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Evaluation of a novel pediatric appendicitis pathway using high- and low-risk scoring systems
Ross J Fleischman1, Miranda K Devine, Marie-Annick N Yagapen
1From the *Department of Emergency Medicine, Oregon Health and Science University; and †Division of Pediatric Surgery, Kaiser Permanente Northwest, Portland, OR.
Insights
A new pathway for pediatric appendicitis shows good sensitivity for ruling out the condition in low-risk patients. However, experienced provider judgment remains superior for high-risk cases.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Pathway Development
- Diagnostic Test Characteristics
Background:
- Appendicitis is a common surgical emergency in children, requiring accurate and timely diagnosis.
- Existing diagnostic approaches can lead to delays, unnecessary imaging, and hospital admissions.
- Development of standardized clinical pathways aims to improve diagnostic accuracy and resource utilization.
Purpose of the Study:
- To evaluate the test characteristics of a novel clinical pathway for diagnosing pediatric appendicitis.
- To assess the pathway's impact on emergency department (ED) length of stay, imaging utilization, and admission rates.
- To compare pathway performance against experienced provider judgment.
Main Methods:
- Prospective enrollment of children (3-18 years) with suspected appendicitis.
- Utilized validated low- and high-risk scoring systems based on history, physical exam, and white blood cell count.
- Retrospective analysis of patient visits before and after pathway implementation.
Main Results:
- The low-risk criteria demonstrated high sensitivity (96.9%) for ruling out appendicitis.
- High-risk criteria showed moderate sensitivity (75.3%) and specificity (75.2%).
- No significant difference in ED length of stay or admission rates was observed post-implementation.
- Computed tomography (CT) utilization decreased significantly after pathway implementation (12.7% vs 6.9%).
Conclusions:
- The low-risk criteria effectively identify children unlikely to have appendicitis.
- High-risk criteria can assist in guiding surgical referral or admission decisions.
- The pathway did not surpass the diagnostic accuracy of experienced clinicians.
Objectives:
This study aimed to determine the test characteristics of a pathway for pediatric appendicitis and its effects on emergency department (ED) length of stay, imaging, and admissions.
Methods:
Children age 3 to 18 years with suspicion for appendicitis at 1 tertiary care ED were prospectively enrolled, using validated low- and high-risk scoring systems incorporating history, physical examination, and white blood cell count. Low-risk patients were discharged or observed in the ED. High-risk patients were admitted. Those meeting neither low-risk nor high-risk criteria were evaluated by surgery, with imaging at their discretion. Chart review or telephone follow-up was conducted 2 weeks after the visit. A retrospective study before and after was also performed. Charts of a random sample of patients evaluated for appendicitis in the 8 months before and after the pathway implementation were reviewed.
Results:
Appendicitis was diagnosed in 65 of 178 patients. Of those with appendicitis, 63 were not low-risk (sensitivity, 96.9%; specificity, 40.7%). The high-risk criteria had a sensitivity of 75.3% and specificity of 75.2%. We reviewed 292 visits before and 290 after the pathway implementation. Emergency department length of stay was similar (253 minutes before vs 257 minutes after, P = 0.77). Computed tomography was used in 12.7% of visits before and 6.9% of visits after (P = 0.02). Use of ultrasound was not significantly different (47.3% vs 53.7%). Admission rates were not significantly different (45.5% vs 42.7%).
Conclusions:
The low-risk criteria had good sensitivity in ruling out appendicitis. The high-risk criteria could be used to guide referral or admission. Neither outperformed the a priori judgment of experienced providers.
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