An Initiative to Reduce Time from Presentation to Incision for Patients with Testicular Torsion

From the 2021 HVPAA National Conference

Justin Nguyen (Yale School of Medicine), Matthew Buck, Alejandro Abello, Marianne Casilla – Lennon, Michael Leapman, Adam Hittelman, Jason Teitelbaum, Beth Emerson, Jaime Cavallo, Patrick Kenney, Sarah Lambert


Time from symptom onset of testicular torsion to detorsion predicts likelihood of testicular salvage. We aimed to reduce time from door-to-incision to under 120 minutes at our institution.


We developed a streamlined process to prioritize suspected torsion cases, coordinating a multidisciplinary team including urology, emergency medicine, radiology, anesthesiology, perioperative services, and transport services. The Initial intervention involved rapid identification of suspected cases in the emergency room (ER), immediate parallel notification of urology and radiology for evaluation, case prioritization by perioperative services, and rapid assessment by anesthesiology. We subsequently implemented portable bedside ultrasound in the ER for all suspected torsion cases. We assessed the effects of the intervention with statistical X-mR process control charts and used Nelson rules to determine special cause.


From January 2019 to February 2021, we observed 33 torsion events requiring surgical intervention, 15 before and 18 after the intervention. Following improvement efforts, mean door-to-incision time decreased from 221 minutes to 123 minutes. After the intervention there was a significant decrease in door to incision time through a shift of 8 patients below the control limit. We further identified a significant reduction in patient-to-patient variation through a shift of 8 in the moving range below the control limit. Compared to cases prior to our intervention time from arrival to ultrasound remained unchanged from 60 minutes to 62 minutes, and time from arrival to urology evaluation decreased from 135 minutes to 62 minutes, ultrasound duration decreased from 43 minutes to 36 minutes, and time from ultrasound to incision decreased from 157 minutes to 76 minutes.


Implementation of multidisciplinary improvement work reduced door to incision time for patients with suspected testicular time. These interventions provide a reproducible model to improve efficiency in treating patients with testicular torsion.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog