88 Infant malrotation with midgut volvulus: A prospective analysis of a new clinical pathway for management of patients presenting with bilious vomiting

Abstract Background Bilious vomiting (BV) is a hallmark warning sign of malrotation with midgut volvulus (MV), a potentially life-threatening condition in infants that requires immediate intervention. A retrospective analysis of MV cases (2015–2022) at our tertiary paediatric center (epoch 1) revealed substantial delays in management, which prompted this study. Objectives The primary objective of this quality improvement (QI) initiative was to assess whether the implementation of a BV clinical pathway improved management times (epoch 2) compared to data from our previous retrospective analysis (epoch 1). Our secondary objective was to analyze clinical presentation and morbidity/mortality for all cases of BV. Design/Methods This QI study employed a prospective cohort design to evaluate the impact of a new clinical pathway for infants < 3 months presenting with BV. The pathway ‘‘Green code’’ was developed using Plan-Do-Study-Act (PDSA) cycles to identify and address delays in care iteratively. Key interventions included standardized preformatted order set and a clinical practice guideline for BV investigation, expedited imaging protocols on-site, and quicker surgical consultations from arrival. Time intervals were systematically recorded, including: 1. Time to first medical evaluation. 2. Time to radiologic investigations (ultrasound [US], upper gastrointestinal radiography [UGI]). 3. Time to surgical consultation and to surgery for patients diagnosed with MV. Demographic and clinical data were collected for all patients, including signs/symptoms, laboratory studies, and imaging results. Surgical findings were recorded for confirmed MV cases. Comparative analysis of time metrics between the pre-intervention cohort (2015–2022) and post-intervention cohort (2022–2024) was performed using run charts. Results During the period study (09/2022–09/2024), 36 patients were investigated for BV in our institution. The median time to US from arrival was 55 min (17–97) compared to 146 min (63–234) in the pre-QI cohort. Five (9%) patients underwent surgery. The median time to surgery from arrival for the MV group was 103 min (63–138) compared to 297 min (206–368) in the pre-QI cohort. No mortality was recorded in this post-QI cohort. Other timepoints and clinical data were recorded and are currently collected. Conclusion Organizational changes, in the form of a new institutional clinical pathway and guideline created by a multidisciplinary team, proved to be effective tools to reduce investigation time of patients presenting with BV and treatment time of patient with MV. The first line of imaging in the clinical pathway studied is US and should strongly be considered as the primary investigation method for BV.