, United States; Teerin Meckmongkol, Nemours Children's Hospital, Orlando, FL, United States; Sharon W. Gould, Nemours Children's Hospital, Wilmington, DE, United States; Arianna Phillips, Nemours Children's Hospital, Hockessin, DE, United States; Ana P. Burleson, Nemours Children's Hospital, Orlando, FL, United States; Anna Lin, Nemours Children's Hospital, Wilmington, DE, United States; Lauren May, Nemours Children's Hospital, Wilmington, DE, United States; Kamal K. Chavda, Nemours Children's Hospital, Orlando, FL, United States; Jillian Savage, NemoursAlfred I. duPont Hospital for Children, Wilmington, DE, United States

Background: Adnexal torsion is an uncommon but important cause of lower abdominal pain in children and adolescents assigned female at birth. Prompt evaluation and treatment is imperative for adnexal preservation and future reproductive health. Transabdominal pelvic ultrasound (TPUS) is the most common imaging modality to assess for adnexal torsion in children and adolescents, but it requires a full bladder for optimal evaluation of the adnexal structures, and an empty bladder can be a source of delay.

Objective: Our aim was to decrease the time from emergency department (ED) presentation for lower abdominal pain to TPUS completion in children and adolescents assigned female at birth by 10% over 12 months.

Design/Methods: This quality improvement project followed the Institute for Healthcare Improvement Model for Improvement with sequential Plan-Do-Study-Act cycles. The outcome measure was the mean time from ED presentation to completion of TPUS. We included all patients assigned female at birth with age ≤ 20 years who presented to the ED with lower abdominal pain and underwent TPUS. The baseline was determined from August 2022-March 2024. In mid-February 2024, the ED triage staff began instructing all patients assigned female at birth with lower abdominal pain to drink 8-16 oz of clear liquids and refrain from voiding prior to provider evaluation. Several additional measures were introduced in December 2024: a template for standardized reporting of adnexal structures on ultrasound, an algorithm for the assessment of patients suspected to have adnexal torsion, and an order set. Both the algorithm and order set addressed prompt oral hydration to expedite bladder filling.

Results: The mean time from presentation to completion of TPUS decreased from 239 minutes to 204 minutes (15%) and met criteria for special cause variation after our first intervention. We did not observe an additional decrease in mean time to completion of TPUS with our second round of interventions, but our improvement has been sustained over time.

Conclusion(s): Implementing a standardized approach, including measures to encourage bladder filling prior to evaluation, can significantly reduce the time to completion of TPUS in Children and adolescents with suspected adnexal torsion.

Mean Time from Presentation to Completion of Transabdominal Pelvic Ultrasound over Time
Control chart showing the change in mean time from presentation to completion of transabdominal pelvic ultrasound over time. First Improvement Event represents the initiation of oral hydration and education to prevent voiding in the waiting room. Second Improvement Event represents addition of algorithm, order set, and ultrasound report template.