Importance of Compliance Audits for a Pediatric Complicated Appendicitis Clinical Practice Guideline

Clinical practice guidelines (CPG) have been shown to decrease practice variation, reduce resource use, and improve patient outcomes. The purpose of this study was to audit compliance of a pediatric complicated appendicitis CPG to identify areas for continued improvement. A comprehensive complicated appendicitis CPG was implemented in a children's hospital system. Outcomes were compared for 48 months pre- (01/2012 to 12/2015) and 28 months post-implementation (01/2016 to 04/2018). A detailed compliance audit was nested within the post-implementation period in 60 consecutive patients from 11/2017 to 03/2018. Feedback was provided to care providers throughout the audit. Overall, 2370 children with complicated appendicitis were identified (1366 pre-CPG and 1004 post-CPG). The CPG resulted in decrease in mean length of stay from 5.3 days to 4.5 days (p = 0.751), postoperative returns to the system (13.0% to 10.1%, p = 0.030), and readmissions (5.3% to 4.3%, p = 0.237). Central line use decreased from 11.2% to 5.5% (p < 0.001) and antibiotic selection improved from 47.0% to 84.1% (p < 0.001). On audit, only 15% (9/60) had full CPG compliance and 49% (29/60) received recommended antibiotic durations. Compliance increased from 7% to 23% with audit-derived feedback. After stratifying by appendicitis severity, audits resulted in improved antibiotic duration compliance for patients with severe appendicitis (38.1% to 66.7%, p = 0.07) and postoperative ambulation for patients with lower grade disease (37.5% to 83.3%, p = 0.06). Audit cycles on a complicated appendicitis CPG and feedback to providers improved CPG compliance and more granular outcomes of interest.