BackgroundAbdominal computed tomography scan (CT) is the preferred radiographic study for the diagnosis of appendicitis in the United States, while radiologist-operated ultrasound (US) is often used in Israel. This comparative international study evaluates the performance of CT vs. US in the evaluation of acute appendicitis.MethodsA retrospective chart analysis was conducted at two tertiary care teaching hospitals, one in each country. Adult patients (age 18-99) with an Emergency Department (ED) working diagnosis of appendicitis between 1 January 2005 and 31 December 2006 were reviewed. Included patients had at least one imaging study, went to the OR, and had documented surgical pathology results.ResultsOf 136 patients in the United States with the ED diagnosis of appendicitis, 79 met inclusion criteria for the CT cohort. Based on pathology, CT had a sensitivity of 100% (95% CI 95.4-100%). The negative appendectomy rate in patients with positive CT was 0%. Total median ED length of stay was 533 min [IQR (450-632)] and median time from CT order to completion was 184 min [IQR (147-228)]. Of 520 patients in Israel, 197 were included in the US cohort. Based on final pathology, US had a sensitivity of 68.4% (95% CI 61.2-74.8%). The negative appendectomy rate in patients with positive US was 5.5%. The median ED length of stay for these patients was 387 min [IQR (259-571.5)]. Of the patients, 23.4% had subsequent CT scans. Median time from US order to completion was 20 min [IQR (7-49)]. Both time values were p < 0.001 when compared with CT. We furthermore calculate that a "first pass" approach of using US first, and then performing a confirmatory CT scan in patients with negative US, would have saved an average of 88.0 minutes per patient in the United States and avoided CT in 65% of patients.ConclusionsRadiologist-operated US had inferior sensitivity and positive predictive value when compared with CT, though was significantly faster to perform, and avoided radiation and contrast in a majority of patients. A "first-pass" approach using US first and then CT if US is not diagnostic may be desirable in some institutions.

Admission handoff is a high-risk component of patient care. Previous studies have shown that a standardized physician electronic signout ("eSignout") may improve ED-to-inpatient handoff safety and efficiency in teaching hospitals. This model has not yet been studied in non-teaching hospitals. The objectives of the study were to determine the efficiency of an eSignout platform at a community affiliate hospital by comparing ED length of stay (LOS) for a 5-month period before and after implementation and to compare the quality assurance (QA) events among admitted patients for the same time period. A retrospective, interventional study was conducted with the main outcome measures including ED LOS with calculation of 95% CI, mean comparison (t test), and number of QA events before and after implementation of the eSignout model. Prior to eSignout implementation, 1045 patients were admitted [mean ED LOS 330.0 min (95% CI 318.6-341.4)]. Following implementation, 1106 patients were admitted [mean ED LOS 338.9 min (95% CI 327.4-350.4, p = 0.2853)]. Nine pre-implementation QA events and six post-implementation events were identified. Use of a physician eSignout in a non-teaching hospital had no statistically significant effect on ED LOS for the admitted patients. The effect of an electronic interdepartmental handoff tool for patient safety and clinical operations in the non-teaching setting is unclear.

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