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An Advanced Nursing Directive for Children With Suspected Appendicitis: Protocol for a Quality Improvement
Hanu Chaudhari1, Michelle Schneeweiss1, Reid Rebinsky1
1Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
Insights
This study pilots an advanced nursing directive (AND) to speed up diagnosis and treatment for pediatric appendicitis. The AND allows nurses to order tests and treatments before physician assessment, aiming to improve emergency department flow.
Area of Science:
- Pediatric Emergency Medicine
- Healthcare Quality Improvement
- Nursing Practice
Background:
- Pediatric appendicitis is a common cause of emergency department visits, often leading to diagnostic delays.
- Current diagnostic and therapeutic processes for pediatric appendicitis are time-consuming.
- The effectiveness of advanced nursing directives (ANDs) in expediting care for pediatric appendicitis requires further investigation.
Purpose of the Study:
- To describe emergency department (ED) patient flow for suspected appendicitis in a pediatric setting.
- To pilot an AND enabling ED nurses to initiate diagnostic and therapeutic orders prior to physician assessment.
- To evaluate the impact of the AND on ED flow metrics and patient/family satisfaction.
Main Methods:
- Retrospective chart review and quality improvement initiative comparing pre- and post-AND implementation metrics.
- Primary outcomes: time to ultrasound, analgesia, blood work results, and disposition.
- Secondary outcomes: patient and caretaker satisfaction surveys; statistical analysis including chi-square and t-tests; variable-controlled run charts.
Main Results:
- Interim data from 3900 screened, 344 enrolled, and 90 directive-treated patients since June 2020.
- Interim results on reduced diagnostic/therapeutic times and satisfaction expected February 2022; final endpoint June 2022.
- The study is ongoing, with preliminary data collection underway.
Conclusions:
- Proposes a novel, evidence-based AND protocol to enhance diagnosis and treatment of pediatric appendicitis.
- This model may establish a standardized international pathway for managing common pediatric and adult emergencies.
- The AND shows potential for improving efficiency and patient care in emergency settings.
Background:
Pediatric appendicitis accounts for an estimated 7% to 10% of abdominal pain cases in the emergency department (ED). The diagnosis is time-consuming, and the investigative process depends on physician assessment, resulting in delays in diagnosis and therapeutic management. The utility of an advanced nursing directive (AND) to expedite this process is unclear and needs further exploration.
Objective:
This study aims to describe key components of ED flow in patients with suspected appendicitis seen at a pediatric ED and pilot a directive that allows ED nurses to perform an order set that includes blood work, urine tests, analgesics, fluids, and an abdominal-pelvis ultrasound prior to physician assessment.
Methods:
This study involves conducting a retrospective chart review alongside a quality improvement initiative to compare key ED flow metrics before and after AND implementation. Primary outcome measures include median time from ED triage assessment to ultrasound completion, analgesia administration, blood work results, and time to disposition (consult or discharge), alongside other key ED flow metrics for suspected appendicitis. Secondary outcomes will involve patient and caretaker satisfaction surveys. Descriptive statistics will be used to summarize the data. For differences in proportions, a chi-square test will be used. The Student t test will be used for continuous variables. A variable-controlled run chart will be performed to assess impact on ED flow metrics. Patient and family satisfaction surveys are administered immediately after the directive encounter and 7 days afterward.
Results:
There are currently 3900 patients who have been screened, 344 patients who have been enrolled, and 90 patients who have received the medical directive since implementation in June 2020. Interim results on reduction of time to diagnostic and therapeutic ED flow parameters and satisfaction surveys are expected to be published in February 2022. The final study endpoint will be in June 2022.
Conclusions:
This study proposes a novel protocol for improving the diagnosis and treatment of suspected pediatric appendicitis through implementation of an evidence-based AND. This model may provide a standardized, international pathway for management of common pediatric and adult emergencies.
International Registered Report Identifier (Irrid):
RR1-10.2196/33158.
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01:29Appendicitis-II: Diagnostic Studies and Management
Diagnosing Appendicitis
It requires a multifaceted approach, starting with a detailed physical examination to pinpoint the location and nature of the pain and identify any associated symptoms. Laboratory tests play a crucial role. A complete Blood Count (CBC) typically reveals leukocytosis (an increased number of...
01:22Appendicitis-I: Introduction
Etiology: Appendicitis can arise from various causes, primarily rooted in the obstruction of the appendix lumen. Factors contributing to this obstruction include fecal accumulation, lymphoid hyperplasia and, in...