237 The Use of a Carepath in the Diagnosis and Management of Appendicitis in Children in a Large Integrated Health System Reduced Unnecessary Computed Tomography Imaging

Abstract

Appendicitis is the most common cause of an acute surgical abdomen in children. More than 100,000 children undergo appendectomy annually in the USA. Diagnosis is often challenging as only 1/3 of pediatric patients present with classical symptoms that include right lower quadrant pain, anorexia, and nausea/vomiting. With the increased usage of advanced imaging, diagnostic accuracy has improved. Although Computed Tomography of abdomen/pelvis (CT abd/pelvis) is the most accurate imaging modality, it requires radiation. Recent studies have shown that ultrasound (US) of the appendix in experienced hands can accurately diagnose appendicitis without radiation and with decreased cost. In addition, the pediatric appendicitis score (PAS) has been shown to be an effective tool to identify patients with appendicitis in the pediatric emergency department (ED). A joint CarePath was created by the Departments of Emergency Medicine, Pediatric Hospital Medicine, Radiology and Pediatric Surgery to manage these patients. The CarePath includes placing patients in an initial risk assessment category with PAS (high suspicion, equivocal, low suspicion), followed by US of the appendix (see figure1-2). The CarePath was initiated in November 2018. We planned to compare CT abd/pelvis and negative appendectomy rates one-year pre and one year post CarePath for patients 0-18 years old who presented to 3 pediatric emergency departments with concerns of appendicitis (RLQ pain, N/V, fever). Aim is to reduce CT abd/pelvis rate by 50%, keeping negative appendectomy (surgical pathology is negative for appendicitis) rate <1 %. Retrospective chart review for Quality Improvement project. We preliminarily reviewed the data for ten months between May 2018 and February 2019(six months pre and four months post CarePath). The rate of CT abd/pelvis for appendicitis evaluation was reduced from 39% in the pre-CarePath period to 22 % in the post-CarePath period. There was one negative appendectomy in pre-CarePath period. Although surgical pathology was negative for appendicitis; there was no other diagnosis identified and patient clinically improved after appendectomy. There was one case of negative appendectomy post-CarePath implementation in which the patient was ultimately diagnosed with pelvic inflammatory disease. A CarePath consisting of the PAS and US imaging can reduce the number of CTs performed without resultant increase of missed diagnosis. These preliminary results suggest that a CarePath can reduce variability and enhance patient and provider satisfaction in the management of suspected pediatric appendicitis. Further education of the Pediatric ED and Pediatric Surgery providers needed to sustain and further improve the desired outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)