An evidenced-based clinical pathway for acute appendicitis decreases hospital duration and cost

Nationwide management of perforated pediatric appendicitis: Interval versus same-admission appendectomy

PURPOSE

Although conservative management followed by readmission for interval appendectomy is commonly used to manage perforated appendicitis, many studies are limited to individual or noncompeting pediatric hospitals. This study sought to compare national outcomes following interval or same-admission appendectomy in children with perforated appendicitis.

METHODS

The Nationwide Readmission Database was queried (2010-2014) for patients <18 years old with perforated appendicitis who underwent appendectomy using ICD9-CM Diagnosis codes. A propensity score-matched analysis (PSMA) utilizing 33 covariates between those with (Interval Appendectomy) and without a prior admission (Same-Admission Appendectomy) was performed to examine postoperative outcomes.

RESULTS

There were 63,627 pediatric patients with perforated appendicitis. 1014 (1%) had a prior admission for perforated appendicitis within one calendar year undergoing interval appendectomy compared to 62,613 (99%) Same-Admission appendectomy patients. The Interval Appendectomy group was more likely to receive a laparoscopic (87% vs. 78% same-admission) than open (13% vs. 22% same-admission; p < 0.001) operation. Patients receiving interval appendectomy were more likely to have their laparoscopic procedure converted to open (5% vs. 3%) and receive more concomitant procedures. PSMA demonstrated a higher rate of small bowel obstruction in those receiving Same-Admission appendectomy while all other complications were similar. Although those receiving Interval Appendectomy had a shorter index length of stay (LOS) and lower admission costs, they incurred an additional $8044 [$5341-$13,190] from their prior admission.

CONCLUSION

Patients treated with interval appendectomy experienced more concomitant procedures and incurred higher combined hospitalization costs while still having a similar postoperative complication profile compared to those receiving same-admission appendectomy for perforated appendicitis.

LEVEL OF EVIDENCE

III.

TYPE OF STUDY

Retrospective Comparative Study.

Diagnostic Accuracy of Suspected Appendicitis: A Comparative Analysis of Misdiagnosed Appendicitis in Children

OBJECTIVE

When evaluating suspected appendicitis, limited data support quality benchmarks for negative appendectomy (NA); none exist for delayed diagnosis of appendicitis (DDA). The objectives of this study are the following: (1) to provide preliminary evidence supporting a quality benchmark for DDA and 2) to compare presenting features and diagnostic evaluations of children with NA and DDA with those with pathology-confirmed appendicitis (PCA) diagnosed during initial emergency department (ED) encounter.

METHODS

Secondary analysis of data from a QI project designed to reduce the use computed tomography when evaluating suspected appendicitis using a case-control design. Patients undergoing appendectomy in an academic tertiary care children's hospital system between January 1, 2015, and December 31, 2016 (n = 1,189) were eligible for inclusion in this case-control study. Negative appendectomy was defined as no pathologic change or findings consistent with a different diagnosis. Delayed diagnosis of appendicitis was defined as patients undergoing appendectomy within 7 days of a prior ED visit for a related complaint. Controls of PCA (n = 150) were randomly selected from all cases undergoing appendectomy.

RESULTS

There were 42 NA (3.5%) and 31 DDA (2.6%). Cases of PCA and NA exhibited similar histories, examination findings, and underwent comparable diagnostic evaluations. Cases of PCA more frequently demonstrated a white blood cell count greater than 10 × 103/μL (85% vs 67%; P = 0.01), a left-shift (77% vs 45%; P < 0.001), and an ultrasound interpretation with high probability for appendicitis (73% vs 54%; P = 0.03). Numerous significant differences in history, examination findings, and diagnostic tests performed existed between cases of PCA and DDA.

CONCLUSIONS

Children with PCA and NA present similarly and undergo comparable evaluations resulting in appendectomy. A 3% to 4% NA rate may be unavoidable given these similarities. Presenting features in DDA significantly differ from those of PCA. An irreducible proportion of appendicitis diagnoses may be delayed.

Techniques of Laparoscopic Appendectomy for Pediatric Appendicitis: How I Do It

Background: Appendicitis is the most common operative emergency in children. As a result of accumulating evidence from randomized trials, observational studies, database work, and meta-analyses, the management of appendicitis in children has been shifting the past 15 years with many new debates emerging. In this article, we review our current management schemes. Methods: We reviewed the current and critical literature relevant to the rationale for our current management. Results: Clinical pathways appear to reduce variation and cost while improving the ability to diagnose and treat the disease. Minimally invasive approaches can be used to treat all forms of appendicitis. Conclusions: The future role of non-operative management deserves ongoing exploration. Refining diagnostic treatment algorithms and enhancing antibiotic stewardship are important moving forward.

Effect of Clinical Decision Support on Diagnostic Imaging for Pediatric Appendicitis: A Cluster Randomized Trial

IMPORTANCE

Appendicitis is the most common pediatric surgical emergency. Efforts to improve efficiency and quality of care have increased reliance on computed tomography (CT) and ultrasonography (US) in children with suspected appendicitis.

OBJECTIVE

To evaluate the effectiveness of an electronic health record-linked clinical decision support intervention, AppyCDS, on diagnostic imaging, health care costs, and safety outcomes for patients with suspected appendicitis.

DESIGN, SETTING, AND PARTICIPANTS

In this parallel, cluster randomized trial, 17 community-based general emergency departments (EDs) in California, Minnesota, and Wisconsin were randomized to the AppyCDS intervention group or usual care (UC) group. Patients were aged 5 to 20 years, presenting for an ED visit with right-sided or diffuse abdominal pain lasting 5 days or less. We excluded pregnant patients, those with a prior appendectomy, those with selected comorbidities, and those with traumatic injuries. The trial was conducted from October 2016 to July 2019.

INTERVENTIONS

AppyCDS prompted data entry at the point of care to estimate appendicitis risk using the pediatric appendicitis risk calculator (pARC). Based on pARC estimates, AppyCDS recommended next steps in care.

MAIN OUTCOMES AND MEASURES

Primary outcomes were CT, US, or any imaging (CT or US) during the index ED visit. Safety outcomes were perforations, negative appendectomies, and missed appendicitis. Costs were a secondary outcome. Ratio of ratios (RORs) for primary and safety outcomes and differences by group in cost were used to evaluate effectiveness of the clinical decision support tool.

RESULTS

We enrolled 3161 patients at intervention EDs and 2779 patients at UC EDs. The mean age of patients was 11.9 (4.6) years and 2614 (44.0%) were boys or young men. RORs for CT (0.94; 95% CI, 0.75-1.19), US (0.98; 95% CI, 0.84-1.14), and any imaging (0.96; 95% CI, 0.86-1.07) did not differ by study group. In an exploratory analysis conducted in 1 health system, AppyCDS was associated with a reduction in any imaging (ROR, 0.82; 95% CI, 0.73- 0.93) for patients with pARC score of 15% or less and a reduction in CT (ROR, 0.58; 95% CI, 0.45-0.74) for patients with a pARC score of 16% to 50%. Perforations, negative appendectomies, and cases of missed appendicitis by study phase did not differ significantly by study group. Costs did not differ overall by study group.

CONCLUSIONS AND RELEVANCE

In this study, AppyCDS was not associated with overall reductions in diagnostic imaging; exploratory analysis revealed more appropriate use of imaging in patients with a low pARC score.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02633735.

Comparing the Cost and Outcomes of Laparoscopic versus Open Appendectomy for Perforated Appendicitis in Children

Although laparoscopic appendectomy (LA) is accepted treatment for perforated appendicitis (PA) in children, concerns remain whether it has equivalent outcomes with open appendectomy (OA) and increased cost. A retrospective review was conducted of patients younger than age 17 years treated for PA over a 12.5-year period at a tertiary medical center. Patient characteristics, pre-operative indices, and postoperative outcomes were analyzed for patients undergoing LA and OA. Of 289 patients meeting inclusion criteria, 86 had LA (29.8%) and 203 OA (70.2%), the two groups having equivalent patient demographics and preoperative indices. Inpatient costs were not significantly different between LA and OA. LA had a lower rate of wound infection (1.2 vs 8.9%, P = 0.017), total parenteral nutrition use (23.3 vs 50.7%, P < 0.0001), and length of stay (5.56 ± 2.38 days vs 7.25 ± 3.77 days, P = 0.0001). There was no significant difference in the rate of postoperative organ space abscess, surgical re-exploration, or rehospitalization. In children with PA, LA had fewer surgical site infections and shorter lengths of hospital stay compared with OA without an increase in inpatient costs.

The Use of Machine Learning Approaches for the Diagnosis of Acute Appendicitis

Acute appendicitis is one of the most common emergency diseases in general surgery clinics. It is more common, especially between the ages of 10 and 30 years. Additionally, approximately 7% of the entire population is diagnosed with acute appendicitis at some time in their lives and requires surgery. The study aims to develop an easy, fast, and accurate estimation method for early acute appendicitis diagnosis using machine learning algorithms. Retrospective clinical records were analyzed with predictive data mining models. The predictive success of the models obtained by various machine learning algorithms was compared. A total of 595 clinical records were used in the study, including 348 males (58.49%) and 247 females (41.51%). It was found that the gradient boosted trees algorithm achieves the best success with an accurate prediction success of 95.31%. In this study, an estimation method based on machine learning was developed to identify individuals with acute appendicitis. It is thought that this method will benefit patients with signs of appendicitis, especially in emergency departments in hospitals.

Ethical dilemmas in providing acute medical care at home for children: a survey of health professionals

OBJECTIVE

Acute care at home is increasing. We aimed to determine the views of healthcare professionals on the ethics of providing home care and compare the impact of situational changes on their opinions.

DESIGN

An analysis of opinions of home healthcare professionals.

SETTING

The Australasian Hospital-in-the-Home Annual Conference, November 2017.

PARTICIPANTS

Eighty physicians, nurses and allied health staff who provide acute care for children and adults at home.

METHODS

Clinical scenarios were presented about a 14 years old receiving intravenous antibiotics at home via an established home care pathway, and participants were asked to vote manually on whether providing home care was ethical.

MAIN OUTCOMES

The proportions of healthcare professionals who believed that provision of home care was ethical in different situations.

RESULTS

For each question the response rate ranged from 71% to 100%. While the provision of acute home care was deemed ethical by the majority (77/80, 96%), this decreased when other factors were involved such as domestic violence (37/63 (59%) OR 0.06, 95% CI 0.02 to 0.20, p<0.001) and parental reluctance (28/67 (42%) OR 0.02, 95% CI 0.008 to 0.09, p<0.001). The age of consent affected the proportion who considered home care ethical against parental wishes: 16 years (48/58, 83%) versus 14 years (33/53, 52%) OR 4.4, 95% CI 1.9 to 10.1, p<0.001. The lowest proportion to consider home care ethical (16%) was when home care was deemed less than hospital care.

CONCLUSIONS

Home healthcare providers are supportive of the ethics of providing acute care at home for children, although differ among themselves with situational complexities. Applying the tenets of medical ethics (autonomy, non-maleficence, beneficence and justice) can provide insights into the factors that may influence opinions.

Prospective Validation of the APPEND Clinical Prediction Rule for Appendicitis: A Cohort Study

BACKGROUND

Right iliac fossa (RIF) pain is a common referral to general surgery as acute appendicitis is one of the most common underlying diagnoses. The clinical diagnosis of appendicitis continues to challenge clinicians. Clinical prediction rules (CPRs) are one method used to improve diagnostic accuracy and reduce negative appendicectomy rates. The APPEND score is a novel CPR that was developed at Middlemore Hospital.

AIM

To prospectively evaluate the performance of the APPEND CPR within a pathway dedicated to the management of RIF pain.

METHODS

A comparative cohort study of the clinical pathway incorporating the APPEND CPR pain was performed from January to July 2016. This was compared to the retrospective cohort used to develop the APPEND CPR. The primary end point was negative appendicectomy rate.

RESULTS

The negative appendicectomy rate in the prospective cohort was 9.2% (95% CI: 5.3%, 13.2%) compared to 19.8% (CI 16.2, 23.4%) in the retrospective cohort that did not use the APPEND CPR. After adjusting for multiple variables, the odds ratio of a negative appendicectomy was 2.33 times higher (95% CI; 1.26, 4.3, P value 0.007) in the retrospective cohort compared to the prospective cohort. An APPEND score of ≥5 was 87 % specific for ruling in appendicitis (PPV 94%) and a score of ≥1 was 100% sensitive in ruling out appendicitis (NPV 100%).

CONCLUSIONS

In a comparative cohort study of an RIF pain pathway incorporating the APPEND CPR, the rate of negative appendicectomy showed a significant reduction by more than 50%.

Impact of Child Abuse Clinical Pathways on Skeletal Survey Performance in High-Risk Infants

OBJECTIVE

We sought: 1) to examine the association between the presence of a child abuse pathway and the odds of skeletal survey performance in infants with injuries associated with high risk of abuse and 2) to determine whether pathway presence decreased disparities in skeletal survey performance.‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬ METHODS: In this retrospective study of children <1 year diagnosed with injuries associated with high risk of abuse at hospitals in the Pediatric Hospital Information System, information regarding the presence of a child abuse pathway was collected via survey. We examined whether the presence of a child abuse pathway was associated with the odds of obtaining a skeletal survey, adjusting for patient-level factors.‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬ RESULTS: Among 2085 included cases 55% were male, 69% had public insurance, and 64% were white. Fifty-eight percent presented to a hospital when a pathway was present. Skeletal surveys were performed in 86% of children between 0 and 5 months and 73% of children 6-11 months. In our regression model, adjusted for covariates (age, race, insurance, injury) the presence of a child abuse pathway in a hospital was associated with greater odds of skeletal survey performance (odds ratio [OR], 1.46, 95% confidence interval [CI], 1.02-2.08). Children with public insurance had greater odds of receiving a skeletal survey (OR 2.75, 95% CI 2.11-3.52) despite presence of pathway.‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬ CONCLUSIONS: When a child abuse clinical pathway was present, children with injuries associated with a high risk of abuse had a greater odds of receiving a skeletal survey. Differences in skeletal survey performance exist between infants with public vs. private insurance regardless of a pathway.

Ruling out Appendicitis in Children: Can We Use Clinical Prediction Rules?

PURPOSE

To identify available clinical prediction rules (CPRs) and investigate their ability to rule out appendicitis in children presenting with abdominal pain at the emergency department, and accordingly select CPRs that could be useful in a future prospective cohort study.

METHODS

A literature search was conducted to identify available CPRs. These were subsequently tested in a historical cohort from a general teaching hospital, comprising all children (< 18 years) that visited the emergency department between 2012 and 2015 with abdominal pain. Data were extracted from the electronic patient files and scores of the identified CPRs were calculated for each patient. The negative likelihood ratios were only calculated for those CPRs that could be calculated for at least 50% of patients.

RESULTS

Twelve CPRs were tested in a cohort of 291 patients, of whom 87 (29.9%) suffered from acute appendicitis. The Ohmann score, Alvarado score, modified Alvarado score, Pediatric Appendicitis score, Low-Risk Appendicitis Rule Refinement, Christian score, and Low Risk Appendicitis Rule had a negative likelihood ratio < 0.1. The Modified Alvarado Scoring System and Lintula score had a negative likelihood ratio > 0.1. Three CPRs were excluded because the score could not be calculated for at least 50% of patients.

CONCLUSION

This study identified seven CPRs that could be used in a prospective cohort study to compare their ability to rule out appendicitis in children and investigate if clinical monitoring and re-evaluation instead of performing additional investigations (i.e., ultrasound) is a safe treatment strategy in case there is low suspicion of appendicitis.

Factors affecting non-operative management of uncomplicated appendicitis in children: Should laparoscopic appendectomy be immediate, interval, or emergency?

INTRODUCTION

We conducted a prospective non-randomized comparison of children with uncomplicated appendicitis treated either by primary laparoscopic appendectomy (PLA) or by non-operative management (NOM) followed by interval laparoscopic appendectomy (ILA) if NOM was successful or emergency laparoscopic appendectomy (ELA) if NOM was unsuccessful.

METHODS

Before 2015, all patients with uncomplicated appendicitis underwent PLA using a standard three-port technique. Postoperatively, piperacillin/tazobactam was administered until the white blood cell count was less than 10 000/μL and patients were afebrile. Since 2015, in cases of uncomplicated appendicitis, intravenous analgesia has been administered once after assessment, and then NOM has been immediately employed, with repeat doses of piperacillin/tazobactam administered every 8 h after admission. We have also used standard management cut-off criteria to determine when to perform laparoscopic appendectomy after NOM: if NOM fails, ELA is performed within 6 h, and if NOM is successful, ILA is planned.

RESULTS

There were 103 eligible subjects for this study. Eleven cases of suspected complicated appendicitis were excluded, leaving 34 PLA cases and 58 NOM cases. After NOM, 27 patients were treated with ILA and 31 with ELA. There was one recurrence after successful NOM, and in two cases, patients' parents refused to consent to ILA after successful NOM. There were more perforations and significantly more residual abscesses in ELA than in PLA. Operative time and postoperative hospitalization were significantly longer among ELA patients than among PLA patients, and operative time was significantly shorter during ILA than in PLA.

CONCLUSION

Further evaluation is required to confirm which patients will benefit most from NOM and what role PLA has in treating uncomplicated appendicitis.

Improving the day case rate for laparoscopic cholecystectomy via introduction of a dedicated clinical pathway

Day case laparoscopic cholecystectomy is a safe and economical procedure. However, successful discharge on the same day of the procedure has been difficult to achieve at our institution. This study introduced a standardised anaesthetic pathway aiming to increase same day discharges. This led to an overall increase in same day discharges from 42.0% to 54.1%. When the pathway was fully followed, 71% of patients were discharged on the same day. When the pathway was not followed at all, the same day discharge rate was 0%. Our study successfully demonstrates that small enhancements to perioperative care can accelerate patient recovery and improve same day discharges.

Intensive Care Unit Enhanced Recovery Pathway for Patients Undergoing Orthotopic Liver Transplants Recipients: A Prospective, Observational Study

BACKGROUND

Liver transplant recipients continue to have high perioperative resource utilization and prolonged length of stay despite improvements in perioperative care. Enhanced recovery pathways have been shown in other surgical populations to produce reductions in hospital resource utilization.

METHODS

A prospective, observational study was performed to examine the effect of an enhanced recovery pathway for postoperative care after liver transplantation. Outcomes from patients undergoing liver transplantation from November 1, 2013, to October 31, 2014, managed by the pathway were compared to transplant recipients from the year before pathway implementation. Multivariable regression analysis was used to assess the association of the clinical pathway on clinical outcomes.

RESULTS

The intervention and control groups included 141 and 106 patients, respectively. There were no demographic differences between the control and intervention group including no differences between the length of surgery and cold ischemic time. Median intensive care unit length of stay was reduced from 4.4 to 2.6 days (P < .001). The intervention group had a higher likelihood of earlier discharge (hazard ratio [95% CI], 2.01 [1.55-2.62]; P < .001), and a 69% and 65% lower odds of receiving a plasma (P < .001) or packed red blood cell (P < .001) transfusion. There was no significant effect on hospital mortality (P = .40), intensive care unit readmission rates (P = .75), or postoperative infections (urinary traction infections: P = .09; pneumonia: P = .27).

CONCLUSIONS

An enhanced recovery pathway focused on milestone-based elements of intensive care unit management and predetermined management triggers including hemodynamic goals, fluid therapy, perioperative antibiotics, glycemic control, and standardized transfusion triggers led to reductions in intensive care unit length of stay without an increase in perioperative complications.

Evolution of a Dedicated Emergency Surgery and Trauma (ESAT) unit over 3 years: sustained improved outcomes

INTRODUCTION

The traditional 24-h call model faces pressure from competing needs between emergency and elective services. Recognizing this, a dedicated ESAT service was developed in Khoo Teck Puat Hospital in Singapore, with improved clinical outcomes. It was initially led by a single consultant (SC) in 2014, and subsequently evolved to a weekly consultant rotation (WC) roster in 2017 to achieve sustainability.

METHODS

Each consultant led the ESAT WC service for a week and maintained ownership of their patients thereafter. All emergency surgical admissions between two distinct 6-month periods were reviewed, from May to October 2014 (pre-ESAT) and January to June 2017 (ESAT WC). Patient demographics, diagnoses, and operations were compared. Efficiency and clinical outcomes were evaluated.

RESULTS

There were 1248 and 1284 patients in the pre-ESAT and ESAT WC group, respectively. Majority were males and in their 50s. Acute appendicitis, gallstone conditions, and soft-tissue infections made up half of the admissions. Trauma workload was comparable (7.8% pre-ESAT vs 9.5% ESAT WC). Cholecystectomies doubled during the ESAT period, 14.2% vs 7.2%, (p = 0.01). More consultants were involved in major cases (95.9% vs 86%), (p = 0.01) and more operations were performed during the day (52.1% vs 47.9%), (p = 0.01). Average time to OT was shorter and there were less major surgical complications (p = 0.02). Mortality (p = 0.08) and length of stay were reduced (4 vs 4.5 days), (p = 0.01).

CONCLUSION

The ESAT WC service has sustained improved outcomes in our institution.

OPAT: proof of concept in a peripheral Belgian hospital after review of the literature

Since its introduction in the 1970s in the United States, outpatient parenteral antibiotic/antimicrobial therapy (OPAT) has been adopted internationally for long-term intravenous (IV) treatment of stable infectious diseases. The aim is to provide a safe and successful completion of IV antimicrobial treatment at the ambulatory care center or at home without complications and costs associated with hospitalization. OPAT implementation has been accelerated by progress in vascular access devices, newly available antibiotics, the emphasis on cost-savings, as well as an improved patient comfort and a reduced incidence of health care associated infections with a similar outcome. OPAT utilization is supported by an extensive published experience and guidelines of the British Society of Antimicrobial Chemotherapy and the Infectious Diseases Society of America for adults as well as for children. Despite these recommendations and its widespread adoption, in Belgium OPAT is only fully reimbursed and established for cystic fibrosis patients. Possible explanations for this unpopularity include physician unfamiliarity and a lack of uniform funding arrangements with higher costs for the patient. This article aims to briefly review benefits, risks, indications, financial impact for supporting OPAT in a non-university hospital as standard of care. Our experience with OPAT at the ambulatory care center of our hospital and its subsequent recent introduction in the home setting is discussed.

Reducing Unnecessary Imaging and Pathology Tests: A Systematic Review

CONTEXT

Unnecessary imaging and pathology procedures represent low-value care and can harm children and the health care system.

OBJECTIVE

To perform a systematic review of interventions designed to reduce unnecessary pediatric imaging and pathology testing.

DATA SOURCES

We searched Medline, Embase, Cinahl, PubMed, Cochrane Library, and gray literature.

STUDY SELECTION

Studies we included were: reports of interventions to reduce unnecessary imaging and pathology testing in pediatric populations; from developed countries; written in the English language; and published between January 1, 1996, and April 29, 2017.

DATA EXTRACTION

Two researchers independently extracted data and assessed study quality using a Cochrane group risk of bias tool. Level of evidence was graded using the Oxford Centre for Evidence-Based Medicine grading system.

RESULTS

We found 64 articles including 44 before-after, 14 interrupted time series, and 1 randomized controlled trial. More effective interventions were (1) multifaceted, with 3 components (mean relative reduction = 45.0%; SD = 28.3%) as opposed to 2 components (32.0% [30.3%]); or 1 component (28.6%, [34.9%]); (2) targeted toward families and clinicians compared with clinicians only (61.9% [34.3%] vs 30.0% [32.0%], respectively); and (3) targeted toward imaging (41.8% [38.4%]) or pathology testing only (48.8% [20.9%]), compared with both simultaneously (21.6% [29.2%]).

LIMITATIONS

The studies we included were limited to the English language.

CONCLUSIONS

Promising interventions include audit and feedback, system-based changes, and education. Future researchers should move beyond before-after designs to rigorously evaluate interventions. A relatively novel approach will be to include both clinicians and the families they manage in such interventions.

Management of Pediatric Perforated Appendicitis: Comparing Outcomes Using Early Appendectomy Versus Solely Medical Management

BACKGROUND

There is controversy regarding whether children with perforated appendicitis should receive early appendectomy (EA) versus medical management (MM) with antibiotics and delayed interval appendectomy. The objective of this study was to compare outcomes of children with perforated appendicitis who receive EA versus MM.

METHODS

Case review of consecutive children <18 years of age with perforated appendicitis who received either EA or MM during an 8-year period. Criteria for hospital discharge included patient being afebrile for at least 24 hours, pain-free and able to tolerate oral intake.

RESULTS

Of 203 patients diagnosed with perforated appendicitis, 122 received EA and 81 received MM. All received parenteral antibiotic therapy initiated in the emergency department and continued during hospitalization. There were no significant differences between groups in mean patient age, mean complete blood count total white blood cells count, gender distribution, rates of emergency department fever or rates of intra-abdominal infection (abscess or phlegmon) identified on admission. Compared with patients receiving MM, those receiving EA experienced significantly fewer (1) days of hospitalization, parenteral antibiotic therapy and in-hospital fever; (2) radiographic studies, percutaneous drainage procedures and placement of central venous catheters performed; (3) post admission intra-abdominal complications and (4) unscheduled repeat hospitalizations after hospital discharge. Only 1 EA-managed patient developed a postoperative wound infection.

CONCLUSIONS

Children with perforated appendicitis who receive EA experience significantly less morbidity and complications versus those receiving MM. The theoretical concern for enhanced morbidity associated with EA management of perforated appendicitis is not supported by our analysis.

Impact of Percutaneous Drainage on Outcome of Intra-abdominal Infection Associated With Pediatric Perforated Appendicitis

BACKGROUND

Perforated appendicitis can result in potentially serious complications requiring prolonged medical care. The optimal approach to successfully managing this condition is controversial.

METHODS

Review of 80 consecutive cases of pediatric acute perforated appendicitis with intra-abdominal infection (IAI) medically managed with parenteral antibiotics and percutaneous drainage (PD) during a 7-year period.

RESULTS

All patients received broad spectrum parenteral antibiotic therapy. One-third were hospitalized for >2 weeks. IAI was identified on admission in 60% compared with developing during hospitalization in 40% of cases. Before performing PD, the mean duration of antibiotic therapy in those who developed IAI during hospitalization was 6 days. IAI cultures yielded 127 bacterial isolates; polymicrobial infection occurred in 65% of cases. Only 7% of aspirates were sterile. The most common pathogens were Escherichia coli (82%), of which 5 isolates exhibited extended-spectrum β-lactamase production, and streptococci (40%). At the time of PD, 60% were febrile (mean duration of in-hospital fever, 7.5 days); 67% defervesced within 24 hours after the procedure. Posthospitalization abdominal complications (recurrent IAI or appendicitis) occurred in one-third of patients.

CONCLUSIONS

Children with perforated appendicitis and IAI often have a complicated and prolonged clinical course. Medical management consisting solely of parenteral antibiotic therapy is frequently ineffective in resolving IAI. Rapid clinical improvement commonly follows PD.

Inpatient versus outpatient parenteral antibiotic therapy at home for acute infections in children: a systematic review

Inpatient management is necessary in many situations, but medical and allied-health treatments are increasingly being used on an outpatient basis to allow patients who would traditionally have been admitted to hospital to remain at home. Home-based clinical management has many potential benefits, including reduced hospital-acquired infections, cost savings, and patient and family satisfaction. Studies in adults provide evidence for the benefits of home-based versus hospital-based intravenous antibiotics, but few studies inform practice in home-based intravenous antibiotic therapy for children. We systematically reviewed the efficacy, safety, satisfaction, and cost of home-based versus hospital-based intravenous antibiotic therapy for acute infections in children. We searched MEDLINE (from Jan 1, 1946, to Jan 31, 2017) and Embase (from Jan 1, 1974, to Jan 31, 2017) for studies investigating home-based and hospital-based intravenous antibiotic therapy and assessed them for quality. 2827 articles were identified and 19 studies were included in the systematic review. Efficacy results differed between studies depending on the outcome assessed. The incidence of complications and readmission to hospital was similar for hospital-based and home-based treatments. In seven (47%) of 15 studies, patients who had all or part of their treatment at home received treatment for longer than patients who were treated entirely in hospital. No studies showed that home-based treatment was less safe than hospital-based treatment. In all studies in which treatment satisfaction or costs were assessed, home-based treatment was satisfactory to patients or patients' families and less expensive per episode than hospital-based treatment by 30-75%. Thus, home-based intravenous antibiotic therapy might be popular and cost-effective, but randomised studies of the efficacy of this strategy are needed. This systematic review was registered with PROSPERO (number CRD42015024406).

Risk Factors for Prolonged Hospitalization in Pediatric Appendicitis Patients with Medical Treatment

BACKGROUND

With effective antibiotics against enteric flora and computed tomography-guided drainage for abscesses, the initial use of nonoperative therapy for children with appendicitis has increased both in recent reports and at our hospital. However, it has been reported that these patients have a relatively longer hospital stay and that their treatment is more expensive than those who undergo aggressive surgical intervention.

METHODS

This was a retrospective cohort study based in a single medical center. A systemic chart review was conducted to identify risk factors for prolonged hospitalization in pediatric appendicitis patients not initially undergoing surgical treatment. Patient demographics, clinical symptoms, duration of symptoms, laboratory findings, imaging findings, complications, and length of hospital stay were analyzed. Logistic regression analysis was used to identify significant predictors of prolonged hospitalization (≥15 days) and readmission.

RESULTS

One hundred and twenty-five patients were recruited in this study, of whom 53 (42.4%) had prolonged hospitalization. The values of serum C-reactive protein (CRP) were significantly higher in patients with prolonged hospitalization compared with those without prolonged hospitalization (203 ± 108.6 mg/L vs. 140 ± 93.0 mg/L, p = 0.001). Risk factors of prolonged hospitalization were serum CRP >150 mg/L (35/53 vs. 28/72, p = 0.001), abscess formation (38/53 vs. 35/72, p = 0.008), and multiple abscesses (10/53 vs. 1/72, p = 0.001). Under multivariate analysis, CRP >150 mg/L (odds ratio=1.004, p = 0.0334) and multiple abscesses (odds ratio = 8.788, p = 0.044) were two independent predictors for prolonged hospitalization.

CONCLUSION

Marked elevation of serum CRP (>150 mg/L) and multiple abscesses are two independent risk factors for prolonged hospitalization in children with appendicitis who are initially treated nonoperatively.

Association of Hospital Resources and Imaging Choice for Appendicitis in Pediatric Emergency Departments

OBJECTIVE

Abdominal pain and concern for appendicitis are common chief complaints in patients presenting to the pediatric emergency department (PED). Although many professional organizations recommend decreasing use of computed tomography (CT) and choosing ultrasound as first-line imaging for pediatric appendicitis, significant variability persists in imaging utilization. This study investigated practice variation across children's hospitals in the diagnostic imaging evaluation of appendicitis and determined hospital-level characteristics associated with the likelihood of ultrasound as the first imaging modality.

METHODS

This was a multicenter (seven children's hospitals) retrospective investigation. Data from chart review of 160 consecutive patients aged 3-18 years diagnosed with appendicitis from each site were compared with a survey of site medical directors regarding hospital resource availability, usual practices, and departmental-level demographics.

RESULTS

In the diagnostic evaluation of 1,090 children with appendicitis, CT scan was performed first for 22.4% of patients, with a range across PEDs of 3.1% to 83.8%. Ultrasound was performed for 54.0% of patients with a range of 2.5% to 96.9%. The only hospital-level factor significantly associated with ultrasound as the first imaging modality was 24-hour availability of in-house ultrasound (odds ratio = 29.2, 95% confidence interval = 1.2-691.8).

CONCLUSION

Across children's hospitals, significant practice variation exists regarding diagnostic imaging in the evaluation of patients with appendicitis. Variation in hospital-level resources may impact the diagnostic evaluation of patients with appendicitis. Availability of 24-hour in-house ultrasound significantly increases the likelihood of ultrasound as first imaging and decreases CT scans. Hospitals aiming to increase the use of ultrasound should consider adding 24-hour in-house coverage.

Pediatric Appendicitis

Appendicitis is one of the most common surgical pathologies in children. It can present with right lower quadrant pain. Scoring systems in combination with selective imaging and surgical examination will diagnose most children with appendicitis. Clinical pathways should be used. Most surgical interventions for appendicitis are now almost exclusively laparoscopic, with trials demonstrating better outcomes for children who undergo index hospitalization appendectomies when perforated. Nonoperative management has a role in the treatment of both uncomplicated and complicated appendicitis. This article discusses the workup and management, modes of treatment, and continued areas of controversy in pediatric appendicitis.

Interventions to optimize recovery after laparoscopic appendectomy: a scoping review

BACKGROUND

No enhanced recovery after surgery protocol has been published for laparoscopic appendectomy. This was a review of evidence-based interventions that could optimize recovery after appendectomy.

METHODS

Interventions for the review Clinical pathway, fast-track or enhanced recovery protocols; needlescopic approach; single incision laparoscopic (SIL) approach; natural orifice transluminal endoscopic surgery (NOTES); regional nerve blocks; intraperitoneal local anaesthetic (IPLA); drains. Data sources MEDLINE, EMBASE, the Cochrane Library, and the Web of Science Core Collection. Study eligibility criteria Randomized controlled trial (RCT); prospective evaluation with historical controls for studies assessing clinical pathways/protocols. Participants People undergoing laparoscopic appendectomy for acute appendicitis. Study appraisal and synthesis methods Meta-analysis, random effects model.

RESULTS

Clinical pathways for laparoscopic appendectomy were safe in selected patients, but may be associated with a higher readmission rate. Needlescopic surgery offered no recovery advantage over traditional laparoscopic appendectomy. SIL afforded no recovery advantage over conventional laparoscopic surgery, but may increase operative time in children. The search found no RCT on NOTES appendectomy. Transversus abdominis plane blocks did not significantly reduce pain after laparoscopic appendectomy. IPLA should be considered in laparoscopic appendectomy; studies in paediatric surgery are needed. The search found no RCT on the use of drains in appendectomy.

CONCLUSIONS

This review identified gaps in the literature on optimizing recovery after laparoscopic appendectomy and found the need for more randomized controlled trials on regional anaesthesia and intraperitoneal local anaesthesia in children.

An easy-to-follow algorithm to improve pre-operative diagnosis for appendicitis in children

GOAL

To evaluate physician compliance with use of a diagnostic algorithm for appendicitis in children. Our secondary objective was to determine the impact of the algorithm on diagnostic accuracy and morbidity.

METHODS

We conducted a clustered randomized trial in eight centers. A total of 866 patients were included and, depending on the period of randomization at particular centers, 543 patients were managed before the formal institution of the diagnostic algorithm; their diagnostic management was compared to that of the subsequent 323 patients.

RESULTS

There was a 29.1% mean increase in the use of imaging studies included in the algorithm after algorithm set-up, rising from 50.8 to 79.9% (P<0.02). When we used a composite endpoint of "poor results" (grouping patients with incorrect diagnoses and/or post-operative complications), no statistically significant difference was found between the two periods (85/543 (15.6%) before vs. 45/323 (13.9%) after set-up, P=0.5). But when the number of incorrect diagnoses of appendicitis made without the use of the algorithm was compared to that of patients who took advantage of the algorithm, the difference was highly significant (67/332 [20.2%] vs. 63/534 [11.8%], P<0.001), and the rate of unnecessary appendectomy decreased from 11.9 to 5.3% (P<0.01).

CONCLUSIONS

Our diagnostic algorithm improved the adherence to good practice for the diagnosis of appendicitis in children, reducing the rates of unnecessary appendectomy and morbidity. This strategy, combining laboratory tests and imaging, should permit pediatric surgeons to adapt their therapeutic approaches to specific cases.

Fast-track surgery for uncomplicated appendicitis in children: a matched case-control study

BACKGROUND

Standardized post-operative protocols reduce variation and enhance efficiency in patient care. Patients may benefit from these initiatives by improved quality of care. This matched case-control study investigates the effect of a multidisciplinary criteria-led discharge protocol for uncomplicated appendicitis in children.

METHODS

Key protocol components included limiting post-operative antibiotics to two intravenous doses, avoidance of intravenous opioid analgesia, prompt resumption of diet, active encouragement of early ambulation and nursing staff autonomy to discharge patients that met assigned criteria. The study period was from August 2015 to February 2016. Outcomes were compared with a historical control group matched for operative approach.

RESULTS

Outcomes for 83 patients enrolled to our protocol were compared with those of 83 controls. There was a 29.2% reduction in median post-operative length of stay in our protocol-based care group (19.6 versus 27.7 h; P < 0.001). The rate of discharges within 24 h improved from 12 to 42%. There was no significant difference in complication rate (4.8 versus 7.2%; P = 0.51). Mean oral morphine dose equivalent per kilogram requirement was less than half (46%) that of control group patients (P < 0.001). Mean number of ondansetron doses was also significantly lower. Projected annual direct cost savings following protocol implementation was AUD$77 057.

CONCLUSION

Implementation of a criteria-led discharge protocol at our hospital decreased length of stay, reduced variation in care, preserved existing low morbidity, incurred substantial cost savings, and safely rationalized opioid and antiemetic medication. These protocols are inexpensive and offer tangible benefits that are accessible to all health care settings.

Critical factors influencing physicians' intention to use computerized clinical practice guidelines: an integrative model of activity theory and the technology acceptance model

Background

With the widespread use of information communication technologies, computerized clinical practice guidelines are developed and considered as effective decision supporting tools in assisting the processes of clinical activities. However, the development of computerized clinical practice guidelines in Taiwan is still at the early stage and acceptance level among major users (physicians) of computerized clinical practice guidelines is not satisfactory. This study aims to investigate critical factors influencing physicians’ intention to computerized clinical practice guideline use through an integrative model of activity theory and the technology acceptance model.

Methods

The survey methodology was employed to collect data from physicians of the investigated hospitals that have implemented computerized clinical practice guidelines. A total of 505 questionnaires were sent out, with 238 completed copies returned, indicating a valid response rate of 47.1 %. The collected data was then analyzed by structural equation modeling technique.

Results

The results showed that attitudes toward using computerized clinical practice guidelines (γ = 0.451, p < 0.001), organizational support (γ = 0.285, p < 0.001), perceived usefulness of computerized clinical practice guidelines (γ = 0.219, p < 0.05), and social influence (γ = 0.213, p < 0.05) were critical factors influencing physicians’ intention to use computerized clinical practice guidelines, and these factors can explain 68.6 % of the variance in intention to use computerized clinical practice guidelines.

Conclusions

This study confirmed that some subject (human) factors, environment (organization) factors, tool (technology) factors mentioned in the activity theory should be carefully considered when introducing computerized clinical practice guidelines. Managers should pay much attention on those identified factors and provide adequate resources and incentives to help the promotion and use of computerized clinical practice guidelines. Through the appropriate use of computerized clinical practice guidelines, the clinical benefits, particularly in improving quality of care and facilitating the clinical processes, will be realized.

Response-based therapy for ruptured appendicitis reduces resource utilization

PURPOSE

We examined the effectiveness of a postoperative ruptured appendicitis protocol that eliminated Pseudomonas coverage and based the duration of IV antibiotic treatment and length of hospital stay on the patient's clinical response.

METHODS

In our new protocol, IV antibiotics were administered until the patient met discharge criteria: adequate oral intake, pain control with oral medications, and afebrile for 24h. We collected data on all patients with ruptured appendicitis at our institution following protocol implementation (May 1, 2012, to April 30, 2013) and compared them to a control group.

RESULTS

306 patients were treated (154 prior protocol, 152 new protocol). The new clinical response-based protocol led to a decrease in hospital stay from 134h (SD 66.1) to 94.5h (SD 61.7) (p<0.001) and total cost of care per patient also decreased from $13,610 (SD $6859) to $9870 (SD $5670) (p<0.001).

CONCLUSION

Our clinical response-based protocol for pediatric patients with ruptured appendicitis decreased LOS, cost, and IV antibiotics use without significant changes in adverse events.

Good practice recommendations for paediatric outpatient parenteral antibiotic therapy (p-OPAT) in the UK: a consensus statement

There is compelling evidence to support the rationale for managing children on intravenous antimicrobial therapy at home whenever possible, including parent and patient satisfaction, psychological well-being, return to school/employment, reductions in healthcare-associated infection and cost savings. As a joint collaboration between the BSAC and the British Paediatric Allergy, Immunity and Infection Group, we have developed good practice recommendations to highlight good clinical practice and governance within paediatric outpatient parenteral antibiotic therapy (p-OPAT) services across the UK. These guidelines provide a practical approach for safely delivering a p-OPAT service in both secondary care and tertiary care settings, in terms of the roles and responsibilities of members of the p-OPAT team, the structure required to deliver the service, identifying patients and pathologies that are suitable for p-OPAT, ensuring appropriate vascular access, antimicrobial choice and delivery and the clinical governance aspects of delivering a p-OPAT service. The process of writing a business case to support the introduction of a p-OPAT service is also addressed.

Utility of CT after sonography for suspected appendicitis in children: integration of a clinical scoring system with a staged imaging protocol

To improve diagnosis of pediatric appendicitis, many institutions have implemented a staged imaging protocol utilizing ultrasonography (US) first and then computed tomography (CT). A substantial number of children with suspected appendicitis undergo CT after US, and the efficient and accurate diagnosis of pediatric appendicitis continues to be challenging. The objective of the study is to characterize the utility of CT following US for diagnosis of pediatric appendicitis, in conjunction with a clinical appendicitis score (AS). Imaging studies of children with suspected appendicitis who underwent CT after US in an imaging protocol were retrospectively reviewed by three radiologists in consensus. Chart review derived the AS (range 0-10) and obtained the patient diagnosis and disposition, and an AS was applied to each patient. Clinical and radiologic data were analyzed to assess the yield of CT after US. Studies of 211 children (mean age 11.3 years) were included. The positive threshold for AS was determined to be 6 out of 10. When AS and US were concordant (N = 140), the sensitivity and specificity of US were similar to CT. When AS and US were discordant (N = 71) and also when AS ≥ 6 (N = 84), subsequent CT showed superior sensitivity and specificity to US alone. In the subset where US showed neither the appendix nor inflammatory change in the right lower quadrant (126/211, 60 % of scans), when AS < 6 (N = 83), the negative predictive value (NPV) of US was 0.98. However, when AS ≥ 6 (N = 43), NPV of US was 0.58, and the positive predictive value of subsequent CT was 1. There was a significant decrease in depiction of the appendix on US with patient weight-to-age ratio of >6 (kg/year, P < 0.001) and after-hours (1700 -0730 hours) performance of US (P < 0.001). Results suggest that the appendicitis score has utility in guiding an imaging protocol and support the contention that non-visualization of the appendix on US is not intrinsically non-diagnostic. There was little benefit to additional CT when AS < 6 and US did not show the appendix or evidence of inflammation; this would have avoided CT in 140/211 (66 %) patients. CT demonstrated benefit when AS ≥ 6, suggesting that cases with AS ≥ 6 and features that limit depiction of the appendix on US may be triaged to CT.

Doctors' compliance with national guidelines and clinical pathway on the treatment of tuberculosis inpatients in Hubei, China

RATIONALE, AIMS AND OBJECTIVES

The Ministry of Health in China has enacted a revised National Tuberculosis Control Program (NTP) guidelines and clinical pathway (CP) on new smear-positive pulmonary tuberculosis (TB) inpatients to improve the quality of TB care and asked doctors' compliance to them on the treatment of TB inpatients. However, it remains unknown whether doctors adhere to them well. So this study focuses on evaluating the doctors' compliance with them in one representative TB hospital for medical quality improvement.

METHODS

A hospital-based retrospective study involving all medical records of newly diagnosed smear-positive pulmonary TB inpatients from July 2011 to July 2013. Analysis indicators including adequate drug regimens rate, adequate drug dosages rate and adequate length of hospital stay rate were chosen to assess doctors' compliance with NTP guidelines and CP on the treatment of new smear-positive pulmonary TB inpatients. The optimal value of these indicators is 100%.

RESULTS

Of the 334 inpatients selected, the rate of adequate drug regimens prescribed is 26.95% (90/334), and the rate of adequate drug dosages is 0% (0/90). For the dosage of single drug, the rates of adequate dosage of isoniazid, rifampicin, pyrazinamide and ethambutol are 24.44% (22/90), 85.56% (77/90), 70% (63/90) and 13.33% (12/90). Moreover, 75.56% (68/90) of isoniazid was prescribed too high and 83.34% (75/90) of ethambutol was prescribed too low. The rate of adequate length of hospital stay provided is 28.44% (95/334).

CONCLUSION

Doctors' compliance with NTP guidelines and CP on new smear-positive pulmonary TB inpatients is depressed and needs improvement.

Emergency medicine physicians' and pediatricians' use of computed tomography in the evaluation of pediatric patients with abdominal pain without trauma in a community hospital

There is a paucity of data regarding emergency department (ED) provider type and computed tomography (CT) scan use in the evaluation of pediatric patients with abdominal pain without trauma. The purpose of this retrospective single community hospital study was to determine if there was a difference in CT use between emergency medicine physicians (EMPs) and pediatricians (PEDs) in all patients younger than 18 years with abdominal pain without trauma who presented to the ED during the study period. The study included 165 patients. EMPs saw 83 patients and used CT in 31 compared with PEDs who saw 82 patients and used CT in 12 (P = .002). EMPs used CT significantly more frequently than PEDs in the designated sample. Economic pressures may cause changes in ED provider type in community and rural hospitals and this study shows that ED provider type may affect medical decision making, including CT use.

Reduced use of computed tomography in patients treated with interval appendectomy after implementing a protocol from a prospective, randomized trial

BACKGROUND

In 2009, we instituted a protocol to standardize care for patients undergoing interval appendectomy based on results from a prospective trial that demonstrated a reduction in the mean number of computed tomography (CT) scans performed. The goal of this study was to determine if our current practice now resulted in fewer CT scans as a result of this trial.

METHODS

A retrospective review of all patients undergoing interval appendectomy for perforated appendicitis from March 2009 to March 2011 was performed. Demographics and outcomes were compared to previously collected data from a retrospective study prior to institution of the protocol and to the prospective trial.

RESULTS

During the study period, 45 patients underwent interval appendectomy. There were no differences in demographics among the three studies. Similar numbers of patients underwent aspiration or percutaneous drainage. There continues to be a significant reduction in the number of CT scans (3.5 ± 2.0 vs. 2.1 ± 1.3, P = 0.0001) and health care visits (7.6 ± 2.8 vs. 4.5 ± 1.4, P = 0.0001) when comparing management prior to the prospective trial to management since its completion.

CONCLUSION

A protocol for management of patients undergoing interval appendectomy care results in fewer health care visits and CT scans.

An update on common gastrointestinal emergencies

The evaluation of the child with acute abdominal pain often poses as a diagnostic challenge due to the wide range of diagnoses. Surgical emergencies need to be rapidly identified and managed appropriately to minimize morbidity and mortality. Presenting symptoms, clinical examination, and laboratory findings can guide selection of diagnostic imaging. This article reviews common surgical causes of abdominal pain in children.

Decreased resource utilization since initiation of institutional clinical pathway for care of children with perforated appendicitis

PURPOSE

We instituted a clinical pathway for the care of patients with perforated appendicitis based on outcomes from several clinical trials. The objective of this study was to review effects on resource utilization with this protocol.

METHODS

A retrospective review was conducted to compare all patients undergoing appendectomy during initial admission for perforated appendicitis prior to the pathway (July 2001 to December 2003) to after (December 2008 to March 2011). Demographics and management strategies were evaluated.

RESULTS

Charts of 151 patients prior to and 259 after the start of the pathway were reviewed. The percentage of patients leaving the operating room with a nasogastric tube (NGT) was significantly lower in the after-group, while similar numbers of patients during each period had a NGT placed on the floor. The proportion of patients receiving peripherally inserted central catheters and total parenteral nutrition, and the number of intravenous antibiotics per day and lab draws were significantly reduced with the protocol. Patients were started on a regular diet significantly earlier, and length of stay was shortened by more than one day.

CONCLUSION

The evidence-based clinical pathway developed from prospective trials has drastically reduced resource utilization for children with perforated appendicitis.

Creating personalised clinical pathways by semantic interoperability with electronic health records

OBJECTIVE

There is a growing realisation that clinical pathways (CPs) are vital for improving the treatment quality of healthcare organisations. However, treatment personalisation is one of the main challenges when implementing CPs, and the inadequate dynamic adaptability restricts the practicality of CPs. The purpose of this study is to improve the practicality of CPs using semantic interoperability between knowledge-based CPs and semantic electronic health records (EHRs).

METHODS

Simple protocol and resource description framework query language is used to gather patient information from semantic EHRs. The gathered patient information is entered into the CP ontology represented by web ontology language. Then, after reasoning over rules described by semantic web rule language in the Jena semantic framework, we adjust the standardised CPs to meet different patients' practical needs.

RESULTS

A CP for acute appendicitis is used as an example to illustrate how to achieve CP customisation based on the semantic interoperability between knowledge-based CPs and semantic EHRs. A personalised care plan is generated by comprehensively analysing the patient's personal allergy history and past medical history, which are stored in semantic EHRs. Additionally, by monitoring the patient's clinical information, an exception is recorded and handled during CP execution. According to execution results of the actual example, the solutions we present are shown to be technically feasible.

CONCLUSION

This study contributes towards improving the clinical personalised practicality of standardised CPs. In addition, this study establishes the foundation for future work on the research and development of an independent CP system.

Use and accuracy of diagnostic imaging by hospital type in pediatric appendicitis

OBJECTIVE

Accurate, timely diagnosis of pediatric appendicitis minimizes unnecessary operations and treatment delays. Preoperative abdominal-pelvic computed tomography (CT) scan is sensitive and specific for appendicitis; however, concerns regarding radiation exposure in children obligate scrutiny of CT use. Here, we characterize recent preoperative imaging use and accuracy among pediatric appendectomy subjects.

METHODS

We retrospectively reviewed children who underwent operations for presumed appendicitis at a single tertiary-care children's hospital and examined preoperative CT and ultrasound use with subject characteristics. Preoperative imaging accuracy was compared with postoperative and histologic diagnosis as the reference standard.

RESULTS

Most children (395/423, 93.4%) who underwent an operation for appendicitis during 2009-2010 had preoperative imaging. Final diagnoses included normal appendix (7.3%) and perforated appendicitis (23.6%). In multivariable analysis, initial evaluation at a community hospital versus the children's hospital was associated with 4.4-fold higher odds of obtaining a preoperative CT scan (P = .002), whereas preoperative ultrasound was less likely (odds ratio 0.20; P = .003). Ultrasound and CT sensitivities for appendicitis were diminished for studies performed at community hospitals compared with the children's hospital. Girls were 4.5-fold more likely to undergo both ultrasound and CT scans and were associated with lower ultrasound sensitivity for appendicitis.

CONCLUSIONS

Widespread preoperative imaging did not eliminate unnecessary pediatric appendectomies. Controlling for factors potentially associated with referral bias, a CT scan was more likely to be performed in children initially evaluated at community hospitals compared with the children's hospital. Broadly-applicable strategies to systematically maximize diagnostic accuracy for childhood appendicitis, while minimizing ionizing radiation exposure, are urgently needed.

Treatment of perforated appendicitis in children: what is the cost?

BACKGROUND/PURPOSE

We compared direct hospital costs and indirect costs to the family associated with immediate appendectomy or initial nonoperative management for perforated appendicitis in children.

METHODS

From June 2009 through May 2010, 61 prospectively identified families completed a cost diary, documenting the numbers of missed school days for the child and missed employment days for the adult caregiver(s) over the treatment course. Hospital costs were obtained from hospital financial databases. Mann-Whitney U tests and Fisher exact tests were used to compare outcome measures for each treatment strategy.

RESULTS

Patients treated by initial nonoperative management had a significantly longer median length of stay (9 days vs 7 days, P = .02) and a significantly greater median total hospital cost per patient ($31,349 vs $21,323, P = .01) when compared with those treated by immediate appendectomy. There was no significant difference in median number of missed school days (9 days vs 10 days, P = .23) or missed employment days for adult caregiver(s) (5 days vs 7 days, P = .18) between treatment strategies.

CONCLUSIONS

Patients with perforated appendicitis treated by initial nonoperative management had a greater length of stay and a significantly greater total hospital cost but were not burdened by significantly greater indirect costs compared with those treated by immediate appendectomy.

Clinical manifestations in children with ruptured appendicitis

OBJECTIVES

Appendicitis is the most common abdominal condition leading to urgent surgery in children. With the goal of identifying signs and symptoms that will allow prompt diagnosis of rupture of the appendix and thus decrease associated morbidities, our aim was to determine factors associated with ruptured appendicitis in children diagnosed with appendicitis.

METHODS

The medical records of children aged 17 years or younger with a postoperative diagnosis of acute appendicitis treated at Cathay General Hospital, Taipei, Taiwan, from January 2002 and May 2009, were retrospectively reviewed. The patients were divided into with and without ruptured appendicitis.

RESULTS

Of the 228 patients, 140 had a postoperative pathological diagnosis of a nonperforated appendix, and 88 had a diagnosis of perforated appendix, resulting in a perforation rate of 38.6%. Younger age, longer duration of abdominal pain, fever, muscle guarding, and elevated C-reactive protein level were significantly associated with a perforated appendix.

CONCLUSIONS

Younger age, longer duration of abdominal pain, fever, muscle guarding, and elevated C-reactive protein level are significantly associated with a perforated appendix; these factors should be closely considered in the evaluation of individuals with suspected appendicitis.

Role of clinical judgment and tissue harmonic imaging ultrasonography in diagnosis of paediatric acute appendicitis

Background

Appendicitis is the most common surgical emergency in children; yet, diagnosis of equivocal presentations continues to challenge clinicians.

Aim

The objective of this study was to investigate the hypothesis that the use of a modified clinical practice and harmonic ultrasonographic grading scores (MCPGS) may improve the accuracy in diagnosing acute appendicitis in the pediatric population.

Patients & Methods

Results

The Number of appendectomies declined from 200 (75.5%) in our previous CPGS to 187 (70.6%) in the MCPGS (P > 0.05).

Specificity was significantly higher when applying MCPGS (90.7%) in this study compared to 70.47% in our previous work when CPGS was applied (P < 0.01). Furthermore, the positive predictive value (PPV) was significantly higher (95.72%) than in our previous study (82.88%), (P < 0.01). Overall agreement (accuracy) of MCPGS was 96.98%. Kappa = 0.929 (P < 0.001). Negative predictive power was 100%. And the Overall agreement (accuracy) was 96.98%.

Conclusions

MCPGS tends to help in reduce the numbers of avoidable and unnecessary appendectomies in suspected cases of pediatric acute appendicitis that may help in saving hospital resources.

Variations in preoperative decision making for antireflux procedures in pediatric gastroesophageal reflux disease: a survey of pediatric surgeons

BACKGROUND/PURPOSE

The purpose of the study was to identify influential factors contributing to the variation with which antireflux procedures (ARPs) are performed at freestanding children's hospitals in the United States.

METHODS

We conducted an online survey of pediatric surgeons working in Child Health Corporation of America (CHCA) member hospitals in which we examined decision making for ARPs.

RESULTS

Thirty-six percent (n = 121) of contacted surgeons responded. Eighty percent reported requiring preoperative upper gastrointestinal series before ARPs, and 13% require a pH probe study. Although surgeons ranked their own opinion as the most important in preoperative decision making, parents and referring physicians played significant roles in hypothetical scenarios. In children with negative/equivocal objective studies, more than half of surgeons reported offering ARP when the referring specialist felt that ARP was indicated. Despite equivocal studies, 20% of the surgeons reported offering ARP when the parents were convinced that ARP would help. In a patient with both a positive pH probe and upper gastrointestinal series, 46% of surgeons reported declining ARP if parents were hesitant.

CONCLUSIONS

These data suggest that a surgeon's final decision to perform ARP may be just as influenced by nonobjective factors, such as referring physician and parental opinions, as it is by objective studies. Our survey reinforces the need for further examination of specific factors in preoperative decision making for ARPs in the pediatric population.

An evidence-based clinical protocol for diagnosis of acute appendicitis decreased the use of computed tomography in children

PURPOSE

The increased use of computed tomography (CT) to diagnose appendicitis in children has led to a concern for the possibility of increased CT-related cancer morbidity. We designed a clinical protocol for the diagnosis and treatment of appendicitis in children in an attempt to decrease the use of CT scans at our institution.

METHODS

Patients who had surgical consultation for suspected appendicitis were placed on the clinical protocol. Data concerning diagnosis and treatment were collected prospectively. Retrospective data from patients admitted to our institution with acute appendicitis before the clinical protocol were collected as historical controls.

RESULTS

One hundred twelve patients were diagnosed and treated by our protocol between June and November 2009. Of these, 100 patients underwent an appendectomy for acute appendicitis. They were compared with 146 patients from 2007. In-house CT use decreased from 71.2% to 51.7% (P = .01). Preoperative ultrasound use increased from 2.7% to 21% (P < .001). The negative appendectomy rate increased (6.8% vs 11%, P = .25).

CONCLUSIONS

Our findings suggest that the implementation of an evidence-based clinical protocol for the diagnosis and treatment of acute appendicitis in children may safely decrease the use of CT scans and increase the use of ultrasound.

Early discharge following laparoscopic appendectomy in children utilizing an evidence-based clinical pathway

BACKGROUND

The utility of laparoscopic appendectomy (LA) in children remains controversial. The determination of the efficacy of LA in children is complicated by variable postoperative management, duration of antibiotics,and criteria for discharge. The aim of this study was to examine the results of a commitment to LA and the concurrent implementation of an evidence-based clinical pathway (CP) for management appendicitis in a children's hospital.

METHODS

With institutional review board approval, all children presenting with appendicitis (n = 72; age =10.6 +/- 0.1 years) were offered LA and management directed by CP. Data were accrued prospectively for 12 consecutive months (May 2006 to April 2007) and analysis performed at 15 months. Data are reported as the mean +/- standard error of the mean.

RESULTS

Children were stratified based on the operative findings: group one - acute 41; group two-suppurative=11; and group 3-gangrenous or perforated 20. Duration of hospital stay differed between the groups:group one= 26 +/- 0.3 hours; group 2 =48 +/- 3 hours; group 3= 127 +/- 6 hours (P <0.05). No patients in groups one or two suffered a complication or were readmitted following discharge. Two patients in group 3 (10%)were readmitted and treated with antibiotic therapy alone. Overall, 66% of the children with acute appendicitis(27/41) and 27% with suppurative appendicitis (3/11) were discharged within 24 hours of admission. Discharge by 24 hours in groups 1 and 2 was not influenced by age, gender, or time of operation (before or after 7 PM).

CONCLUSIONS

The commitment to LA and use of CP resulted in discharge within 24 hours in 2 of 3 of children with acute appendicitis without readmission or complications being observed. Early discharge was not influenced by age, gender, or time of admission. For advanced appendicitis, length of hospital stay, determined by clinical parameters, resulted in a low rate of complication or readmission.