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Reducing Postoperative CT Imaging for Children With Complicated Appendicitis: A Pediatric Surgical Quality
Peter Juviler1, Alicia C Greene2, Terry Fisher3
1Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, United States.
Insights
Pediatric hospitals can reduce postoperative CT scans for appendicitis by improving ultrasound use, adhering to imaging protocols, and prioritizing radiation stewardship. These strategies help minimize unnecessary radiation exposure in children.
Area of Science:
- Pediatric Surgery
- Radiology
- Quality Improvement
Background:
- Computed tomography (CT) scanning postoperatively for appendicitis remains common despite efforts to reduce ionizing radiation.
- The Pediatric Surgery Quality Collaborative (PSQC) investigated variations in CT usage among children's hospitals.
Purpose of the Study:
- To identify differences in postoperative CT utilization for complicated appendicitis between high and low-usage children's hospitals.
- To explore factors influencing the decision-making process for postoperative imaging in pediatric appendicitis cases.
Main Methods:
- Analysis of National Surgery Quality Improvement Program Pediatric data from PSQC hospitals (April 2020-March 2021).
- Semi-structured interviews with key stakeholders from 11 hospitals (5 low CT, 6 high CT).
- Qualitative analysis of interview transcripts using the Theoretical Domains Framework (TDF).
Main Results:
- Five TDF domains significantly influenced CT use: skills, beliefs about capabilities, intentions/goals, memory/decision processes, and environment.
- Low-CT hospitals demonstrated trust in ultrasound technicians, prioritized delayed imaging (≥7 days), possessed quality improvement resources, fostered interdisciplinary trust, and emphasized radiation stewardship.
Conclusions:
- Hospitals with extreme variations in postoperative CT use offer insights into effective strategies.
- Key improvement strategies include developing and adhering to imaging protocols, ensuring quality improvement resources, promoting interdisciplinary collaboration, and championing radiation stewardship.
Background:
Despite widespread initiatives to reduce ionizing radiation for appendicitis diagnosis, computed tomography (CT) scanning postoperatively remains common. The Pediatric Surgery Quality Collaborative (PSQC) aimed to identify differences between children's hospitals with high and low postoperative CT usage for complicated appendicitis.
Methods:
Using National Surgery Quality Improvement Program Pediatric data from PSQC children's hospitals, we compared postoperative CT imaging for complicated appendicitis (April 2020-March 2021). Key stakeholders from 11 hospitals (5 low CT utilization, 6 high CT utilization) participated in semi-structured interviews regarding postoperative imaging. Qualitative analysis of transcripts was performed deductively and inductively based on the Theoretical Domains Framework (TDF).
Results:
Five of twelve TDF domains were most prominent in influencing CT use: skills, beliefs about capabilities, intentions/goals, memory and decision processes, and environment. Children's hospitals with lower rates of postoperative CT use tended to: trust and educate the ultrasound technicians; believe US strengths outweigh weaknesses; image no sooner than 7 days postoperatively; have access to sufficient quality improvement resources; maintain trusting relationships between specialties; and prioritize radiation stewardship.
Conclusion:
Hospitals at extremes of postoperative CT use for complicated appendicitis reveal strategies for improvement, which include imaging protocol development and adherence, quality improvement resource availability, interdisciplinary collaboration, and promoting radiation stewardship.
Level Of Evidence:
Level V.
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