R. J. D’Cruz1, C. Devin3, J. Savage2, A. F. Linden1, A. Choudhary4, K. Reichard1, L. Berman1 1Nemours Alfred I DuPot Hospital for Children,Pediateric General Surgery,Wilmington, DELAWARE, USA 2Nemours Alfred I DuPot Hospital for Children,Emergency Medicine,Wilmington, DELAWARE, USA 3Thomas Jefferson University,General Surgery,Philadelphia, PA, USA 4University Of Arkansas,Radiology,Little Rock, AR, USA
Introduction: Ultrasound (US) of the appendix is recommended as the initial imaging study for suspected appendicitis in children but has wide variability in its accuracy. Magnetic Resonance Imaging (MRI) has become the preferred confirmatory study due to its lack of radiation and high sensitivity/specificity. A retrospective study of patients who underwent imaging for appendicitis at our institution in 2017 revealed a high non-diagnostic rate for US, particularly in patients with a low (<3) or intermediate (4-6) Pediatric Appendicitis Score (PAS) (81% and 74.2% respectively). We subsequently created an algorithm (Figure 1) to streamline imaging decisions based on PAS to reduce unnecessary imaging.
Methods: The algorithm was developed by a multidisciplinary team of radiologists, surgeons and emergency physicians. The primary goal of the algorithm was to reduce unnecessary imaging by 1) eliminating any imaging for low PAS patients, and 2) utilizing MRI as the initial imaging study for intermediate PAS patients because of the high rate of non-diagnostic ultrasound and frequent subsequent need for axial imaging. We collected data on all patients who presented to the ED with abdominal pain suspicious for appendicitis and had a PAS score documented in the four months following pathway implementation and compared imaging utilization to the baseline 2017 data using Chi-square.
Results: A total of 144 patients were evaluated post-implementation and were grouped according to PAS as low (n=32), intermediate (n=57) and high (n=55). Twelve patients with prior imaging at another institution were excluded, leaving 132 for analysis. Compliance with the pathway was 75.8%. The overall MRI utilization rate increased from 26% to 40% (p = 0.0001) after pathway implementation primarily due to the increased number of MRIs performed in intermediate PAS patients. An average of 86 patients with a low PAS were imaged every 4 months during the one-year pre-pathway time frame versus only 7 in the 4 months post-pathway. The requirement for additional imaging (axial imaging after ultrasound) was significantly lower in the intermediate group (8.9% vs. 31.4%, p = 0.0004), but remained similar in the high PAS group (43.8% vs. 40%, p = 0.68).
Conclusion: Use of a PAS-based pathway resulted in reduction of overall imaging in low PAS patients and a reduction in additional imaging in intermediate PAS patients. Further studies will evaluate the cost-effectiveness of the algorithm including its impact on emergency room length of stay and likelihood of admission for serial abdominal exams. Standardization of diagnostic pathways has great potential to streamline care, decrease cost, and improve patient satisfaction.
