A. F. Tyson1, R. Sola1, S. Lawson1, A. E. Furr1, R. Cordle1, A. M. Schulman1, G. H. Cosper1 1Carolinas Medical Center,Charlotte, NC, USA
Introduction: Acute appendicitis (AA) is the most common surgical condition in children in the United States, yet the diagnosis remains a challenge. Ultrasound is the recommended diagnostic study of choice in pediatric patients, but up to 63% of ultrasounds are non-diagnostic. In a previous study, we found that 39% of pediatric patients with a non-diagnostic ultrasound in our ED received a surgical consultation and 30% were admitted to the hospital. In that population, only 10% of patients were ultimately diagnosed with AA. The purpose of this project was to develop an evidence-based algorithm for the workup of pediatric patients with concern for AA and a non-diagnostic ultrasound.
Methods: Pediatric patients (≤18 years old) presenting to the pediatric ED with symptoms concerning for AA who had a non-diagnostic ultrasound were included in the population, and the ED staff was encouraged to follow the algorithm for these patients. Specific outcome measures including rates of surgical consultation, hospital admission, appendicitis, and compliance with the algorithm were tracked to assess improvements in outcomes following implementation of the protocol. We followed a Plan-Do-Study-Act format for quality intervention and met monthly with the ED staff to solicit feedback and adjust the algorithm as necessary.
The primary goal of this quality improvement project was to achieve ≥90% compliance with the algorithm by December 31, 2016. The secondary goal was to determine whether compliance with the algorithm decreased the rate of hospital admission or surgical consultations, without increasing the rate of missed appendicitis in the pediatric population.
Results: Thus far, 85 children have been included in the study. The average age is 10 years and 48% are male. The average modified Alvarado score is 4.1 (range 0-9). The overall rate of surgical consultation thus far is 28%, although this has decreased from 38% for the first three months to 19% for the next three months. Twelve patients have been admitted for suspected appendicitis (14%) and 4 of these patients were eventually diagnosed with AA (4.7%). There were no cases of missed appendicitis. The overall compliance to date is 84%, although compliance fluctuated between 80% and 100% over the past four months.
Conclusion: The rate of AA in children with non-diagnostic ultrasounds is low and children ultimately diagnosed with AA can be appropriately identified using the algorithm. Our results demonstrate that greater than 90% compliance with the algorithm is possible. Although preliminary, the results suggest that compliance with the algorithm may decrease the number of surgical consultations and hospital admissions to rule out appendicitis in this population. In the future, we hope to be able to determine whether compliance with the algorithm can decrease resource utilization, cost, and length of stay in the pediatric emergency room, thereby making these patient encounters more efficient and cost-effective.