C. D. Flores1,2, B. Patel3, J. Bee5, J. McManemy3, D. D’Ambrosio5, M. McPherson4,5, M. A. Lyn3, S. R. Shah1,2 1Texas Children’s Hospital,Pediatric Surgery,Houston, TX, USA 2Baylor College Of Medicine,Pediatric Surgery,Houston, TX, USA 3Texas Children’s Hospital,Emergency Medicine,Houston, TX, USA 4Texas Children’s Hospital,Critical Care,Houston, TX, USA 5Texas Children’s Hospital,Transfer Center,Houston, TX, USA
Introduction: Prior studies have shown that 35 – 50% of appendicitis patients seen at tertiary-care children’s hospitals are diagnosed at outside hospitals (OSH) by CT scan. We recently initiated a workflow for direct inpatient admission of these patients to prevent a second emergency department (ED) evaluation. The objective of this study was to conduct an early evaluation of the feasibility and outcomes of our direct admission process for appendicitis.
Methods: A prospective pilot trial of the direct admission process was conducted from 05/13/18 – 08/15/18 at a tertiary-care children’s hospital. Criteria for direct admission included patients that were ≥ 4 years-old, stable for acute care, and had an OSH CT with appendicitis. The transfer center accepted eligible patients as a direct admission to the surgical service. Upon arrival, vital signs were collected in ED triage and patients stable for acute care were directly admitted to the surgical service. Patient characteristics, clinical outcomes, delays in care, escalation of care, and pathway compliance were collected and analyzed.
Results: There were 53 patients transferred from an OSH for suspected appendicitis and 33 (62%) had a CT with appendicitis. There were 27 (51%) patients that underwent direct admission [25 CTs and 2 MRIs with appendicitis]. Of the 25 admitted with a CT, 24 (96%) underwent an appendectomy and one patient was discharged upon further evaluation. Both patients admitted with an MRI underwent appendectomies. Acute appendicitis was confirmed by pathology on all patients who had an appendectomy. None of these patients required escalation in care and no significant delays were identified during their hospital course.
Of the 26 patients that did not undergo direct admission, there were 8 patients that had an OSH CT with appendicitis. One patient was appropriately held for resuscitation based on unstable vital signs in ED triage. This patient ultimately underwent an appendectomy and appendicitis was confirmed by pathology. The remaining 7 patients were deviations from our new workflow and were eligible for direct admission. All seven of these patients eventually underwent appendectomies and had confirmed appendicitis on pathology (Fig 1).
Conclusions: Our data demonstrate that direct admission of children diagnosed with appendicitis by an outside institution CT is safe and feasible at a tertiary-care children’s hospital. Next steps include increasing compliance with our direct admission workflow for eligible patients, and considering the inclusion of outside institution MRIs diagnostic of appendicitis.
