S. P. Anandalwar1, C. C. Glass1, D. A. Graham1, M. A. Kashtan1, J. L. Hills-Dunlap1, S. J. Rangel1 1Boston Children’s Hospital,Pediatric Surgery,Boston, MASSACHUSETTS, USA
Introduction: Previous investigation has demonstrated that the combined predictive value of white blood cell (WBC) count and ultrasound findings is superior to either alone in children with suspected appendicitis. The purpose of this study was to prospectively evaluate the impact of a clinical pathway leveraging the combined predictive value of these tests on computed tomography (CT) and resource utilization.
Methods: This was a pre-post intervention study comparing 8 months of retrospectively collected data prior to pathway implementation to 18 months of prospectively collected data following implementation. The pathway utilized previously established risk profiles based on combining laboratory and ultrasound data to stratify patients into low, moderate, and high-risk groups. Department-wide meetings with Radiology, Emergency Medicine, and Surgery were then conducted to establish consensus around disposition based on each risk profile (figure). The primary outcome was CT utilization. Balancing measures included time to appendectomy (TTA), negative appendectomy rate (NAR), magnetic resonance imaging (MRI) utilization, and imaging-related cost.
Results: 97 consecutive patients in the pre-intervention period were compared to 319 consecutive patients in the post-intervention period. During the post-intervention period, CT utilization decreased from 21% to 3% (p<0.001), reflecting an 85.7% reduction. During the same period, median TTA decreased from 7.6 to 6.0 hours (p<0.001), reflecting a 21% decrease. MRI utilization increased during the post-implementation period (1% vs 7%, p=0.02), although median imaging-related cost was significantly lower ($283 vs. $270, p=0.002). No difference in NAR was observed (5% vs. 4%, p=0.54).
Conclusion: Implementation of a clinical pathway leveraging the combined predictive value of WBC count and ultrasound findings was associated with a reduction in CT utilization, time to appendectomy, and imaging-related cost in children with suspected appendicitis.
