Imaging stewardship for the diagnosis of pediatric appendicitis: Improved ultrasound performance can decrease...

When ultrasound (US) is non-diagnostic in pediatric patients being evaluated for appendicitis, additional imaging may be required, which incurs delays and increased cost in diagnosis. Our baseline diagnostic rate of US for appendicitis was 27.1 % and was lower for patients with moderate pediatric appendicitis scores (PAS). Due to poor US performance, in our original pathway, patients with moderate PAS underwent magnetic resonance imaging (MRI) initially, resulting in increased emergency department length of stay (ED LOS). Our goal was to improve ultrasound performance so it could be used as first-line imaging for all patients.

In 2022, all appendix ultrasounds performed in 2020 were reviewed for diagnostic accuracy. During this review, scanning technique and ambiguity in the reporting of findings were identified as major contributors to suboptimal ultrasound performance. In August 2022, sonographers participated in focused bowel and appendix US training. In November 2022, a standardized template for ultrasound and MRI was implemented. Due to improved ultrasound performance, in May 2024, the pathway was adapted so that all PAS levels underwent ultrasound initially. We monitored the impact of this pathway change on: 1) need for MR imaging after ultrasound, and 2) clinical team time (CTT, defined as time from patient being placed in an ED room to disposition).

Our diagnostic US rate increased to 56 % from baseline of 27 %. After adjustment of the imaging protocol to an US first approach for all patients as opposed to high PAS scores only, we did not see an increase in the percentage of patients requiring axial imaging after ultrasound. CTT decreased from 347 to 299 min and imaging cost per patient decreased from $6177.38 to $4812.30 (p < 0.001).

Sonographer training and a standardized template for reporting ultrasound findings can improve appendix ultrasound performance, and in turn reduce ED LOS.