Controversy in the classification of appendicitis and utilization of postoperative antibiotics

BACKGROUND

There is wide variability and considerable controversy regarding the classification of appendicitis and the need for postoperative antibiotics. This study aimed to assess interrater agreement with respect to the classification of appendicitis and its influence on the use of postoperative antibiotics amongst surgeons and surgical trainees.

METHODS

A survey comprising 15 intraoperative images captured during appendectomy was distributed to surgeons and surgical trainees. Participants were asked to classify severity of disease (normal, inflamed, purulent, gangrenous, perforated) and whether they would prescribe postoperative antibiotics. Statistical analysis included percent agreement, Krippendorff's alpha for interrater agreement, and logistic regression.

RESULTS

In total, 562 respondents completed the survey: 206 surgical trainees, 217 adult surgeons, and 139 pediatric surgeons. For classification of appendicitis, the statistical interrater agreement was highest for categorization as gangrenous/perforated versus nongangrenous/nonperforated (Krippendorff's alpha = 0.73) and lowest for perforated versus nonperforated (Krippendorff's alpha = 0.45). Fourteen percent of survey respondents would administer postoperative antibiotics for an inflamed appendix, 44% for suppurative, 75% for gangrenous, and 97% for perforated appendicitis. Interrater agreement of postoperative antibiotic use was low (Krippendorff's alpha = 0.28). The only significant factor associated with postoperative antibiotic utilization was 16 or more years in practice.

CONCLUSIONS

Surgeon agreement is poor with respect to both subjective appendicitis classification and objective utilization of postoperative antibiotics. This survey demonstrates that a large proportion (59%) of surgeons prescribe antibiotics after nongangrenous or nonperforated appendectomy, despite a lack of evidence basis for this practice. These findings highlight the need for further consensus to enable standardized research and avoid overtreatment with unnecessary antibiotics.

Optimal Timing of Postoperative Imaging for Complicated Appendicitis

PURPOSE

Approximately one quarter of children with complicated appendicitis develop postoperative abscess, leading to additional procedures and increased length of stay (LOS), but the optimal timing of postoperative imaging to detect abscess is unknown.

METHODS

The Pediatric Health Information System database was reviewed, and children who underwent laparoscopic appendectomy in 2013-2014 with postoperative LOS ≥5 days were included. Demographics, imaging, drainage procedures, LOS, and 30-day readmission were analyzed. Chi-squared analysis was performed.

RESULTS

A total of 21,985 patients underwent laparoscopic appendectomy and 3332 met inclusion criteria. A total of 1174 (35.2%) patients underwent postoperative imaging, among whom 38.4% underwent ultrasound and 75.0% underwent computed tomography scan. Timing of first imaging varied significantly between hospitals, ranging from 0% to 76% on postoperative day (POD) 5. Initial imaging was performed on POD 5, 6, and 7 in 19.7%, 31.3%, and 36.2%, respectively. Imaging on POD 5 compared with POD 7 was associated with shorter LOS (10.6 ± 5.7 versus 11.8 ± 4.4 days), but also lower rates of intervention (42.4% versus 50.8%), increased repeat imaging (10.8% versus 5.2%), and higher readmission rates (35.9% versus 28.2%) (P < .05).

CONCLUSION

Timing of postoperative imaging for complicated appendicitis is variable across hospitals. While earlier imaging was associated with a decreased LOS, these children also had lower rates of subsequent intervention coupled with higher rates of repeat imaging and readmission. These findings suggest that delaying imaging until at least POD 6 may maximize the diagnostic yield of imaging while decreasing radiation exposure and readmission. Prospective investigation should be undertaken to guide the development of standardized clinical practice guidelines for the management of perforated appendicitis.

Risk stratification in pediatric perforated appendicitis: Prospective correlation with outcomes and resource utilization

PURPOSE

Despite a wide spectrum of severity, perforated appendicitis in children is typically considered a single entity in outcomes studies. We performed a prospective cohort study to define a risk stratification system that correlates with outcomes and resource utilization.

METHODS

A prospective study was conducted of all children operated for perforated appendicitis between May 2015 and December 2016 at a tertiary free-standing university children's hospital. Surgical findings were classified into one of four grades of perforation: I. localized or contained perforation, II. Contained abscess with no generalized peritonitis, III. Generalized peritonitis with no dominant abscess, IV. Generalized peritonitis with one or more dominant abscesses. All patients were treated on a clinical pathway that involved all points of care from admission to final follow-up. Outcomes and resource utilization measures were analyzed using Fisher's exact test, Kruskal-Wallis test, One-way ANOVA, and logistic regression.

RESULTS

During the study period, 122 patients completed treatment, and 100% had documented follow-up at a median of 25days after operation. Grades of perforation were: I, 20.5%; II, 37.7%; III, 10.7%; IV, 31.1%. Postoperative abscesses occurred in 12 (9.8%) of patients, almost exclusively in Grade IV perforations. Hospital stay, duration of antibiotics, TPN utilization, and the incidence of postoperative imaging significantly increased with increasing grade of perforation.

CONCLUSION

Outcomes and resource utilization strongly correlate with increasing grade of perforated appendicitis. Postoperative abscesses, additional imaging, and additional invasive procedures occur disproportionately in patients who present with diffuse peritonitis and abscess formation. The current stratification allows risk-adjusted outcome reporting and appropriate assignment of resource burden.

LEVEL OF EVIDENCE

I (Prognosis Study).

Standardization of care for pediatric perforated appendicitis improves outcomes

BACKGROUND

The treatment of perforated appendicitis in children is characterized by significant variability in care, morbidity, resource utilization, and outcomes. We prospectively studied how minimization of care variability affects outcomes.

METHODS

A clinical pathway for perforated appendicitis, in use for three decades, was further standardized in May 2015 by initiation of a disease severity classification, refinement of discharge criteria, standardization of the operation, and establishment of criteria for use of postoperative total parenteral nutrition, imaging, and invasive procedures. Prospective evaluation of all children treated for 20months on the new fully standardized protocol was conducted and compared to a retrospective cohort treated over 58months prior to standardization. Differences between outcomes before and after standardization were analyzed using regression analysis techniques to adjust for disease severity.

RESULTS

Median follow-up time post discharge was 25 and 14days in the post- and prestandardization groups, respectively. Standardization significantly reduced postoperative abscess (9.8% vs. 17.4%, p=0.001) and hospital stay (p=0.002). Standardization reduced the odds of developing a postoperative abscess by four fold.

CONCLUSION

Minimizing variability of care at all points in the treatment of perforated appendicitis significantly improves outcomes.

TYPE OF STUDY

Prospective Cohort Study.

LEVEL OF EVIDENCE

Level II.

Low Infection-Related Re-Admission Rates in a Retrospective of 4725 Children with Appendicitis Using a Clinical Pathway in a Tertiary Care Pediatric Center

BACKGROUND

Standardization of antibiotic management of appendicitis in tertiary care pediatric centers has been associated with improved outcomes. Rady Children's Hospital-San Diego implemented an appendicitis clinical pathway in 2005. We evaluated infection-related re-admission risk factors since 2010, when an electronic medical record was established, with the aim to optimize the clinical pathway.

METHODS

Between January 2010 and August 2015, 4725 children with a diagnosis of appendicitis were evaluated for demographic data, pathology diagnoses, culture results, and inpatient and oral step-down antibiotic therapy regimens. From children originally admitted for appendicitis, those who were re-admitted with infection were compared with those who were not re-admitted for infection. The populations were controlled by severity of infection using a pathology-defined appendicitis severity scale: Grade 0, no appendicitis; grade 1, simple acute appendicitis with gross and microscopic evidence of inflammation, but no perforation; grade 2, gangrenous/necrotizing/micro-perforated appendicitis with subserosal or serosal exudate, but no frank or visually appreciated perforation; and grade 3, frank perforation.

RESULTS

Of 4725 children (total population, TP) admitted with a diagnosis of appendicitis, only 199 (4.2%) were re-admitted, with 125 of these admissions for infection (2.65% of the TP). Age, race/ethnicity, language preference, and body mass index were not found to correlate with re-admission for infection. Length of stay significantly differed between the no infection-related re-admission population and infection-related re-admission population (3.02 vs. 4.03 d, p < 0.001). There was a trend toward higher infection-re-admission rates as the pathology grade increased (odds ratio grade 1 vs. grade 3 = 2.28, 95% confidence interval 1.03, 5.03).

CONCLUSIONS

Infection-related re-admission rates for children on the clinical pathway in our institution were infrequent. The greater association of all-cause and infection-related re-admission rates with pathology grade suggest that defining appendicitis by pathology and clinical severity may provide an evidence-based scoring system to support clinical observation in the use and duration of antibiotic therapy.

The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection

BACKGROUND

Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations.

METHODS

Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council.

RESULTS

This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included.

SUMMARY

The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.

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.

The contribution of practice variation to length of stay for children with perforated appendicitis

BACKGROUND

Postoperative length of stay (pLOS) is an easily tracked outcome that reflects health care efficiency and resource utilization. The purpose of this study was to determine the contribution of practice variation on pLOS for children with perforated appendicitis.

METHODS

Children ages 2-18years with appendectomy for complicated appendicitis were selected from the National Surgical Quality Improvement Program-Pediatric. Extended pLOS (EpLOS) was defined as ≥7days (75th percentile). The contribution of comorbidities, operative traits, and postoperative complications to EpLOS was evaluated using regression models and matched subgroup analyses.

RESULTS

Of 2585 children with complicated appendicitis in our study, 835 had EpLOS. Regression analysis found that EpLOS was associated with extended operative time (odds ratio (OR) 1.99; 95% confidence interval (CI) 1.63-2.44), dehiscence (OR 13.19; 95% CI 1.52-114.23), wound infection (OR 7.39; 95% CI 2.63-20.80), organ space infection (OR 92.51; 95% CI 34.03-251.50), and pneumonia (OR 4.55; 95% CI 1.06-19.44). Over three-fourths of the variation in pLOS could not be explained by preoperative, intraoperative, or postoperative factors.

CONCLUSIONS

There is significant variation in pLOS for children undergoing appendectomy that is not accounted for by comorbidities, operative traits, or complications indicating an opportunity to improve outcomes through modifying practice patterns.

Current level and determinants of inappropriate admissions to township hospitals under the new rural cooperative medical system in China: a cross-sectional study

BACKGROUND

The increased funding and reimbursement for the New Rural Cooperative Medical System (NRCMS) have provided residents in rural China with better access to inpatient services. This research aims to examine the level of inappropriate admissions to township hospitals under NRCMS, and the determinants that influence inappropriate admissions.

METHODS

A total of 2,044 medical records in 10 township hospitals were collected from five counties in Midwestern China by stratified cluster sampling and evaluated using the Appropriateness Evaluation Protocol (AEP), which was developed by a Delphi expert consultation of 32 experts. A two-level logistic regression model by MLwiN 2.30 was used to examine the determinants of inappropriate admissions.

RESULTS

Township hospitals had an average inappropriate admission rate of 26.5%. The highest rate of inappropriate admission was among patients aged more than 59 years old (30.1%). Inappropriate admissions mostly occurred for respiratory and circulatory diseases. Township hospital similarity and clustering were observed. Two-level logistic regression analysis showed that age, treating department, and disease were determinants of inappropriate admission.

CONCLUSIONS

Township hospitals have a high rate of inappropriate admissions. Explicit diagnostic criteria and a standardized supervision system should be developed to reduce this.

Determinants of postoperative abscess occurrence and percutaneous drainage in children with perforated appendicitis

PURPOSE

Postoperative abscesses after perforated appendicitis have no clear risk factors or indications for percutaneous drainage. Our study addressed these two issues.

METHODS

A logistic regression model was used to delineate risk factors for postoperative abscess in children with perforated appendicitis treated during a recent 5-year period. Drainage of abscess was compared to antibiotic treatment.

RESULTS

Postoperative abscess occurred in 42 (14.8%) of 284 patients. Higher WBC count, presence of bowel obstruction at presentation, diffuse peritonitis with a dominant abscess at surgery, and one specific surgeon were significantly associated with postoperative abscess, while fever or pain requiring narcotics at the time of abscess diagnosis was significantly associated with drainage. Compared to non-drainage, those drained had longer hospital stay including readmissions (15.9 ± 5.3 vs. 12.2 ± 4.6 days, p < 0.005) and less readmissions (9.5 vs. 33.3%, p = 0.06). Over the 5-year period, there was no increased trend in abscess occurrence (p = 0.56), but there was an increased trend in the use of percutaneous drainage (p = 0.02).

CONCLUSIONS

The risk of a postoperative abscess can be predicted by specific clinical characteristics, surgical findings, and treatment-related factors. Percutaneous drainage was associated with longer hospital stays, but less readmissions.

Benefits of an abridged antibiotic protocol for treatment of gangrenous appendicitis

BACKGROUND

We previously reported a validated, objective definition of gangrenous, nonperforated appendicitis. In this study, we compared a cohort of children with gangrenous appendicitis treated with abridged antibiotics (AA) to another treated with prolonged antibiotics (PA).

METHODS

In 2012, our service changed its standard of care for gangrenous appendicitis from PA to AA. In PA, patients received postoperative triple antibiotics until ileus resolved, they were afebrile (<37.5°C) for 24hours, and achieved a normal WBC count. In AA, patients received two doses of postoperative triple antibiotics. A PA cohort during a 12-month period (February 2010-January 2011) was compared to an AA cohort during another 12-month period (April 2012-March 2013).

RESULTS

Twenty patients were treated with AA and 38 patients with PA. AA patients had a significantly shorter overall length of stay (2.1±1.58 vs. 3.18±1.09days, p=0.003), as well as a significantly shorter postoperative stay (1.85±1.42 vs. 2.95±1.14days, p=0.002). There were no differences between the AA and PA cohorts in wound infections (0%), intraabdominal infections (0%), or appendicitis-related readmissions (0%).

CONCLUSIONS

Abridged postoperative antibiotics for gangrenous appendicitis significantly shorten hospital stay without increasing complications.

Determinants of appendicitis outcomes in Canadian children

BACKGROUND

Outcomes of appendicitis may be influenced by access to healthcare. We investigated the determinants of pediatric appendicitis outcomes in the single-payer Canadian healthcare system.

METHODS

Children coded for urgent appendectomy by the Canadian Institute of Health Information during the period 2004-2010 were analyzed. Misdiagnosis rate, perforated appendicitis rate, and hospital stay were the outcomes studied. Analyzed variables included age, gender, domicile, socioeconomic status, surgeon's specialty, hospital type, region, and operative approach. Logistic regression analysis was used to examine associations, and a quintile regression model examined the effect on median hospital stay.

RESULTS

41,702 patients were studied. A higher rate of perforated appendicitis was associated with lower age [OR 2.66], male gender [OR 1.18], pediatric surgeon [OR 1.25], and treatment outside the Maritimes. A higher rate of misdiagnosis was associated with lower age [OR 1.53], female gender [OR 2.29], non-children's hospital [OR 1.33], and western Canada [OR 1.22]. A significantly longer hospital stay was associated with open appendectomy, pediatric surgeon, and the Territories for simple appendicitis, and open appendectomy, pediatric surgeon, children's hospital, and the Maritimes for perforated appendicitis.

CONCLUSIONS

In Canada, outcomes of pediatric appendicitis are associated with regional and treatment-level factors. Rural domicile and socioeconomic status do not affect outcomes.

Use of a clinical pathway to improve the acute management of vaso-occlusive crisis pain in pediatric sickle cell disease

BACKGROUND

The most common, debilitating morbidity of sickle cell disease (SCD) is vaso-occlusive crisis (VOC) pain. Although guidelines exist for its management, they are generally not well-followed, and research in other pediatric diseases has shown that clinical pathways improve care. The purpose of our study was to determine whether a clinical pathway improves the acute management of sickle cell vaso-occlusive crisis (VOC) pain in the pediatric emergency department (PED).

PROCEDURE

Pain management practices were prospectively investigated before and after the initiation of a clinical pathway in the PED of an urban, tertiary care center with 50,000 ED visits per year and approximately 200 active sickle cell patients. The pathway included instructions for triage, monitoring, medication administration, and timing of assessments and interventions. Data were eligible from 35 pre-pathway and 33 post-pathway visits. Primary outcome was time interval to administration of first analgesic medication. Statistical analysis was by Student's t-test, using natural-log-transformed data for outcomes with skewed distribution curves.

RESULTS

Time interval to first analgesic improved from 74 to 42 minutes (P = 0.012) and to first opioid from 94 to 46 minutes (P = 0.013). The percentage of patients who received ketorolac increased from 57% to 82% (P = 0.03). Decrease in time interval to subsequent pain score assessment was not statistically significant (110 to 72 minutes (P = 0.07)), and change in pain score was not different (P = 0.25).

CONCLUSIONS

The use of a clinical pathway for sickle cell VOC in the PED can improve important aspects of pain management and merits further investigation and implementation.

Gangrenous appendicitis in children: a prospective evaluation of definition, bacteriology, histopathology, and outcomes

INTRODUCTION

The definition and treatment of gangrenous appendicitis are not agreed upon. We performed a prospective study in children to evaluate an objective definition of gangrenous appendicitis, as well as associated bacteriology, histopathology, and outcomes.

METHODS

Five staff pediatric surgeons prospectively enrolled patients in the study at the time of appendectomy if the following five criteria were met: gray or black discoloration of the appendiceal wall; absence of fecalith outside the appendix; absence of visible hole in the appendix; absence of gross purulence or fibrinous exudate remote from the appendix; and absence of intraoperative appendiceal leak. Peritoneal fluid was cultured, and a standard histopathologic review was undertaken. Persistence of fever (>37.5°C) and ileus was documented daily. Patients were continued postoperatively on ampicillin, gentamicin, and metronidazole until they tolerated diet, manifested a 24-h afebrile period, and had a normal leukocyte count. Hospital stay, readmissions, and infectious complications were recorded. The study took place over a 12-mo period.

RESULTS

Thirty-eight patients were enrolled, representing 17% of all patients with appendicitis treated during the year. Average age was 10.8 ± 3.5 y. Peritoneal cultures were positive in 53% of cases. Gangrene was documented histologically in 61% of specimens. Hospital stay was 3.2 ± 1.1 d. There were no postoperative infectious complications or readmissions related to the disease. Neither culture results nor histologic gangrene had a statistically significant effect on hospital stay.

CONCLUSIONS

An objective definition of gangrenous appendicitis is reproducible and has good histopathologic association. Recovery from gangrenous appendicitis is not influenced by culture or pathology results, and postoperative complications are rare. Limiting postoperative antibiotics to 24 h in gangrenous appendicitis may significantly decrease the cost of treatment without increasing morbidity.

The process of treating pediatric appendicitis

BACKGROUND

A large service and distant geographical area can make the process of diagnosing and treating appendicitis a challenge.

METHODS

Hospital records of children treated for appendicitis between 2007 and 2009 were retrospectively analyzed, including time from emergency (ER) to operating room (OR), diagnostic imaging (DI) utilization, preoperative antibiotic usage, operating time, length of stay (LOS), and perforation rate.

RESULTS

The perforation rate was 34%, with longer LOS. Transfer time to the children's hospital between ER inside and outside the city was not different. ER to OR time was significantly shorter for patients assessed at the children's hospital directly. Ultrasound remained the most used DI modality (55%). Preoperative antibiotics were only fully administered in 42% of the cases.

CONCLUSION

A clinical pathway for pediatric appendicitis may address the challenges of the process of pre-ER, ER to OR, and OR care to maintain an acceptable perforation rate.

Emerging ethical issues in pediatric surgery

With the rapid pace of technological advancement and changing political, social, and legal attitudes, physicians face new ethical dilemmas. For pediatric surgeons, these emerging issues affect our relationship with, and the care we provide, to our patients and their families. In this review, we explore issues related to professionalism in pediatric surgery practice, the value of apology, and the risks associated with sleep deprivation. Furthermore, we discuss how the imperative of patient safety presents an opportunity for specialty-driven effort to define standards for the surgical care of children and a responsible process for introducing surgical innovations. Finally, we remind pediatric surgeons of their ethical and professional duty to support clinical research, and advocate the acceptance of community equipoise as sufficient basis for enrolling children in clinical trials.

A complete course of intravenous antibiotics vs a combination of intravenous and oral antibiotics for perforated appendicitis in children: a prospective, randomized trial

INTRODUCTION

In a previous prospective randomized trial, we found a once-a-day regimen of ceftriaxone and metronidazole to be an efficient, cost-effective treatment for children with perforated appendicitis. In this study, we evaluated the safety of discharging patients to complete an oral course of antibiotics.

METHODS

Children found to have perforated appendicitis at the time of laparoscopic appendectomy were enrolled in the study. Perforation was defined as a hole in the appendix or fecalith in the abdomen. Patients were randomized to antibiotic treatment with either once daily dosing of ceftriaxone and metronidazole for a minimum of 5 days (intravenous [IV] arm) or discharge to home on oral amoxicillin/clavulanate when tolerating a regular diet (IV/PO arm) to complete 7 days.

RESULTS

One hundred two patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in age, weight, sex distribution, days of symptoms, maximum temperature, or leukocyte count between the 2 groups. There was no difference in the postoperative abscess rate between the two treatment groups. Discharge was possible before day 5 in 42% of the patients in the IV/PO arm.

CONCLUSIONS

When patients are able to tolerate a regular diet, completing the course of antibiotics orally decreases hospitalization with no effect on the risk of postoperative abscess formation.

Appendicitis in northern aboriginal children: does delay in definitive treatment affect outcome?

BACKGROUND

The treatment of northern aboriginal children (NAC) is often complicated by distance from a treating facility. We sought to compare outcomes of NAC requiring transfer with appendicitis to those who presented locally. We hypothesized that NAC with appendicitis experienced higher rates of perforation and increased length of stay (LOS).

METHODS

A retrospective chart review of 210 appendectomies was performed. Charts were reviewed for age, sex, weight, days of symptoms before presentation, time of transfer, leukocyte count (white blood cell count), usage of antibiotics prior to transfer, time to operation, type of procedure and findings, pathology, postoperative outcomes, and LOS.

RESULTS

Sixty-eight children were NAC, whereas 142 were local. The average transfer times for NAC was 10 hours (range, 4-20 hours). The two groups had similar ages (11.1 vs 10.7 years), time to presentation (1.64 vs 1.85 days), and LOS (2.91 vs 2.90 days). Significantly higher perforation rates (44 vs 28%; P = .02), higher white blood cell count (17.9 vs 16.0; P = .02), and longer times to operation after arrival (10.3 vs 7.0 hours; P = .0002) were noted in NAC. Postoperative complications were similar between groups. Forty-seven (69%) NAC received antibiotics prior to transfer, which did not affect rate of rupture.

CONCLUSION

NAC with appendicitis experience longer transfer times and higher perforation rates than local children without a difference in length of stay or complications. Pretransfer antibiotics do not reduce perforation rates but may impact complications. We endorse their use if a delay in transfer is anticipated.

Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs

BACKGROUND

Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency.

OBJECTIVES

To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs.

SEARCH STRATEGY

We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care.

MAIN RESULTS

Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 13.65: 95%CI 5.38 to 34.64). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD -4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results. An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups.

AUTHORS' CONCLUSIONS

Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.

Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003–2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

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.

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.

It is not what you do, it is the way that you do it: impact of a care pathway for appendicitis

BACKGROUND/PURPOSE

Appendicitis is the most common surgical emergency in children. However, management varies widely. The aim of this study was to assess the impact of introducing a care pathway on the management of childhood appendicitis.

METHODS

Data were collected prospectively for 3 successive cohorts: All patients operated for suspected appendicitis were included. The pathway was modified after interim analysis of group B data. P < .05 was significant.

RESULTS

Six hundred patients were included. When compared with group A, group C patients were more likely to receive preoperative antibiotics (P < .0001), undergo formal pain assessment (P < .0001), and be operated before midnight (P = .025). There was a significant decrease in readmission rates from 10.0% to 4.2% (P = .023) despite an increase in cases of gangrenous and perforated appendicitis (P = .010).

CONCLUSIONS

The introduction of a care pathway resulted in improved compliance with antibiotic regimens, more frequent pain assessment, and fewer post-midnight operations. Postappendicectomy readmission rates were reduced despite an increase in disease severity. This was achieved by critical reevaluation of outcomes and pathway redesign where appropriate.

Antibiotic Therapy and Interval Appendectomy for Perforated Appendicitis in Children: A Selective Approach

The role of initial nonoperative treatment in pediatric perforated appendicitis remains controversial. We examined our outcomes after using this approach in a selective manner. Children with perforated appendicitis treated during a 28-month period were retrospectively reviewed. Antibiotics and delayed appendectomy were used if there were more than 3 days of symptoms, absence of bowel obstruction, absence of diffuse peritonitis, and an appendiceal mass. Of 221 patients with perforated appendicitis, 32 (14%) were treated with this approach. Average age was 7.4 ± 4.2 years. Twenty-eight patients (88%) were successfully managed and 26 (81%) underwent appendectomy 8.6 ± 4.2 weeks after first presentation. Two patients did not respond completely, and underwent appendectomy during the same admission. Two patients initially responded, but had recurrent symptoms necessitating earlier appendectomy. There were no complications. Average total hospital stay was 7.2 ± 3.0 days. Initial nonoperative treatment is highly successful in selected children who meet specific criteria. Failure is not associated with increased morbidity.