Development of a Clinical Decision Support System for Pediatric Abdominal Pain in Emergency Department Settings Across Two Health Systems Within the HCSRN

Abstract

Background: Appendicitis is a common surgical emergency in children, yet diagnosis can be challenging. An electronic health record (EHR) based, clinical decision support (CDS) system called Appy CDS was designed to help guide management of pediatric patients with acute abdominal pain within the Health Care Systems Research Network (HCSRN). Objectives: To describe the development and implementation of a clinical decision support tool (Appy CDS) built independently but synergistically at two large HCSRN affiliated health systems using well-established platforms, and to assess the tool’s Triage component, aiming to identify pediatric patients at increased risk for appendicitis. Results: Despite differences by site in design and implementation, such as the use of alerts, incorporating gestalt, and other workflow variations across sites, using simple screening questions and automated exclusions, both systems were able to identify a population with similar appendicitis rates (11.8 percent and 10.6 percent), where use of the full Appy CDS would be indicated. Discussion: These 2 HCSRN sites designed Appy CDS to capture a population at risk for appendicitis and deliver CDS to that population while remaining locally relevant and adhering to organizational preferences. Despite different approaches to point-of-care CDS, the sites have identified similar cohorts with nearly identical background rates of appendicitis. Next Steps: The full Appy CDS tool, providing personalized risk assessment and tailored recommendations, is undergoing evaluation as part of a pragmatic cluster randomized trial aiming to reduce reliance on advanced diagnostic imaging. The novel approaches to CDS we present could serve as the basis for future ED interventions.

Automated Retrospective Calculation of the EDACS and HEART Scores in a Multicenter Prospective Cohort of Emergency Department Chest Pain Patients

“…Smoker in past 90 days (%) 12 (12)(13) Family history of premature coronary disease (%) 20 (19)(20)(21) Body mass index ≥ 30 kg/m 2 (%) 37 (37-38) Symptoms Diaphoresis (%) 11 (10)(11)(12) Radiating pain (%) 25 (24)(25)(26) Pain worse with palpation (%) 17 (16)(17)(18) Pain worse with inspiration (%) 16 (15)(16) Exertional symptoms (%) 15 (14)(15) Sharp or stabbing pain (%) 27 (26)(27) Nausea or vomiting (%) 15 (14)(15)(16) Crescendo and continuous EDACS score, respectively, corresponding to a kappa of 0.73 and an ICC of 0.87 in our study. Taken together, these findings support the validity of the automated retrospective risk determination approach presented herein.…”

“…Prospective risk score data were collected via a Webbased eCDS interface nested within the EHR containing separate modules for specific clinical use cases; the underlying structure of this eCDS interface (referred to herein as RISTRA, for RIsk STRAtification) has been previously reported for several other use cases. 17,18 Clinicians were reminded upon eCDS activation that patients were appropriate for the RISTRA chest pain module if all three of the following criteria were satisfied: 1) age ≥ 18 years, 2) chief complaint of chest pain or chest discomfort, and 3) clinical concern for acute coronary syndrome (ACS). RISTRA imported relevant structured data from the EHR, allowed the clinician to modify these data if deemed necessary (e.g., adding or removing risk factors), and required input of subjective data elements, such as pain characteristics and ECG interpretation, in a multiple-choice fashion.…”

Diagnostic Performance of Emergency Physician Gestalt for Predicting Acute Appendicitis in Patients Age 5 to 20 Years

“…This larger investigation consisted of a pre–post cluster‐randomized trial of providing CDS with the pediatric Appendicitis Risk Calculator (pARC) score to providers. Detailed implementation methods of the larger study are reported elsewhere …”

“…The age range, with an upper limit of 20 years, was chosen based on the inclusion criteria of the parent study. Exclusion criteria included abdominal trauma, known appendicitis or history of appendectomy, current pregnancy, or other uncommon chronic or confounding conditions described previously . To ensure that gestalt assessment was not influenced by imaging results, patients were excluded if enrollment occurred after ordering advanced abdominal imaging (US or CT).…”

“…Negative appendectomy was defined as an appendectomy without a confirmed diagnosis of appendicitis based on operative or pathology notes. Perforation was defined as perforated appendicitis confirmed by operative and pathology notes …”