Improving Turnaround Time of Transabdominal Pelvic Ultrasounds with Ovarian Doppler in a Pediatric Emergency Department

Abstract

Introduction: Adnexal torsion is an emergent surgical condition. Transabdominal pelvic ultrasound (US) with ovarian Doppler is used to diagnose adnexal torsion and requires a sufficient bladder volume. Reduce the turnaround time for US by 25% in girls 8-18 years of age who present to the emergency department (ED) for 24 months.

Methods: Our baseline period was from January 2020 to June 2021, and the intervention period was from July 2021 to June 2023. Patients 8-18 years old who required an US in the ED were included. There are two key drivers: early identification of US readiness and expeditious bladder filling. Interventions were (1) bladder volume screening; (2) utilization of bladder volume nomogram to identify US readiness; (3) epic order panels; and (4) rapid intravenous fluid method. The primary outcome was US turnaround time. Secondary outcomes were percentage of patients requiring invasive interventions to fill the bladder and patients with an US study duration of ≤45 minutes. The percent of patients screened by bladder scan was used as a process measure. Balancing measures used episodes of fluid overload and ED length of stay.

Results: Turnaround time for USs improved from 112.4 to 101.6 minutes. The percentage of patients who had successful USs without invasive bladder filling improved from 32.1% to 42.6%. Bladder volume screening using a bladder scan increased from 40.3% to 82.9%. The successful first-pass US completion rate improved from 77% to 90% consistently.

Conclusions: Through quality improvement methodology, we have identified pelvic US readiness earlier, eliminated some invasive bladder-filling measures, and implemented a rapid fluid protocol. We have sustained these successful results for 2 years. This study can be generalized to any ED with similar patients.

Fig. 1.

A, Baseline process map. B, Process map during the intervention period. When comparing (A) with (B), the blue boxes in (B) represent the change from the baseline process map. C, Key driver diagram with the specific aim on the left, the three key drivers in the middle column, and the eight main interventions on the right-hand column. IVF, intravenous fluids.

Fig. 2.

The bladder volume nomogram shows bladder volume percentiles by age, adjusted for weight. The y axis represents the bladder volume in milliliters, and the x axis represents the age in years.

Fig. 3.

Improved turnaround time of all transabdominal pelvic USs with ovarian Doppler. The y axis on this x-bar chart shows the time in minutes. The x axis shows the date with the number of patients in parentheses.

Fig. 4.

Percentage of pelvic USs with documented bladder volume. This p-chart’s y axis shows the percentage of pelvic USs with documented bladder volume. The x axis shows the date and the number of pelvic USs in parentheses.

Fig. 5.

Percentage of patients that did not require peripheral IV fluids or a Foley catheter to fill their bladders. On this p-chart, the y axis shows the percentage of patients who do not require a peripheral IV or Foley catheter. The x axis is the date with the number of patients in parentheses.

Fig. 6.

Improvement of completed first-attempt pelvic USs. This p-chart’s y axis shows the percentage of completed pelvic USs on the first attempt. The x axis shows the date, month, and year.