Faculty Collaboration Database

Clinical practice guidelines for pediatric appendicitis evaluation can decrease computed tomography utilization while maintaining diagnostic accuracy. Pediatr Emerg Care 2013 May;29(5):568-73

Date

04/25/2013

Pubmed ID

23611916

DOI

10.1097/PEC.0b013e31828e5718

Scopus ID

2-s2.0-84877767841 (requires institutional sign-in at Scopus site)   69 Citations

Abstract

OBJECTIVES: The objective of this study was to compare usage of computed tomography (CT) scan for evaluation of appendicitis in a children's hospital emergency department before and after implementation of a clinical practice guideline focused on early surgical consultation before obtaining advanced imaging.

METHODS: A multidisciplinary team met to create a pathway to formalize the evaluation of pediatric patients with abdominal pain. Computed tomography scan utilization rates were studied before and after pathway implementation.

RESULTS: Among patients who had appendectomy in the year before implementation (n = 70), 90% had CT scans, 6.9% had ultrasound, and 5.7% had no imaging. The negative appendectomy rate before implementation was 5.7%. In patients undergoing appendectomy in the postimplementation cohort (n = 96), 48% underwent CT, 39.6% underwent ultrasound, and 15.6% had no imaging. The negative appendectomy rate was 5.2%. We demonstrated a 41% decrease in CT use for patients undergoing appendectomy at our institution without an increase in the negative appendectomy rate or missed appendectomy. The results were even more striking when comparing the rate of CT scan use in the subset of patients undergoing appendectomy without imaging from an outside hospital. In these patients, CT scan utilization decreased from 82% to 20%, a 76% reduction in CT use in our facility after protocol implementation.

CONCLUSIONS: Implementation of a clinical evaluation pathway emphasizing examination, early surgeon involvement, and utilization of ultrasound as the initial imaging modality for evaluation of abdominal pain concerning for appendicitis resulted in a marked decrease in the reliance on CT scanning without loss of diagnostic accuracy.

Author List

Russell WS, Schuh AM, Hill JG, Hebra A, Cina RA, Smith CD, Streck CJ

Author

Abigail M. Schuh MD Associate Professor in the Pediatrics department at Medical College of Wisconsin

MESH terms used to index this publication - Major topics in bold

Abdomen, Acute
Adolescent
Appendectomy
Appendicitis
Child
Child, Preschool
Critical Pathways
Delayed Diagnosis
Diagnostic Errors
Education, Medical, Continuing
Emergency Medicine
Female
Guideline Adherence
Hospitals, Pediatric
Hospitals, Urban
Humans
Infant
Infant, Newborn
Length of Stay
Male
Patient Care Team
Pediatrics
Practice Guidelines as Topic
Prospective Studies
Retrospective Studies
Tertiary Care Centers
Tomography, X-Ray Computed
Ultrasonography
Unnecessary Procedures