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Protocol for suspected pediatric appendicitis limits computed tomography utilization
Amy E Wagenaar1, Jun Tashiro1, Bo Wang1
1Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida.
Insights
Implementing an ultrasound-first protocol significantly reduced computed tomography (CT) use for pediatric appendicitis, lowering radiation exposure and costs. This approach enhances diagnostic efficiency while prioritizing patient safety in children
Area of Science:
- Pediatric Imaging
- Abdominal Imaging
- Diagnostic Accuracy
Background:
- Computed tomography (CT) is frequently used for diagnosing appendicitis in children, despite concerns regarding radiation exposure.
- There is a need for alternative imaging strategies to minimize radiation risks in pediatric patients.
- Ultrasound (US) offers a radiation-free imaging option for evaluating suspected appendicitis.
Purpose of the Study:
- To decrease the utilization of CT scans for diagnosing appendicitis in a pediatric hospital setting.
- To implement and evaluate an algorithm prioritizing a 24-hour ultrasound (US) as the primary imaging modality.
- To assess the impact of the US-first protocol on imaging utilization, radiation exposure, and healthcare costs.
Main Methods:
- An ultrasound-based protocol for suspected appendicitis was adopted, with data collected for 12 months prior and 24 months after implementation.
- Imaging test usage and associated charges were analyzed, adjusted per annual appendectomy numbers.
- Continuous training for emergency department staff was provided for over one year post-implementation.
Main Results:
- CT utilization decreased by 42% from FY 2011 to FY 2013 (2.43 to 1.40 CTs per appendectomy).
- Ultrasound use increased by 27% after protocol implementation (4.11 to 5.20 US per appendectomy).
- Average length of hospital stay decreased (2.57 days to 2.15 days), and imaging-related charges per appendectomy were significantly reduced.
Conclusions:
- A protocol-driven workup prioritizing ultrasound significantly reduces CT utilization and radiation exposure in children with suspected appendicitis.
- This strategy also leads to a notable decrease in imaging-related healthcare costs.
- Sustained staff training is crucial for ensuring consistent protocol adherence and maximizing benefits.
Background:
Despite radiation concerns, computed tomography (CT) remains the favored imaging modality at many children's hospitals for appendicitis. We sought to reduce CT utilization for appendicitis in a children's hospital with an algorithm relying on 24-h ultrasound (US) as the primary imaging study.
Materials And Methods:
An US-based protocol for suspected appendicitis was adopted at the end of the fiscal year (FY) 2011. Data were collected for 12 mo before and 24 mo after implementation. Imaging test usage and charges were adjusted per annual number of appendectomies. Training of emergency department staff continued over 1 y after protocol implementation.
Results:
For FY 2011, 644 abdominal CT and 1088 appendix US were ordered, and 249 laparoscopic appendectomies (LAs) were performed. After protocol implementation, FY 2012: 535 CT, 1285 US, and 265 LA were performed; and FY 2013: 330 CT, 1235 US, and 236 LA were performed. Length of stay decreased from before to after protocol (2.57 ± 0.29 versus 2.15 ± 0.11 d), P < 0.001. CTs per appendectomy decreased 42% from FY 2011 to FY 2013 (2.43 versus 1.40, P < 0.001) and 30% from before to after protocol (2.43 versus 1.70, P < 0.001). A corresponding 27% increase in number of US before to after protocol (4.11 versus 5.20 US/appendectomy, P = 0.004) occurred. CT and US charges decreased $2253 and $6633 per appendectomy for FY 2012 and 2013, respectively.
Conclusions:
Protocol-driven workup with US significantly reduced CT utilization, radiation exposure, and imaging-related charges in children with suspected appendicitis. Ongoing training of emergency department staff is required to ensure protocol compliance.
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