CT Scan Utilization Decreases With Implementation of a Clinical Pathway for Children With Suspected Acute
Emily Barricelli1, Julia N Lo Cascio1, Ashley Noiman2
1NYU Grossman Long Island School of Medicine.
Insights
A new clinical pathway significantly reduced computed tomography (CT) scan use for pediatric appendicitis diagnosis. This approach prioritized ultrasound, decreasing CT scans from 39% to 22% and improving emergency department efficiency.
Area of Science:
- Pediatric Surgery
- Diagnostic Imaging
- Healthcare Quality Improvement
Background:
- The National Surgical Quality Improvement Program-Pediatric (NSQIP-P) guidelines recommend limiting computed tomography (CT) scans to under 25% for suspected pediatric appendicitis.
- Overutilization of CT scans in children raises concerns regarding radiation exposure and healthcare costs.
Purpose of the Study:
- To implement and evaluate a multidisciplinary pediatric appendicitis clinical pathway aimed at reducing CT scan utilization.
- To assess the impact of the pathway on diagnostic imaging choices and emergency department length of stay (LOS).
Main Methods:
- A local cohort study reviewed appendicitis cases in patients under 19 years old from 2021 to 2023.
- A clinical pathway was implemented using Plan-Do-Study-Act cycles, emphasizing ultrasound as the primary imaging modality.
- Statistical Process Control charts and Six Sigma rules were used to analyze variations and pathway effectiveness.
Main Results:
- Ultrasound was utilized as first-line imaging in over 90% of cases.
- CT scan utilization decreased from 39% to 22% over the study period.
- Emergency department LOS decreased from an average of 538 to 435 minutes; non-diagnostic ultrasounds decreased from 35% to 20%.
Conclusions:
- Implementation of a pediatric appendicitis clinical pathway successfully reduced CT scan utilization.
- The pathway optimized diagnostic imaging strategies and improved patient flow within the emergency department.
Objectives:
The National Surgical Quality Improvement Program-Pediatric (NSQIP-P) recommends reducing computed tomography (CT) scan use to <25% in children with suspected appendicitis. Our multidisciplinary team developed a pediatric appendicitis clinical pathway that emphasizes the use of ultrasound as first-line imaging and reserves CT for patients with both non-diagnostic ultrasounds and agreement from pediatric emergency medicine and surgery teams.
Methods:
For this local study, all cases of patients aged younger than 19 years who were diagnosed with appendicitis from 2021 to 2023 were reviewed, with emergency department (ED) length of Stay (LOS) as a balancing measure. A series of Plan-Do-Study-Act cycles was used to implement the clinical pathway and to involve multiple teams. A Statistical Process Control chart was generated and possible special cause variations were analyzed using Six Sigma rules.
Results:
Ultrasound was the first-line imaging in over 90% of total cases. However, CT utilization steadily decreased from 39% to 22% by the end of our initiative. This was paralleled by a sharp increase in surgical consults before CT scan order from 21% to 41%, and a decrease in non-diagnostic ultrasounds from 35% to 20% across the 3 years of the study. ED LOS decreased from 538 to 435 minutes on average. In addition, 2 patients underwent an MRI in quarter 4 of 2023, demonstrating its potential in the workflow.
Conclusions:
Overall, by implementing a clinical pathway this team was able to significantly reduce CT scan utilization in the diagnosis of pediatric appendicitis.
Study Type And Evidence Level:
Cohort study, level III.
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