Children's Hospital Emergency Department Research Articles

Inactivated influenza vaccine highly effective in young and immunocompromised children.

There are few studies on the effectiveness of influenza trivalent inactivated vaccine in high-risk children. Since 2008, the Western Australian government has offered free trivalent inactivated vaccine immunisation for children aged 6–59 months, facilitating a large case control study.1 Children aged 6–59 months presenting with an influenza-like illness to the main children's hospital Emergency Department from 2008 to 2014 (excluding the H1N1 epidemic year 2009) were tested for influenza infection by nasopharyngeal culture or polymerase chain reaction. Reported immunisation status was verified from national and doctor records. Vaccine efficacy (VE) was calculated by comparing the vaccine status of 546 influenza positive children with that of 2177 negative children. Overall, VE was 70.0% (95% confidence interval (CI) 47.7–82.9%). Surprisingly, there was a non-significant trend for VE to be higher for children <2 years old = 84.7% (49.6–95.3%), children born preterm (<37 weeks) = 79.2% (95%CI 10.9–95.1%) and children with defined medical co-morbidities at risk of severe influenza = 82.5% (95%CI 14.6–96.4%), the very groups in which reduced VE was expected. However, absolute numbers were low for these groups. Influenza vaccine efficacy varies from year to year, depending on the match between vaccine and circulating strains. These data show promisingly high efficacy for those children at the highest risk of severe influenza and should encourage progress towards universal childhood immunisation.

Older adolescent presentations to a children's hospital emergency department.

To describe the characteristics, diagnoses and outcomes of older adolescents, aged 16-19years, presenting to a paediatric ED. A retrospective review of total ED presentations by older adolescents to a tertiary paediatric hospital between 2010 and 2012, inclusive, was undertaken to determine if behavioural or mental health problems were common. A total of 1184 ED presentations by 730 older adolescents were identified. Injury and abdominal pain were the most common complaints for presentations by older adolescents to the ED. The median length of stay in ED was 241 (range: 0-3873) min. More than 60% of the older adolescent ED presentations were triaged urgent or semi-urgent, and 39% of all these presentations resulted in hospital admission. Two-thirds of these older adolescents had a chronic illness, which accounted for 77% of all ED presentations by older adolescents. The history of chronic illness was considered related or relevant in the evaluation and management of over 80% of older adolescents. Of all the ED presentations by older adolescents with chronic illness, only one quarter had transition planning documentation. A high prevalence of chronic illness was found in older adolescents attending the paediatric ED. There was no evidence that behavioural and mental health issues dominated. These findings reflect admission policy.

Urinary Tract Infection and Antimicrobial Stewardship in the Emergency Department.

The aims of this study were to assess empiric antibiotic use for presumed urinary tract infection (UTI) in the emergency department (ED) and to determine how often urine culture results subsequently do not confirm the diagnosis. This study is a retrospective cohort study of patients aged 21 years or younger in the Nationwide Children's Hospital ED from May 1, 2012, to October 31, 2012, who had a urinalysis and urine culture performed and were discharged home with empiric antibiotic therapy for presumed UTI. Patients with known urinary tract anomaly or antibiotic use in the previous 7 days were excluded. Confirmed UTI was defined as pyuria (>5 white blood cells per high-power field or dipstick positive for leukocyte esterase) and a positive urine culture (≥50,000 colony-forming units/mL of a uropathogen). Of the 175 enrolled patients, urine was obtained by clean catch in 138 (79%), catheterization in 35 (20%), first-pass void in 1 (0.6%), and undocumented method in 1 (0.6%). Pyuria was demonstrated in 164 patients (94%), but only 97 (55%) had a positive urine culture. The combination of pyuria and a positive urine culture confirmed UTI in 90 patients (51%). The most commonly prescribed antibiotics were cefdinir in 103 patients (59%), trimethoprim/sulfamethoxazole in 40 (23%), and ciprofloxacin in 23 (13%). The median duration of prescribed therapy was 10 days (interquartile range, 7-10 days). Treatment duration was correlated negatively with age (r = -0.53, P < 0.01). The current management of suspected UTI in ED patients results in unnecessary antibiotic exposure, highlighting an important opportunity for outpatient antimicrobial stewardship efforts.

Use of a Dedicated, Non-Physician-led Mental Health Team to Reduce Pediatric Emergency Department Lengths of Stay.

Utilization of emergency departments (EDs) for pediatric mental health (MH) complaints is increasing. These patients require more resources and have higher admission rates than those with nonpsychiatric complaints. A multistage, multidisciplinary process to reduce length of stay (LOS) and improve the quality of care for patients with psychiatric complaints was performed at a tertiary care children's hospital's ED using Lean methodology. This process resulted in the implementation of a dedicated MH team, led by either a social worker or a psychiatric nurse, to evaluate patients, facilitate admissions, and arrange discharge planning. We conducted a retrospective, before-and-after study analyzing data 1year before through 1year after new process implementation (March 28, 2011). Our primary outcome was mean ED LOS. After process implementation there was a statistically significant decrease in mean ED LOS (332minutes vs. 244minutes, p<0.001). An x-bar chart of mean LOS shows special cause variation. Significant decreases were seen in median ED LOS (225minutes vs. 204minutes, p=0.001), security physical interventions (2.0% vs. 0.4%, p= 0.004), and restraint use (1.7% vs. 0.1%, p< 0.001). No significant change was observed in admission rate, 72-hour return rate, or patient elopement/agitation events. Staff surveys showed improved perception of patient satisfaction, process efficacy, and patient safety. Use of quality improvement methodology led to a redesign that was associated with a significant reduction in mean LOS of patients with psychiatric complaints and improved ED staff perception of care.

Video intervention changes parent perception of all-terrain vehicle (ATV) safety for children

BackgroundChildren aged <16 years account for 25% of deaths on all-terrain vehicles (ATVs), despite public health and industry warning against paediatric use. Parents often underestimate instability and other risks associated...

Infectious Etiologies and Patient Outcomes in Pediatric Septic Shock

Septic shock remains an important cause of death and disability in children. Optimal care requires early recognition and treatment. We evaluated a retrospective cohort of children (age <19) treated in our emergency department (ED) for septic shock during 2008-2012 to investigate the association between timing of antibiotic therapy and outcomes. The exposures were (1) receipt of empiric antibiotics in ≤1 hour and (2) receipt of appropriate antibiotics in ≤1 hour. The primary outcome was development of new or progressive multiple system organ dysfunction syndrome (NP-MODS). The secondary outcome was mortality. Among 321 patients admitted to intensive care, 48% (n = 153) received empiric antibiotics in ≤1 hour. These patients were more ill at presentation with significantly greater median pediatric index of mortality 2 (PIM2) scores and were more likely to receive recommended resuscitation in the ED (61% vs 14%); however, rates of NP-MODS (9% vs 12%) and hospital mortality (7% vs 4%) were similar to those treated later. Early, appropriate antibiotics were administered to 33% (n = 67) of patients with identified or suspected bacterial infection. These patients had significantly greater PIM2 scores but similar rates of NP-MODS (15% vs 15%) and hospital mortality (10% vs 6%) to those treated later. Critically ill children with septic shock treated in a children's hospital ED who received antibiotics in ≤1 hour were significantly more severely ill than those treated later, but they did not have increased risk of NP-MODS or death.

Impact of a Pediatric Dermatology Service on Emergency Department Utilization for Children with Dermatitis.

Atopic dermatitis (AD) is the most common chronic pediatric skin disease, and it can profoundly affect a family's quality of life. Children with flaring AD often seek treatment in emergency departments (EDs), which leads to expensive care and ineffective long-term disease control. The objective of the current study was to determine the effect of a pediatric dermatology service (PDS) on ED use and charges and of disease outcomes for patients diagnosed with AD before and after establishing an intramural PDS. This retrospective study reviewed electronic medical records of patients presenting to an urban children's hospital ED with diagnoses encompassing the terms AD, eczema, dermatitis and International Classification of Diseases, Ninth Revision (ICD-9) codes 691.8 and 692.9 during the year before (pre-PDS period) and 3 years after establishing a PDS. There were 205 ED visits for dermatitis in the pre-PDS period and 130 in the with-PDS period, a 36.6% decrease (p < 0.001). In the pre-PDS period, 53.7% (n = 110/205) of patients presenting to the ED had moderate dermatitis, compared with 26.2% (n = 34/130) in the with-PDS period, a 69.1% decrease (p < 0.001). Total ED charges were $142,885 for the pre-PDS period and $90,610 for the with-PDS period, a $52,275 decrease. This study provides a salient example of achieving the triple aim of health care reform: improving health outcomes (decreased ED visits) improving the patient experience (transitioning care from the ED to the more appropriate ambulatory clinical setting), and decreasing the cost of care (decreased ED charges).

Quality of life impacts from rotavirus gastroenteritis on children and their families in the UK

AimsRotavirus vaccines (RV) are safe and effective but demand significant investment of healthcare resource. In countries with low mortality due to rotavirus, a key component to assessing cost-effectiveness is quantifying the Health Related Quality of Life (HRQoL) lost due to rotavirus acute gastroenteritis (RVAGE). MethodsFamilies with children less than six years old with gastroenteritis were recruited from attendees to Bristol Children's Hospital Emergency Department. Stools were tested for viral causes of gastroenteritis. Children's HRQoL was assessed at presentation using Health Utilities Index 2 (HUI2) with visual analogue scale (VAS). The effect of the child's illness on the HRQoL of up to two adult carers was assessed using EQ-5D-5L. Families completed a daily symptom diary to assess time to recovery and within-family transmission. Results127 families consented to take part, 84(65%) had rotavirus as the cause of illness. At the time of attendance, mean paediatric HRQoL with RVAGE was 0.74(HUI2) and 0.42(VAS). Primary/secondary carer's HRQoL was 0.68/0.80 (EQ5D) or 0.70/0.79 (VAS). The mean number of QALYs lost due to RVAGE was 3.1–3.5 per thousand children and 7.7–8.7 per thousand family units.In 52% of RVAGE families at least one other member developed a secondary case of gastroenteritis. For working parents, 69% missed work, for a mean of 2.8 days (95% CI 2.3–3.4). ConclusionsWe have found the HRQoL loss associated with RVAGE in children and their carers to be significantly higher than estimates used for all RV medical attendances in UK cost-effectiveness calculations.

Factors associated with emergency department discharge after pediatric interhospital transport: a role for outreach education?

To characterize the disposition of children transported from an outside emergency department (ED) to a children's hospital ED and examine associations between patient and referring ED factors with discharge from the receiving ED. We collected data from existing electronic data sources and telephone interviews of referring ED directors. We included all pediatric patients who were transported from an outside ED to the Children's National Medical Center ED between July 2009 and June 2010. We examined patient factors of age, diagnosis, and illness severity and referring ED factors of annual pediatric volume and staffing for associations with ED discharge. Of 3288 transported patients, 2230 (68%) were admitted, 1025 (31%) were discharged, and less than 1% died. In univariate analyses, discharge from the receiving ED was associated with trauma diagnoses (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.7-2.4), transports from low pediatric volume EDs (OR, 2.0; 95% CI, 1.7-2.4), and from EDs without pediatric physician staffing (OR, 2.1; 95% CI, 1.8-2.6). In multivariate analyses, discharge was associated with trauma and gastrointestinal diagnoses (adjusted OR 1.6 [95% CI, 1.2-2.2] and 1.9 [95% CI, 1.4-2.6], respectively) as well as low referring ED pediatric volume and nonpediatric physician staffing (adjusted OR, 1.7 [95% CI, 1.4-2.1] and 1.9 [95% CI, 1.5-2.5], respectively) when controlling for all other factors. In this single-site study, children referred from outside EDs with lower pediatric volumes and staffed by nonpediatricians were more likely to be discharged from a children's hospital ED after transport. These transports may represent unnecessary resource use. Outreach education, shared staffing models, and telemedicine are potential methods to address unnecessary transfers.

Effect of Oral Ondansetron on Vomiting Associated with Intramuscular Ketamine Sedation in Children: A Double-Blind, Randomized, Placebo-Controlled Trial

Purpose The purpose of this study is to investigate the effect of oral ondansetron on the incidence of vomiting in children who receive intramuscular (IM) ketamine for procedural sedation and analgesia in the emergency department (ED). Methods In this double-blind, randomized, placebo-controlled trial in a children's hospital ED, patients receiving IM ketamine (5 mg/kg) for ED procedures were randomized to receive either oral ondansetron (2 mg or 4 mg) or placebo 15 minutes before the ketamine injection. We recorded whether vomiting occurred in the ED postsedation or up to 12 hours after discharge with telephone follow-up and compared ED length of stay and parental satisfaction. Results Thirty two children were randomized to placebo and 31 to ondansetron. The groups were similar in age, sex, and fasting duration. ED vomiting was no significant difference with ondansetron: 7 of 31 (22.6%) versus 6 of 32 (18.8%), P=0.707, difference -3.8 (95% confidence interval -23.8% to 16.2%). Follow-up completed in 82.5%. The vomiting in the ED or after discharge in two groups, there was no significant difference: 7 of 27 (25.9%) versus 12 of 25 (48.0%), P=0.165, difference 22.1% (95% confidence interval -3.5% to 47.7%). ED length of stay and parental satisfaction were similar between groups. Conclusion There is no significant reduction of the incidence of vomiting in oral ondansetron group with IM ketamine procedural sedation in children. Key Words: Ketamine; Conscious Sedation; Vomiting

Pediatric psychiatric emergency department visits during a full moon.

This study aimed to verify the hypothesis that the lunar cycle influences the number of pediatric psychiatric emergency department (ED) visits. Pediatric psychiatric ED visits between 2009 and 2011 were obtained retrospectively. Patients aged between 4 and 21 years presenting to Miami Children's Hospital ED with a primary psychiatric complaint were included in the study. Patients with a concomitant psychiatric problem and a secondary medical condition were excluded. The number of psychiatric visits was retrieved for the full moon dates, control dates as well as the day before and after the full moon when the moon appears full to the naked eye (full moon effect). A comparison was made using the 2-sample independent t test. Between 2009 and 2011, 36 dates were considered as the true full moon dates and 108 dates as the "full moon effect." A total of 559 patients were included in the study. The 2-sample independent t tests were performed between the actual full moon date and control dates, as well as between the "full moon effect" dates and control dates. Our results failed to show a statistical significance when comparing the number of pediatric psychiatric patients presenting to a children's hospital ED during a full moon and a non-full moon date. Our study's results are in agreement with those involving adult patients. The full moon does not affect psychiatric visits in a children's hospital.

Rhinovirus Disease in Children Seeking Care in a Tertiary Pediatric Emergency Department.

Rhinovirus is the most common cause of viral respiratory tract infections in children. Virologic predictors of lower respiratory tract infection (LRTI), such as viral load and the presence of another respiratory virus (coinfection), are not well characterized in pediatric outpatients. Mid-nasal turbinate samples were collected from children presenting for care to the Seattle Children's Hospital emergency department (ED) or urgent care with a symptomatic respiratory infection between December 2011 and May 2013. A subset of samples was tested for rhinovirus viral load by real-time polymerase chain reaction. Clinical data were collected by chart reviews. Multivariate logistic regression was used to evaluate the relationship between viral load and coinfection and the risk for LRTI. Rhinovirus was the most frequent respiratory virus detected in children younger than 3 years. Of 445 patients with rhinovirus infection, 262 (58.9%) had LRTIs, 231 (51.9%) required hospital admission and 52 (22.5%) were hospitalized for 3 days or longer. Children with no comorbidities accounted for 142 (54%) of 262 rhinovirus LRTIs. Higher viral load was significantly associated with LRTI among illness episodes with rhinovirus alone (OR, 2.11; 95% confidence interval [CI], 1.24-3.58). Coinfection increased the risk of LRTI (OR, 1.83; 95% CI, 1.01-3.32). Rhinovirus was the most common pathogen detected among symptomatic young children in a pediatric ED who had respiratory viral testing performed, with the majority requiring hospitalization. Higher rhinovirus viral load and coinfection increased disease severity. Virologic data may assist clinical decision making for children with rhinovirus infections in the pediatric ED.

PC-FACS

PC-FACS

Severe complications in influenza-like illnesses.

Data on complications from upper respiratory infection are limited. We examined development of severe complications in children presenting to the emergency department (ED) for moderate to severe influenza-like illness (ILI). Prospective cohort study of children 0 to 19 years presenting to a tertiary care children's hospital ED during peak respiratory viral seasons from 2008 to 2010. Subjects included had moderate to severe ILI, defined by performance of venipuncture and nasopharyngeal multiplex polymerase chain reaction for respiratory viruses. Severe complications (respiratory failure, encephalopathy, seizures, pneumonia, bacteremia, death) were prospectively determined. Risk factors for severe complications were collected, including demographics, comorbidities, and household exposures. There were 241 enrolled subjects with median age of 27.4 months (interquartile range 8.9-68.5); 59.3% were boys and 48.5% were black. High-risk conditions were present in 53.5%. Severe complications developed in 35.3% (95% confidence interval [CI] 29.3-41.3), most frequently pneumonia (26.1%). The risk for severe complications was increased in subjects with neurologic or neuromuscular conditions (relative risk 4.0; 95% CI 1.9-8.2). No specific respiratory virus was associated with development of severe complications. Among patients with influenza, severe complications were greater with subtype H1N1 infection (relative risk 1.45, 95% CI 0.99-2.13, P = .048), and were at highest risk for pneumonia (relative risk 4.2, 95% CI 1.2-15.9). In children presenting to the ED for moderate to severe ILI, those with neurologic and neuromuscular disease are at increased risk for severe complications. Development of severe complications did not differ by infecting virus; however, risk of severe complications was greater with subtype H1N1 compared with other influenza.

Retrospective review of dog bite injuries in children presenting to a South Australian tertiary children's hospital emergency department.

To describe the characteristics, circumstances and consequences of dog bite injuries in children in order to inform the discourse concerning preventative approaches. A retrospective review of children presenting to the emergency department (ED) of the Women's and Children's Hospital (WCH) in South Australia between the years 2009 and 2011 was performed. A total of 277 children presented to the WCH with dog bite injuries between 2009 and 2011. Of those, 141(51.0%) were referred for admission. Injury rates were highest in those aged 0-4, declining thereafter with age. In the 0-4 year age group, 89.5% of children presented after being bitten by a familiar dog with 92.5% occurring at home. The head/neck region constituted the most common location for injuries. We found that 67.5% of dog bite injuries were provoked and occurred between the child and a familiar dog (78.0%). Dogs from the bull terrier group (20.0%) and Jack Russell Terriers (11.0%) were the two most documented breeds. Almost half of the children presenting during the specified timeframe required at least one operation under a general anaesthetic. Two children were referred to a psychologist for management of post-traumatic stress. Dog bite injuries are common in children and often require admission for inpatient care. This presents as a significant public health burden. For this reason, prevention initiatives need to be implemented on an ongoing basis.

Ringette-Related Injuries in Young Female Players

To document the injuries sustained during organized ringette games. Retrospective data. Canadian Children's Hospital Emergency Department. Information reported by the Canadian Hospitals Injury Reporting Prevention Program on the injuries of 494 female ringette players (age, 10-17 years) between 2004 and 2010. The injuries (types, body part, and mechanisms) presenting to emergency departments were compared between the 4 levels of minor organized ringette. Proportions of injuries by diagnosis, body site, and mechanisms. The common injuries noted were contusions and head injuries, fractures of the upper extremities, and contusions to both lower and upper extremities. Hospitalizations after injury were rare (1.0%). Body contacts, intentional or incidental, accounted for 63% of all injuries. The actual ringette (rubber ring) was not involved in any injury. Even though all types of contact are forbidden in ringette, our research showed that in minor leagues, a significant proportion of the injuries were caused by body contact. As with regular ice hockey, enforcing policies regarding contacts, use of proper equipment, good maintenance (ice conditions should be checked regularly), and proper skill training should help diminish these types of injuries.

Computerized Self-Interviews Improve Chlamydia and Gonorrhea Testing Among Youth in the Emergency Department

National guidelines recommend annual Chlamydia trachomatis and Neisseria gonorrhoeae screening for sexually active youth at risk for infection. These infections have serious sequelae in women if untreated, and methods to improve testing are needed. We hypothesize that an electronic method of identifying at-risk youth will significantly increase testing for these sexually transmitted infections during emergency department (ED) visits. We developed an audio-enhanced computer-assisted self-interview (ACASI) to obtain sexual histories from ED patients and an embedded decision tree to create a sexually transmitted infection testing recommendation. ED health care providers were prompted by the electronic medical record to review the participant answers and testing recommendations, and to offer testing to at-risk youth. Patients aged 15 to 21 years and visiting the St. Louis Children's Hospital ED, regardless of complaint, were eligible for participation. Sexually transmitted infection testing among all 15- to 21-year-old ED patients increased from 9.3% in the 3 months before the ACASI to 17.8% during the 8-month period the ACASI was available and diminished to 12.4% in the 3 months after ACASI withdrawal (P<.001). During the ACASI period, we approached 51.4% of eligible patients and enrolled 59.8% (800/1,337) of those approached. Among ACASI participants, 52.4% (419/800) received a recommendation to receive sexually transmitted infection testing. Of these patients, 52.7% (221/419) received testing in the ED and 18.1% (40/221) of those tested had positive results for chlamydia or gonorrhea, 55% of whom (22/40) had chief complaints unrelated to sexually transmitted infections. Most participants (89%) rated the ACASI easy to use. Sexually transmitted infection testing in the ED significantly increased during ACASI use and diminished after withdrawal. The ACASI was well accepted by youth and holds promise for enhancing sexually transmitted infection testing in the ED.

Pediatric Marijuana Exposures in a Medical Marijuana State

An increasing number of states are decriminalizing the use of medical marijuana, and the effect on the pediatric population has not been evaluated. To compare the proportion of marijuana ingestions by young children who sought care at a children's hospital in Colorado before and after modification of drug enforcement laws in October 2009 regarding medical marijuana possession. Retrospective cohort study from January 1, 2005, through December 31, 2011. Tertiary-care children's hospital emergency department in Colorado. A total of 1378 patients younger than 12 years evaluated for unintentional ingestions: 790 patients before September 30, 2009, and 588 patients after October 1, 2009. Marijuana ingestion. Marijuana exposure visits, marijuana source, symptoms, and patient disposition. The proportion of ingestion visits in patients younger than 12 years (age range, 8 months to 12 years)that were related to marijuana exposure increased after September 30, 2009, from 0 of 790 (0%; 95% CI, 0%-0.6%) to 14 of 588 (2.4%; 95% CI, 1.4%-4.0%) (P < .001). Nine patients had lethargy, 1 had ataxia, and 1 had respiratory insufficiency. Eight patients were admitted, 2 to the intensive care unit. Eight of the 14 cases involved medical marijuana, and 7 of these exposures were from food products. We found a new appearance of unintentional marijuana ingestions by young children after modification of drug enforcement laws for marijuana possession in Colorado. The consequences of unintentional marijuana exposure in children should be part of the ongoing debate on legalizing marijuana.

Pediatric oral burns: A ten-year review of patient characteristics, etiologies and treatment outcomes

ObjectiveTo summarize etiologies and treatments of pediatric oropharyngeal burns. DesignRetrospective summary of 75 patients treated from January 1999 to January 2009. SettingTertiary Children's Hospital. MethodsData collected included demographics, etiology of burn, site of injury, medical and/or surgical treatments, need for endoscopy, duration of hospitalization, and complications. Results75 patients were treated with 50 being males (66%). Mean age was 4.3 years (median 2.7 years). The five most common causes were chemical (34.6%), electrical (12.3%), hot liquids (12.3%), food (12.3%) and battery ingestion (9.9%). Ingestion of hair products made up nearly 1/3 of the chemical causes (9/28) and alone made up 12% of the burns in our study. Main sites of injury included buccal mucosa (77.3%), lips (56%), tongue (48%), and palate (22.7%). One-third of the patients’ required PICU/Burn unit admissions, 1/3 were admitted to floor, and 1/3 were discharged home from the ED. Average duration of hospitalization was 5 days. Of those admitted, 30% received antibiotics and only 8% received systemic steroids. Patients were made NPO on the first day of admission in 33.3% of patients and allowed to resume normal diet after surgical consultation. Only 9/75 (12%) patients required intubation. Otolaryngology consultation was obtained in 10.7% of cases. Only 18% of all patients required surgical intervention with debridement being most common (>60%). In this group, 20% received esophagogastroduodenoscopies due to ingestion of alkali substance. Complications occurred in less than 6% of all cases. ConclusionIngestion of chemicals, including hair dye/relaxer products, as well as overheated liquids and foods, are leading causes of oropharyngeal burns treated at our Children's Hospital Emergency Department over the past decade.

Clinical Practice Guidelines for Pediatric Appendicitis Evaluation Can Decrease Computed Tomography Utilization While Maintaining Diagnostic Accuracy

The objective of this study was to compare usage of computed tomography (CT) scan for evaluation of appendicitis in a children's hospital emergency department before and after implementation of a clinical practice guideline focused on early surgical consultation before obtaining advanced imaging. A multidisciplinary team met to create a pathway to formalize the evaluation of pediatric patients with abdominal pain. Computed tomography scan utilization rates were studied before and after pathway implementation. Among patients who had appendectomy in the year before implementation (n = 70), 90% had CT scans, 6.9% had ultrasound, and 5.7% had no imaging. The negative appendectomy rate before implementation was 5.7%. In patients undergoing appendectomy in the postimplementation cohort (n = 96), 48% underwent CT, 39.6% underwent ultrasound, and 15.6% had no imaging. The negative appendectomy rate was 5.2%. We demonstrated a 41% decrease in CT use for patients undergoing appendectomy at our institution without an increase in the negative appendectomy rate or missed appendectomy. The results were even more striking when comparing the rate of CT scan use in the subset of patients undergoing appendectomy without imaging from an outside hospital. In these patients, CT scan utilization decreased from 82% to 20%, a 76% reduction in CT use in our facility after protocol implementation. Implementation of a clinical evaluation pathway emphasizing examination, early surgeon involvement, and utilization of ultrasound as the initial imaging modality for evaluation of abdominal pain concerning for appendicitis resulted in a marked decrease in the reliance on CT scanning without loss of diagnostic accuracy.