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Reducing Computed Tomography Use for Appendicitis Evaluation in a Pediatric Emergency Department: A Multidisciplinary
Jennifer Hockenbury1, Monica E Lopez2, Caroline M Godfrey2
1From the Division of Pediatric Emergency Medicine, University of Louisville, Louisville, Ky.
Insights
A quality improvement initiative successfully reduced computed tomography (CT) use for pediatric appendicitis evaluation from 31.3% to 12.1%. This sustained reduction in CT scans did not negatively affect patient outcomes.
Area of Science:
- Pediatric Surgery
- Radiology
- Quality Improvement Science
Background:
- Appendicitis is a common pediatric surgical emergency.
- Computed tomography (CT) is frequently overused in diagnosing pediatric appendicitis.
- Institutional CT utilization rates exceeded those of peer hospitals.
Purpose of the Study:
- To decrease CT utilization for pediatric appendicitis evaluation from 31.3% to 15% within 12 months.
- Implement a multidisciplinary quality improvement initiative.
Main Methods:
- A quality improvement initiative was conducted in a pediatric emergency department (PED) from September 2021 to October 2022.
- Interventions included a clinical practice guideline, electronic medical record order set for decision support, and standardized ultrasound reporting.
- Data were analyzed using statistical process control charts.
Main Results:
- A total of 2,010 patients were evaluated for appendicitis.
- CT utilization decreased from a baseline of 31.3% to 12.1% and was sustained for 10 months.
- No significant impact was observed on negative pathology appendectomy rates or 72-hour return visits.
Conclusions:
- Quality improvement methodologies can effectively reduce CT utilization in pediatric appendicitis diagnosis.
- Sustained reduction in CT scans is achievable without compromising patient safety or diagnostic accuracy.
Introduction:
Appendicitis is the most common pediatric surgical emergency, and computed tomography (CT) remains an overused diagnostic test for appendicitis. Our institutional rate of CT utilization for suspected appendicitis was higher than in peer children's hospitals, so we aimed to reduce CT utilization during the evaluation of pediatric appendicitis from 31.3% to 15% within 12 months.
Methods:
From September 2021 to October 2022, we conducted a multidisciplinary quality improvement initiative among patients evaluated for appendicitis in the pediatric emergency department (PED). Interventions included standardizing evaluation with a clinical practice guideline, an order set in the electronic medical record for clinical decision support, and radiologist use of an ultrasound report template. The primary measure was the percentage of patients undergoing evaluation for appendicitis who received an abdominal CT scan. Process measures were the timing of surgical consultation and ultrasound report template use. Balancing measures included negative pathology appendectomies and PED return visits within 72 hours with subsequent appendicitis diagnosis. We analyzed data using statistical process control charts and Nelson rules to detect special cause variation.
Results:
We evaluated a total of 2,010 patients for acute appendicitis, with 624 representing baseline encounters with a CT rate of 31.3%. Quality improvement interventions reduced the CT rate to 12.1% sustained for 10 months without impacting the rate of negative pathology appendectomy or PED return visits within 72 hours.
Conclusions:
Quality improvement methodology led to a sustained reduction in CT utilization for patients undergoing evaluation for appendicitis in a PED.
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