The use of a pediatric appendicitis pathway in a large integrated health system reduced computed tomography imaging in the ED.

Abstract

Appendicitis is the most common cause of an acute surgical abdomen in children. Diagnosis is often challenging as few pediatric patients present with classic symptoms. Clinicians are thus dependent on imaging to reach an accurate diagnosis. Although computerized tomography (CT) has high sensitivity and specificity, it has the disadvantage of imparting ionizing radiation. Ultrasound (US) is readily available and has comparable accuracy to CT when performed by experienced sonographers. We sought to examine the impact of a system-wide process improvement plan on CT use and other metrics in pediatric patients who presented to the Emergency Department (ED) with suspected appendicitis. This is a retrospective study of the impact of a Pediatric Appendicitis Pathway (PAP) within a large integrated hospital system with 12 EDs including 3 designated hub EDs. Patients were placed in an initial risk category utilizing the Pediatric Appendicitis Score (PAS), and received US of the appendix at a hub ED if indicated by the PAS. Patients presenting to community EDs who required US appendix were transferred to hub EDs for imaging. Patients presenting in the 6-month pre-implementation period were compared to patients presenting in a 14-month post-implementation period on CT and US utilization, negative and missed appendectomy rates, and ED length of stay (LOS). 1874 patients (401 pre-PAP and 1473 post-PAP) were included in the study. At the hub EDs the rate of CT imaging for suspected appendicitis was reduced from 31% to 17% with a resultant increase in US utilization from 83% (333/401) to 90% (1331/1473) (p < 0.001). At community general EDs (404 pre-PAP and 449 post-PAP), the rate of CT was decreased from 45% (181/404) to 32%(144/449) (p < 0.001)) There was no significant change in the negative appendectomy rate pre-PAP (1/59 = 1.7%) and post-PAP (4/168 = 2.4%) (p = 0.99) at the hub EDs. There were no missed appendicitis cases after PAP implementation compared to 1 case in the pre-PAP period. Overall LOS was similar pre and post-PAP, however LOS was longer in patients that required transfer from community general EDs to hub EDs (median 264 vs 342 min, p < 0.001). A PAP that stratified patients into risk groups using the PAS and encouraged the use of US as a first line imaging modality, reduced the number of CT performed in a large integrated health system without significant changes to clinical outcomes. Furthermore, transferring select patients for an US as opposed to obtaining an initial CT in community general EDs was feasible and reduced CT use in the pediatric population.