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Cumulative effects of stepwise quality improvement in postoperative care for pediatric complicated appendicitis
Jeannette M Joly1, Erin M Morris2, Krysta M Sutyak3
1Department of Pediatric Surgery, McGovern Medical School at UTHealth Houston and Children's Memorial Hermann Hospital, Houston, TX, USA; Center for Surgical Trials and Evidence-Based Practice (CSTEP), McGovern Medical School at UTHealth Houston, Houston, TX, USA. Electronic address: https://twitter.com/jeannettemjoly.
Insights
Stepwise quality improvement (QI) in pediatric appendicitis care reduced postoperative imaging, infections, and hospital stays. Further QI is needed to address a rise in readmissions for surgical site infections.
Area of Science:
- Pediatric Surgery
- Quality Improvement Science
- Healthcare Management
Background:
- Complicated appendicitis in children necessitates effective postoperative care strategies.
- Quality improvement (QI) initiatives aim to optimize patient outcomes and resource utilization.
- Stepwise implementation of QI protocols can lead to cumulative benefits in surgical patient management.
Purpose of the Study:
- To evaluate the cumulative impact of phased quality improvement (QI) interventions on postoperative care for pediatric complicated appendicitis.
- To assess changes in key clinical outcomes and resource utilization following sequential QI efforts.
Main Methods:
- Retrospective analysis of 863 pediatric patients with complicated appendicitis from July 2019 to June 2025.
- Comparison of outcomes before (pre-QI), between (inter-QI), and after (post-QI) two distinct QI implementation phases (postoperative imaging and discharge criteria).
- Statistical analysis using univariate and multivariate regression models to compare baseline and endpoint patient cohorts.
Main Results:
- The post-QI group showed significant reductions in postoperative imaging (21% vs 10%) and organ space surgical site infections (OS-SSIs) (18% vs 7.8%) during index hospitalization.
- Lengths of hospital stay were significantly shorter in the post-QI group (median 3 days vs 4 days).
- While 30-day readmissions and OS-SSIs showed no significant difference, a trend towards increased readmissions for OS-SSIs was observed post-QI.
Conclusions:
- Cumulative stepwise quality improvement effectively reduced index hospitalization resource use and complications like OS-SSIs in pediatric appendicitis.
- Shorter lengths of stay were achieved without compromising 30-day outcomes like emergency department visits or readmissions.
- An observed increase in readmissions for OS-SSIs suggests a potential shift in diagnosis burden, highlighting areas for continued quality improvement efforts.
Purpose:
This study evaluates the cumulative effect of stepwise quality improvement (QI) in postoperative care for pediatric complicated appendicitis.
Methods:
A retrospective study was conducted of pediatric patients with complicated appendicitis (7/2019-6/2025). Demographics, hospitalizations, and 30-day outcomes were collected. Initial QI (7/2022) focused on postoperative imaging. Second QI (9/2023) focused on discharge criteria. Patients were treated before (pre-QI), between (inter-QI), or after QI efforts (post-QI). Univariate and multivariate regression models compared the first year of pre-QI patients (baseline) to the last year of post-QI patients (endpoint).
Results:
Overall, 863 patients were treated: 390 (45%) pre-QI, 212 (25%) inter-QI, 261 (30%) post-QI. Patients were median age 10 years (IQR:7.0-13.3) and 65% male. Baseline (131) and endpoint (128) patients were similar in age (10 years, IQR: 7-13; p = 0.31) and sex (63% male; p = 0.13). During index hospitalization, fewer endpoint patients had postoperative imaging (21% vs 10%; p = 0.03) and organ space surgical site infections (OS-SSIs) (18% vs 7.8%; p = 0.04); drainage procedures were fewer though not significantly (14% vs 6.3%; p = 0.10). Additionally, endpoint lengths-of-stay were shorter (4 days [IQR:3-5.5] vs 3 [IQR:2-5]; p < 0.01). At 30 days, baseline and endpoint patients were similar in emergency department visits (7.6% vs 1.6%; p = 0.08) and hospital readmissions (11% vs 17%; p = 0.14). Endpoint 30-day OS-SSIs were fewer without reaching statistical significance (28% vs 22%; p = 0.46).
Conclusion:
Cumulative effects of stepwise QI reduced index hospitalization imaging, OS-SSIs, and drainage procedures, and shortened lengths-of-stay. A clinically relevant increase in readmissions for OS-SSIs represents a shift in the burden of diagnosis, providing opportunity for further QI.
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