Quality Assurance and Performance Improvement Project for Suspected Appendicitis

Abstract

Introduction: Considerable variability exists in the diagnosis and management of acute appendicitis, affecting both quality and costs of care. This prospective cohort study aimed to decrease unnecessary radiological investigations, standardize radiological imaging, avoid unnecessary hospital admissions, and decrease our institution rate of negative appendectomy. Methods: A multidisciplinary appendicitis care pathway was implemented. This pathway involved the use of the Pediatric Appendicitis Score, standardization of ultrasound reporting, and risk stratification to determine patient disposition. Patients were prospectively enrolled in the pathway and compared a preimplementation retrospective cohort. Results: We included 235 patients in this study that took place between February 2017 and January 2018. An 88.5% pathway adherence rate for appropriate referral for ultrasounds, an 84% compliance rate for correct risk stratification, and the need for a surgical consult were achieved. After implementation, standardization of ultrasound (U/S) reporting increased from 0% to 78%. The rate of computed tomography utilization decreased from 7.3% to 4.7%. An appendectomy was completed in 68 (29%) of patients. There was only 1 (1.5%) negative appendectomy, compared to the prepathway institutional negative appendectomy rate of 4%. Conclusion: The implementation of a standardized, evidence-based, appendicitis care pathway has the potential to improve quality of care by reducing negative appendectomies, unnecessary computed tomography scans, and unnecessary hospital admissions. The participation of the emergency and diagnostic imaging departments is critical to the successful implementation of this quality improvement measure. This simple, effective model can be easily implemented at other centers to improve the care of children.

An Advanced Nursing Directive for Children With Suspected Appendicitis: Protocol for a Quality Improvement Feasibility Study

“…Two prior studies [ 18 , 19 ] with similar concepts served as the basis for this integrative study. The authors involved with the studies have also served as collaborators for this study (GT, HF).…”

“…Our study adds additional outcomes such as patient satisfaction and time to US to further understand the effectiveness of this directive in quality of care and diagnostic efficiency. Another study [ 19 ] that was conducted at our institution examined the implementation of a standardized appendicitis care pathway for ED physicians. This study found that this process could reduce negative appendectomies, unnecessary computed tomography scans, and unnecessary hospital admissions.…”

“…This novel AND was designed in collaboration with physicians, allied health care workers, members of our institution’s family council, and hospital management leaders. This project was developed to build on a prior successful appendicitis QI project from our institution [ 19 ], which was a clinical pathway that assisted physicians in risk stratification of patients with suspected appendicitis after US completion to expedite disposition.…”

Reduced Computed Tomography for Appendicitis in Children after Implementation of Next-day Surgery Clinic Follow-up

“…7 Others have described using a limited right lower quadrant MRI to reduce ionizing radiation exposure. 8,9 However, these gains in reduction of CT use resulted in increased utilization of MRI, longer ED length of stay (over 5 hours), 10 increased in-ED surgical consultation (70%), 11 and high rates of admission (above 50%). 2 These authors and others 13 have recommended follow-up for undifferentiated abdominal pain, yet none with pediatric surgeons.…”

“…These studies emphasize the selective use of US, resulting in reduced CT utilization. 2,[10][11][12][13] Recent studies have successfully reduced CT rates in children evaluated for suspected appendicitis with diagnostic protocols within single institutions 10,11 and in regional care systems of community hospitals. 12…”