The Effect of Point‐of‐care Ultrasonography on Emergency Department Length of Stay and Computed Tomography Utilization in Children With Suspected Appendicitis

Abstract

Objectives: The role of clinician-performed ultrasonography (US) for suspected appendicitis is unclear. Published data conclude that US has high specificity to rule in the diagnosis of appendicitis, with variable sensitivity to rule it out. Newer data suggest that point-of-care (POC) US may have similar test characteristics. Our objective was to evaluate the effect of POC US in children with suspected appendicitis and its effect on emergency department (ED) length of stay (LOS) and computed tomography (CT) utilization.Methods: This was a prospective observational convenience sample of children with suspected appendicitis requiring imaging evaluation that adhered to the Standards for the Reporting of Diagnostic accuracy studies (STARD) criteria. Outcomes were determined by operative or pathology report in those who had appendicitis, and 3-week phone follow-up in those patients who were nonoperative. Differences in ED LOS were analyzed by one-way analysis of variance (ANOVA) between patients who received dispositions after POC US, radiology US, or CT. Test performance characteristics were calculated for all imaging modalities.Results: Among 150 enrolled patients, 50 had appendicitis (33.3%). There were no missed cases of appendicitis in discharged patients at 3-week phone follow-up, nor negative laparotomies in those who went to the operating room. Those who had dispositions after POC US (n = 25) had a significantly decreased mean ED LOS (154 minutes, 95% confidence interval [CI] = 115 to 193 minutes) compared with those requiring radiology US (288 minutes, 95% CI = 257 to 319 minutes) or CT scan (487 minutes; 95% CI = 434 to 540 minutes). Baseline CT rate was 44.2% (95% CI = 30.7% to 57.7%) prior to study start and decreased to 27.3% (95% CI = 20.17% to 34.43%) during the study. CTs were avoided in four patients with conclusive POC US results and inconclusive radiology US results. The sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for POC US were 60% (95% CI = 46% to 72%), 94% (95% CI = 88% to 97%), 10 (95% CI = 4 to 23), and 0.4 (95% CI = 0.3 to 0.6). For radiology US they were 63% (95% CI = 48% to 75%), 99% (95% CI = 94% to 99%), 94 (95% CI = 6 to 1,500), and 0.4 (95% CI = 0.3 to 0.6); and for CT they were 83% (95% CI = 58% to 95%), 98% (95% CI = 85% to 99%), 45 (95% CI = 3 to 707), and 0.2 (95% CI = 0.05 to 0.5).Conclusions: It may be feasible to reduce ED LOS and avoid CT scan when using POC US to evaluate children with suspected appendicitis. Test characteristics for POC US have high specificity to rule in appendicitis, similar to radiology US. Addition of POC US prior to sequential radiology imaging was safe, without missed cases of appendicitis or negative laparotomies.

Development and validation of an ultrasound scoring system for children with suspected acute appendicitis

“…3 Frequency of surgically proven appendicitis for each Appy-Score stratum pre-and post-implementation. The numerical percentage value of each bar is given above the bar and the P-value for comparisons between percentages pre-and post-implementation are given for each Appy-Score stratum [14][15][16]. A barrier to more universal adoption of US as a first-line imaging exam for suspected pediatric appendicitis is the perception of increased variability related to provider interpretation.…”

National specialty trends in billable diagnostic ultrasound in the ED: analysis of Medicare claims data

“…In addition, the appropriate application of ultrasound in the ED setting can decrease length of stay and improve patient satisfaction [13][14][15][16]. In at least some centers, when emergency physicians directly perform and interpret ultrasound examinations, they achieve faster examination times and increased imaging access at off-hours when radiology-performed ultrasound may not be available [5,[17][18][19][20][21]. To this end, emergency physicians have been actively promoting the expansion of ultrasound services by the specialty by incorporating basic ultrasonography training into residency programs, creating dedicated emergency ultrasound fellowships, and allocating funds toward the acquisition of ultrasound equipment [22,19,[23][24][25]20,26,21].…”

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

“…Sivitz et al [28], with 264 POCUS studies by PEM fellows and attendings, found a sensitivity of 85 % (95 % CI 75–95), specificity of 93 % (85–100), positive likelihood ratio of 11.7 (6.9–20), and negative likelihood ratio of 0.17 (0.1–0.28). Elikashvili et al [29], looking at 150 patients also demonstrated the specificity of PEM-performed POCUS to be 94 % (95 % CI 88–97), indicating that a positive POCUS exam can be acceptable as a rule-in study. They also demonstrated a significantly decreased length of stay for patients with disposition by POCUS compared to radiology (154–288 min) without any cases of missed appendicitis.…”