K. J. Baxter1, H. L. Short1, C. D. Travers2, K. F. Heiss1, M. V. Raval1 1Emory University School Of Medicine, Children’s Healthcare Of Atlanta,Division Of Pediatric Surgery, Department Of General Surgery,Atlanta, GA, USA 2Emory University School Of Medicine,Department Of Pediatrics,Atlanta, GA, USA
Introduction: The purpose of this study was to evaluate a novel surgeon-reported categorization (SRC) schema for pediatric appendicitis severity. We hypothesized that the SRC assigned prospectively at the time of surgery would be superior to standard surgical wound classification in predicting outcomes.
Methods: We conducted an IRB-approved retrospective review of all appendectomies in children 1-18 years performed at two children's hospitals within a single institution from January to December 2016. Interval appendectomies were excluded. The SRC is defined as: simple acute (1), complicated gangrenous or adherent (2A), complicated with perforation and localized abscess (2B), or complicated with perforation and gross contamination (2C). Logistic regression was used to model surgical site infections (SSI) and returns to the system. Cox proportional hazards survival analyses were used to model length of stay (LOS). All models were adjusted for patient age, sex, and race.
Results: The cohort included 397 children and the combined morbidity (SSI and revisits) rate was 9.8%. Over the course of a 15 month implementation, surgeon compliance with SRC documentation increased from 33.5% to 85.9% and chart review revealed 100% concordance of SRC with reported operative findings. When modeling combined morbidity, SRC displayed improved model calibration (Hosmer-Lemeshow statistic from 0.418 to 0.829), but had similar outcome discrimination to wound class (C-statistic 0.661 vs. 0.657). SRC showed an advantage over wound class in predicting SSI alone (C-statistic 0.740 vs. 0.684). SRC better predicted LOS compared to wound class (Figure).
Conclusion: Despite an overall low morbidity rate in this cohort, SRC improved prediction of SSI and LOS when compared to wound class. SRC implementation is feasible and provides a more granular assessment of appendicitis severity which may guide future quality improvement efforts through development of grade-specific care pathways.
