J. Stevens4, N. Vaughan3, L. Burkhalter2, G. Wools2, A. Alder1,2 1University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 2Children’s Medical Center,Department Of Pediatric Surgery,Dallas, Tx, USA 3Baylor Scott and White Medical Center,Department Of Surgery,Dallas, TEXAS, USA 4University Of Texas Southwestern Medical Center,Medical School,Dallas, TX, USA
Introduction: Acute appendicitis is the most common cause for urgent surgical intervention in children. Accurate and timely diagnosis of pediatric appendicitis is thought to minimize complications. The pediatric appendicitis score (PAS) was developed by Samuel in 2002 and has been refined to help guide decision-making for diagnosing appendicitis with a goal to limit unnecessary imaging or procedures and to lower hospital costs. PAS is the core of a practice guideline that was implemented at our institution in September 2012 with intent to minimize unnecessary imaging and lower negative appendectomy rates. The purpose of this study was to evaluate the integration of the PAS into our appendicitis pathway to determine appropriateness of utilization.
Methods: This is a retrospective review of all patients at an urban, referral children’s hospital whose evaluation for appendicitis included a PAS from July 2017 to December 2017. Data analyzed included imaging rates, appendectomy rates and pathology reports.
Results: 1741 patients were evaluated with 503 undergoing appendectomy. 423(24.3%) patients had a complete PAS with the remaining missing portions of the PAS, most commonly lab results. 1501(92%) patients had an ultrasound and 339(20.8%) had a CT with 66(4%) having imaging done before the PAS was filled out. 109 patients had conclusive imaging from an outside hospital and were excluded from these results. Overall compliance with the PAS protocol was 11.3% with 96.6% of patients with a completed PAS >7 having imaging.
Conclusion: The PAS has not become a valuable tool as part of our appendicitis pathway to reduce over-imaging of children and lower negative appendectomy rates. Compliance with the guideline (PAS >7) would have resulted in a reduction of ultrasound and CT utilization of 243(16.2%) and 78(23%), respectively. In contrast, compliance would have doubled the negative appendectomy rate from 4 to 8%. Often, imaging is ordered prior to completion of the PAS. The default approach to any patient with possible appendicitis appears to be an ultrasound first and possibly a CT if it is still inconclusive. The PAS has not proven to be an important component of an acute appendicitis practice guideline at a busy tertiary children’s facility with a high volume of patients with appendicitis. A practice guideline that reflects our current practice potentially would save time, money and prevent patients from unnecessary radiation exposure from CT scans.