Pediatric patients transferred for operative management of appendicitis: are they at a disadvantage?

Clinical Characteristics of Avoidable Patient Transfers for Suspected Pediatric Appendicitis

INTRODUCTION

Pediatric surgical care is becoming increasingly regionalized, often resulting in limited access. Interfacility transfers pose a significant financial and emotional burden to when they are potentially avoidable. Of transferred patients, we sought to identify clinical factors associated with avoidable transfers in pediatric patients with suspected appendicitis.

METHODS

We performed a single-center retrospective study at an academic tertiary referral children's hospital in an urban setting. We included children who underwent interfacility transfer to our center with a transfer diagnosis of appendicitis from July 1, 2021 to June 30, 2023. Encounters were designated as either an appropriate transfer (underwent appendectomy) or an avoidable transfer (did not undergo appendectomy). Encounters treated nonoperatively for complicated appendicitis were excluded. Bivariate analysis was performed using Mann-Whitney test and chi-square tests.

RESULTS

A total of 444 patients were included: 71.2% were classified as appropriate transfers and 28.8% as avoidable transfers. Patients with avoidable transfer were younger compared to those in the appropriate transfer cohort (median age 9 y, interquartile range: 7-13 versus 11 y, interquartile range: 8-14; P < 0.001). Avoidable transfers less frequently presented with the typical symptoms of fever, migratory abdominal pain, anorexia, and nausea/emesis (P = 0.005). Avoidable transfers also reported shorter symptom duration (P = 0.040) with lower median white blood cell count (P < 0.001), neutrophil percentage (P < 0.001), and C-reactive protein levels (P < 0.003). Avoidable transfers more frequently underwent repeat imaging upon arrival (42.9% versus 12.7%, P < 0.001).

CONCLUSIONS

These findings highlight the importance of clinical history in children with suspected appendicitis. Younger patients without typical symptoms of appendicitis, those with a shorter duration of symptoms, and lower serum inflammatory markers may benefit from close observation without transfer.

False Positive Rate Among Pediatric Appendicitis Patients Transferred to a Tertiary Children's Hospital

BACKGROUND

Many patients with suspected appendicitis are initially evaluated at outlying hospitals and then transferred to a tertiary care pediatric hospital for surgical management. We sought to evaluate whether diagnosis prior to transfer provides a reliable basis for direct admission to a pediatric surgery service.

METHODS

Patients transferred during calendar year 2018 with the principal diagnosis of acute appendicitis were compared based on the service accepting the patient: Emergency Department (ED) or Pediatric Surgery (PS). Data were evaluated using Student's t-tests.

RESULTS

Overall patient characteristics were consistent among ED and PS transfers. The number of patients accepted directly to PS underwent significantly more computed tomography (80.2% vs 54.1%, P = .0002). Despite diagnostic "confirmation" with cross-sectional imaging, 14.7% of patients admitted directly to PS were found to be false positives.

CONCLUSION

A significant proportion of patients referred to pediatric hospitals for appendicitis do not require admission or operation. A protocol which encourages cross-sectional imaging before PS evaluation may subject children to unnecessary radiation and still result in non-surgical admissions. Routine ED transfer allows PS evaluation, targeted imaging, and discharge for non-surgical patients. This approach decreases costs for the families whose children received a false positive diagnosis at a referring facility, while preserving inpatient bed availability.

Negative Appendectomies: Evaluating Diagnostic Imaging Techniques at General versus Pediatric Emergency Departments

BACKGROUND

Although appendicitis is the most common pediatric surgical emergency, the path to diagnosis remains equivocal, with utilization of imaging modalities largely institution dependent.

OBJECTIVES

Our objective was to compare imaging practices and negative appendectomy rates between patients transferred from nonpediatric hospitals to our pediatric hospital and primary patients presenting directly to our institution.

METHODS

We retrospectively reviewed all laparoscopic appendectomy cases performed at our pediatric hospital in 2017 for imaging and histopathologic results. Two-sample z-test was used to examine negative appendectomy rates between transfer and primary patients. The negative appendectomy rates of patients who received different imaging modalities were analyzed using the Fisher's exact test.

RESULTS

Of 626 patients, 321 (51%) were transferred from nonpediatric hospitals. The negative appendectomy rate for transfer patients was 6.5% and 6.6% for primary patients (p = 0.99). Ultrasound (US) was the only imaging obtained in 31% of transfer and 82% of primary patients. The negative appendectomy rate of US performed at transfer hospitals compared with our pediatric institution was not significantly different (11% vs. 5%, p = 0.06). Computed tomography (CT) was the only imaging obtained in 34% of transfer and 5% of primary patients. Both US and CT were completed for 17% of transfer and 19% of primary patients.

CONCLUSION

The negative appendectomy rates of transfer and primary patients were not significantly different despite more frequent CT use at nonpediatric facilities. It may be valuable to encourage US utilization at adult facilities given the potential to safely reduce CT use in the evaluation of suspected pediatric appendicitis.

Relationship between the time required for transfer and outcomes in patients with appendicitis: Experience at a tertiary military hospital in South Korea

A few studies have compared patients who were directly admitted with patients who were transferred to a tertiary facility for an appendectomy. However, there have been no reports of an association between the time to transfer and outcome in patients who underwent an appendectomy. As the only tertiary military hospital in South Korea, we occasionally encountered patients who were delayed for transfer due to the military environment. We hypothesize that patients with a longer time to transfer have a worse outcome. This study aimed to evaluate the relationship between the time to transfer and the outcome of patients who underwent an appendectomy.Patients who underwent appendectomy in the tertiary military hospital in South Korea from May 2015 to April 2017 were analyzed retrospectively. The groups were divided by the time for the transfer. Four hours was used as the cut-off point to divide the early and delayed transfer groups. Time from symptom onset to hospitalization, time from diagnosis to surgery, and time from hospitalization to surgery were also analyzed to assess the effect of time for the transfer.A total of 449 patients were analyzed: 293 with direct admission, 110 with early transfer, and 46 with delayed transfer. The time required for transfer was more critical for delaying appendectomy than the time from hospital admission to surgery. There was no difference in outcomes among the groups. When patients were compared according to the perforation, no differences were found in time from hospitalization to surgery, time from diagnosis to surgery, and presence of transfer. Multivariate analysis showed that a greater than 72 hours delay from symptom onset to hospitalization was associated with perforation (odds ratio = 12.61; 95% confidence interval: 3.84-41.40; P < .001).Even if a long transfer time is necessary, an appendectomy can be performed safely if patients were administered antibiotics immediately after diagnosis.