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Standardized protocol for treating children with appendicitis. a Complicated appendicitis includes suppurative, gangrenous, and perforated appendicitis. b Discharge criteria include afebrile for 24 hours, tolerating a regular diet, pain controlled with oral medications.
Source publication
Appendicitis is the most common condition requiring emergency surgery in children. We implemented a standardized protocol (SP) for treating children with appendicitis to provide more uniform care and reduce resource utilization.
Methods:
All patients younger than 21 years were managed with the SP beginning in January 2017. We compared data from 2...
Context in source publication
Context 1
... SP applies to all children treated surgically for appendicitis, including uncomplicated and complicated cases ( Fig. 1). After the diagnosis of acute appendicitis, clinicians administered single preoperative doses of ceftriaxone (50 mg/kg, maximum 2,000 mg) and metronidazole (30 mg/kg, maximum 1,500 mg). They took the child for an appendectomy at the next available operating room (OR) time. For children with severe beta-lactam allergies, clinicians ...
Citations
... Hospitalization costs following an uncomplicated or complicated appendectomy vary from an estimated USD 6000 to USD 15,500, costing an estimated three billion annually [2,3]. The estimated cost of an uncomplicated appendectomy per encounter is variable in the literature. ...
An uncomplicated appendectomy in children is common. Safely minimizing the post-operative length of stay is desirable from hospital, patient, and parent perspectives. In response to an overly long mean length of stay following uncomplicated appendectomies in children of 2.5 days, we developed clinical pathways with the goal of safely reducing this time to 2.0 or fewer days. The project was conducted in an urban, academic children’s hospital. The pathways emphasized the use of oral, non-narcotic pain medications; the education of parents and caregivers about expectations regarding pain control, oral food intake, and mobility; and the avoidance of routine post-operative antibiotic use. A convenience sample of 46 patients aged 3–16 years old was included to evaluate the safety and efficacy of the intervention. The mean post-operative length of stay was successfully reduced by 80% to 0.5 days without appreciable complications associated with earlier discharge. The hospital length of stay following an uncomplicated appendectomy in children may be successfully and safely reduced through the use of carefully devised, well-defined, well-disseminated clinical pathways.
... Según el apéndice se encuentre en fase flemonosa, gangrenosa o perforada se establece un plan de tratamiento antibiótico, pruebas complementarias postoperatorias y una estimación de estancia hospitalaria (EH). Sin embargo, existe variabilidad en cuanto a la elección y duración del tratamiento antibiótico, así como la indicación del momento de alta hospitalaria (2)(3)(4)(5)(6) . ...
... En cuanto a la selección de antibiótico, autores como Zachary I Willis et al. (12) , o Cundy TP (6) abogan por la monoterapia con piperacilina-tazobactam (PT) para las AA complicadas; mientras que otros estudios defienden la terapia combinada de cefalosporinas de amplio espectro y metronidazol (3,5) , como la empleada en nuestro centro. Atendiendo a la duración de la APO, Pennell C et al. (4) , proponen un mínimo de 3 días de ceftriaxona y metronidazol i.v y posteriormente cambio a APO oral entre 5 o 7 días; Skarda et al. (3) emplean ceftriaxona y metronidazol durante 5 días. La realización de control analítico antes del alta en las AA complicadas es frecuente (3,4,12) . ...
... Atendiendo a la duración de la APO, Pennell C et al. (4) , proponen un mínimo de 3 días de ceftriaxona y metronidazol i.v y posteriormente cambio a APO oral entre 5 o 7 días; Skarda et al. (3) emplean ceftriaxona y metronidazol durante 5 días. La realización de control analítico antes del alta en las AA complicadas es frecuente (3,4,12) . Dada la heterogeneidad de los protocolos existentes, resulta complicado realizar comparaciones, pero el factor común es la mejoría de los resultados clínicos y menor empleo de recursos con la implementación de protocolos (10,12) . ...
... The management of patients undergoing AA surgery depends on intraoperative findings. According to whether the appendix is in a phlegmonous, gangrenous, or perforated stage, antibiotic treatment, additional However, there is variability in terms of choice and duration of antibiotic treatment, as well as hospital discharge timing (2)(3)(4)(5)(6) . According to the WHO recommendations regarding the increase in antibiotic resistance (7) , the antibiotic regimen is to be chosen for each patient on an individual basis. ...
... Regarding the antibiotic choice, authors such as Zachary I Willis et al. (12) or Cundy TP (6) advocate monotherapy with piperacillin-tazobactam (PT) for complicated AA, whereas other studies support combined therapy with wide-spectrum cephalosporins and metronidazole (3,5) , as it is the case in our institution. According to POAT duration, Pennell C et al. (4) propose a minimum of 3 days with IV ceftriaxone and metronidazole, then swap to oral POAT for 5 to 7 days, whereas Skarda et al. (3) use ceftriaxone and metronidazole for 5 days. Control blood test before discharge in complicated AA is frequent (3,4,12) . ...
... According to POAT duration, Pennell C et al. (4) propose a minimum of 3 days with IV ceftriaxone and metronidazole, then swap to oral POAT for 5 to 7 days, whereas Skarda et al. (3) use ceftriaxone and metronidazole for 5 days. Control blood test before discharge in complicated AA is frequent (3,4,12) . Given the heterogeneity of the existing protocols, comparisons are uneasy to make, but clinical result improvement and lower resource use are common following protocol implementation (10,12) . ...
Objective:
Acute appendicitis (AA) is the most frequent urgent surgical pathology in the pediatric population, but postoperative management is variable, with protocols minimizing variability. We present our results following the optimization of the management protocol in our institution in order to establish its efficacy in terms of number of infectious complications and optimization of resources in our environment.
Materials and methods:
An observational, retrospective study of patients undergoing AA surgery from January 2018 to August 2022 was carried out. Two cohorts were compared, both before (1) and after (2) the implementation of the new protocol. They were divided according to severity in order to conduct a subgroup-based analysis -phlegmonous (PH), gangrenous (G), and perforated (P) appendicitis.
Results:
771 patients (1: 390; 2: 381) were included, with a homogeneous distribution and a median age of 9.3 ± 2.8 years. Blood tests requested prior to discharge experienced a significant reduction (PH: 3.9% vs. 0.5%; p= 0.026; G: 97.6% vs. 13.4%, p< 0.001). Days of hospital stay decreased in the PH (1.2 IQR: 0.7 vs. 1 IQR: 0.36; p< 0.001) and G (4 IQR: 1 vs. 3 IQR: 1 days; p< 0.001) subgroups. No differences in the number of abscesses were found between groups (41 vs. 43; p= 0.73), but they were noted within subgroup G (9 vs. 2; p= 0.029). A reduction in resource expenses was detected in PH and G appendicitis.
Conclusions:
In our study, the most widely benefited subgroup following protocol optimization was the gangrenous appendicitis subgroup, with a significant reduction in the number of complications and the use of hospital resources.
... Investigation of clinical pathways across medical disciplines, pediatric conditions, and pediatric appendicitis show improved outcomes related to CPG use, including decreased inpatient complications, length of stay, and costs without impacting readmission or in-hospital mortality. 14,15 Quality improvement projects in pediatric appendicitis have shown a positive impact on outcomes and value, which includes decreased antibiotic usage, reduced hospital stay, mitigation of racial disparities in care, and decrease in overall cost burden 3,4,[16][17][18][19] Guideline creation does not guarantee a change in outcomes. Guideline nonadherence can mitigate the effects of a well-crafted pathway. ...
Unlabelled:
Same-day discharge of children after appendectomy for simple appendicitis is safe and associated with enhanced parent satisfaction. Our general pediatric surgeons aimed to improve the rate of same-day discharge after appendectomy for simple appendicitis.
Methods:
We implemented a clinical practice guideline in September 2019. A surgeon-of-the-week service model and the urgent operating room started in November 2019 and January 2020, respectively. Data for children with simple appendicitis from our academic medical center were gathered prospectively using National Surgical Quality Improvement Program-Pediatric. Patient outcomes before intervention implementation (n = 278) were compared with patients following implementation (n = 264).
Results:
The average monthly percentage of patients discharged on the day of surgery increased in the postimplementation group (32% versus 75%). Median postoperative length of stay decreased [16.5 hours (interquartile range, 15.9) versus 4.4 hours (interquartile range, 11.7), P < 0.001], and the proportion of patients discharged directly from the postoperative anesthesia care unit increased (22.8% versus 43.6%; P < 0.001). There were no differences in balancing measures, including the return to the emergency department and readmission. Fewer children were discharged home on oral antibiotics after implementation (6.8% versus 1.5%, P = 0.002), and opioid prescribing at discharge remained low (2.5% versus 1.1%, P = 0.385).
Conclusions:
Using quality improvement methodology and care standardization, we significantly improved the rate of same-day discharge after appendectomy for simple appendicitis without impacting emergency department visits or readmissions. As a result, our health care system saved 140 hospital days over the first 21 months.
... various factors, from patient characteristics to the type of surgery, play a role in the planning of care standards. 4,9,10 Care planning also includes preoperative preparation of the gastrointestinal system, informing the child and family about the procedure, postoperative nutrition, mobilization, and medical treatment. 9 Timely identification of perforation status in preoperative planning and tailored care can improve the patient's response to treatment, expedite recovery, and shorten hospital stays, thus reducing mortality and morbidity rates. ...
... Comprehensive postoperative planning, which includes aspects like nutrition, excretory mobilization, and pain relief, is pivotal for recovery 5,10,22,23 and can reduce the duration of hospitalization. 24 It is crucial to initiate nutrition early, and this decision should be based on the perforation status. ...
Objective: Appendicitis is the most common surgical emergency in childhood and requires urgent intervention. The goal of this research was to identify the factors influencing healing in perforated and non-perforated appendectomy procedures.
Materials and Methods: This descriptive research involved 75 children who underwent appendectomy. Information was collected during the preoperative and postoperative stages using a data collection form and a pain assessment scale. Both parents and children hospitalized with appendicitis contributed to this information.
Results: The primary complaints leading children to the hospital were nausea and vomiting, which started, on average, 2.7 days prior to admission. While 96% of the children underwent open surgery, 77.3% presented with non-perforated appendicitis. Feeding was ceased 9 hours pre-operation and recommenced in the 15th postoperative hour. A significant difference was noted between perforation status and discharge time. Factors influencing healing included the length of hospital stay, perforation status, preoperative information, time of postoperative oral feeding initiation, and intravenous fluid therapy.
Conclusion: The study suggests that early feeding, mobilization, and patient counseling can reduce pain and expedite recovery and discharge.
Keywords: Appendectomy, child, nutritional status, healing, operation.
... The clinical results of the established protocols in the management of appendicitis are insufficient, and it is reported that more data are required to determine standard protocols (3)(4)(5)(6)(7)(8)(9) .The aim of this study is to present our clinical outcomes of setting standardization in the management of appendicitis in children. ...
... There are many studies in the literature about the benefits of setting a standard protocol in the management of the patients with appendicitis (3)(4)(5)(6)(7)(8)(9) . These protocols have been shown to reduce variation in the management of appendicitis, reduce resource utilization, and improve outcomes. ...
... The results of different studies on clinical protocols applications in children with appendicitis are shown in Table 5 (3)(4)(5)(6)(7)(8)(9) . When the results of the different standardized protocols determined for the preoperative, operative and postoperative periods are reviewed, it is seen that the postoperative complication rates in perforated appendicitis are mostly reduced. ...
... Our findings are consistent with the medical literature demonstrating that standardization of care with clinical practice guidelines can improve outcomes after appendectomy [ 3 , 21-24 ]. Specifically, utilization of care pathways has been correlated with reduced SSI development [ 3 , 21 ] and decreased healthcare resource utilization [3,[21][22][23][24] in children with CA. ...
Background
The rate of surgical site infection (SSI) after appendectomy for complicated appendicitis (CA) was high at our children's hospital. We hypothesized that practice standardization, including obtaining intra-operative cultures of abdominal fluid in patients with CA, would improve outcomes and reduce healthcare utilization after appendectomy.
Methods
A quality improvement team designed and implemented a clinical practice guideline for CA that included obtaining intra-operative culture of purulent fluid, administering piperacillin/tazobactam for at least 72 hours post-operatively, and transitioning to oral antibiotics based on intraoperative culture data. We compared outcomes before and after guideline implementation.
Results
From July 2018-October 2019, 63 children underwent appendectomy for CA compared to 41 children from January-December 2020. Compliance with our process measures are as follows: Intra-operative culture was obtained in 98% of patients post-implementation; 95% received at least 72 hours of piperacillin-tazobactam; and culture results were checked on all patients. Culture results altered the choice of discharge antibiotics in 12 (29%) of patients. All-cause morbidity (SSI, emergency department visit, readmission to hospital, percutaneous drain, unplanned return to operating room) decreased significantly from 35% to 15% (p=0.02). Surgical site infections became less frequent, occurring on average every 27 days pre-implementation and every 60 days after care pathway implementation (p=0.03).
Conclusions
Utilization of a clinical practice guideline was associated with reduced morbidity after appendectomy for CA. Intra-operative fluid culture during appendectomy for CA appears to facilitate the selection of appropriate post-operative antibiotics and, thus, minimize SSIs and overall morbidity.
Background
Obesity is a growing public health concern that places patients at risk of morbidity and mortality following surgery. We sought to determine whether obesity influences our resource utilization and postoperative outcomes for patients who present with appendicitis.
Methods
Charts were reviewed for patients age 1–18 years identified from a prospective registry who presented with a diagnosis of appendicitis from 2017 to 2020. Patients who underwent appendectomy were eligible. Charts were reviewed for demographics, imaging studies, laboratory studies, length of stay, operative times and thirty-day postoperative adverse events defined as return to the emergency room, re-admission, postoperative abscess or return to the operating room. A multivariate logistic regression analysis was performed to identify differences in resource utilization and outcome.
Results
A total of 451 patients were identified. There were 126 obese patients (27.9%). Obese patients were not more likely to present with perforated appendicitis and were not more likely to undergo computed tomography scans. All patients underwent laparoscopic appendectomy. Although intraoperative times were significantly longer for Black patients and older patients, BMI did not influence length of surgery. Length of stay was significantly higher for younger patients (p = 0.019). Adverse events were seen in 38 patients (8.4%). There was no association between BMI and adverse events.
Conclusions
Within our standardized management pathway, obesity does not influence management or patient outcomes for the treatment of appendicitis. Furthermore, obese patients did not require additional resource utilization.
