Quality Assurance and Performance Improvement Project for Suspected Appendicitis
Yasser AlFraih1,2,3, Tessa Robinson1,4, Nina Stein2,5
1Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
Insights
Implementing a standardized appendicitis care pathway significantly reduced negative appendectomies and unnecessary imaging in pediatric patients. This evidence-based approach improved care quality and can be adopted by other institutions.
Area of Science:
- Pediatric Surgery
- Quality Improvement
- Healthcare Management
Background:
- Acute appendicitis diagnosis and management show significant variability, impacting care quality and costs.
- Standardizing care pathways is crucial for improving patient outcomes and reducing healthcare expenses.
Purpose of the Study:
- To decrease unnecessary radiological investigations and hospital admissions for acute appendicitis.
- To standardize radiological imaging and reduce the rate of negative appendectomies.
Main Methods:
- A multidisciplinary appendicitis care pathway was implemented, incorporating the Pediatric Appendicitis Score and standardized ultrasound reporting.
- Patient disposition was determined by risk stratification, with prospective enrollment and comparison to a preimplementation cohort.
Main Results:
- Pathway adherence reached 88.5% for appropriate ultrasounds and 84% for risk stratification.
- Standardized ultrasound reporting increased to 78%, while computed tomography utilization decreased from 7.3% to 4.7%.
- The negative appendectomy rate dropped from 4% to 1.5%.
Conclusions:
- A standardized, evidence-based appendicitis care pathway can enhance care quality by reducing negative appendectomies and unnecessary imaging.
- Multidisciplinary collaboration, particularly from emergency and diagnostic imaging departments, is vital for successful implementation.
- This model offers a simple, effective strategy for improving pediatric appendicitis care at other centers.
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.
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