Evaluation of a Novel Pediatric Appendicitis Pathway Using High- and Low-Risk Scoring Systems

From the *Department of Emergency Medicine, Oregon Health and Science University
Pediatric emergency care (Impact Factor: 1.05). 09/2013; 29(10). DOI: 10.1097/PEC.0b013e3182a5c9b6
Source: PubMed


This study aimed to determine the test characteristics of a pathway for pediatric appendicitis and its effects on emergency department (ED) length of stay, imaging, and admissions.
Children age 3 to 18 years with suspicion for appendicitis at 1 tertiary care ED were prospectively enrolled, using validated low- and high-risk scoring systems incorporating history, physical examination, and white blood cell count. Low-risk patients were discharged or observed in the ED. High-risk patients were admitted. Those meeting neither low-risk nor high-risk criteria were evaluated by surgery, with imaging at their discretion. Chart review or telephone follow-up was conducted 2 weeks after the visit. A retrospective study before and after was also performed. Charts of a random sample of patients evaluated for appendicitis in the 8 months before and after the pathway implementation were reviewed.
Appendicitis was diagnosed in 65 of 178 patients. Of those with appendicitis, 63 were not low-risk (sensitivity, 96.9%; specificity, 40.7%). The high-risk criteria had a sensitivity of 75.3% and specificity of 75.2%. We reviewed 292 visits before and 290 after the pathway implementation. Emergency department length of stay was similar (253 minutes before vs 257 minutes after, P = 0.77). Computed tomography was used in 12.7% of visits before and 6.9% of visits after (P = 0.02). Use of ultrasound was not significantly different (47.3% vs 53.7%). Admission rates were not significantly different (45.5% vs 42.7%).
The low-risk criteria had good sensitivity in ruling out appendicitis. The high-risk criteria could be used to guide referral or admission. Neither outperformed the a priori judgment of experienced providers.

1 Follower
19 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: Peritonitis is a progressive disease leading inexorably from local peritoneal irritation to overwhelming sepsis and death unless this trajectory is interrupted by timely and effective therapy. In children peritonitis is usually secondary to intraperitoneal disease the nature of which varies around the world. In rich countries appendicitis is the principal cause whilst in poor countries diseases such as typhoid must be considered in the differential diagnosis. Where resources are limited the clinical diagnosis of peritonitis mandates laparotomy for diagnosis and source control. In regions with unlimited resources radiological investigation, ultrasound, CT scan or MRI, may be used to select patients for non-operative management. For patients with appendicitis laparoscopic surgery has achieved results comparable to open operation however in many centres open operation remains the standard. In complicated peritonitis “damage control surgery” may be appropriate wherein source control is undertaken as an emergency with definitive repair or reconstruction awaiting improvement in the patient’s general condition. Awareness of abdominal compartment syndrome is essential. Primary peritonitis in rich countries is seen in high-risk groups such as steroid-dependent nephrotic syndrome patients whilst in poor countries the at-risk population is less well defined and the diagnosis is often made at surgery. (196 words)
    No preview · Article · Jun 2014 · Seminars in Pediatric Surgery

  • No preview · Article · Oct 2014 · Annals of Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: The objective was to characterize the variations in practice in the diagnosis and management of children admitted to hospitals from Canadian pediatric emergency departments (EDs) with suspected appendicitis, specifically the timing of surgical intervention, ED investigations, and management strategies. Twelve sites participated in this retrospective health record review. Children aged 3 to 17 years admitted to the hospital with suspected appendicitis were eligible. Site-specific demographics, investigations, and interventions performed were recorded and compared. Factors associated with after-hours surgery were determined using generalized estimating equations logistic regression. Of the 619 children meeting eligibility criteria, surgical intervention was performed in 547 (88%). After-hours surgery occurred in 76 of the 547 children, with significant variation across sites (13.9%, 95% confidence interval = 7.1% to 21.6%, p < 0.001). The overall perforation rate was 17.4% (95 of 547), and the negative appendectomy rate was 6.8% (37 of 547), varying across sites (p = 0.004 and p = 0.036, respectively). Use of inflammatory markers (p < 0.001), blood cultures (p < 0.001), ultrasound (p = 0.001), and computed tomography (p = 0.001) also varied by site. ED administration of narcotic analgesia and antibiotics varied across sites (p < 0.001 and p = 0.001, respectively), as did the type of surgical approach (p < 0.001). After-hours triage had a significant inverse association with after-hours surgery (p = 0.014). Across Canadian pediatric EDs, there exists significant variation in the diagnosis and management of children with suspected appendicitis. These results indicate that the best diagnostic and management strategies remain unclear and support the need for future prospective, multicenter studies to identify strategies associated with optimal patient outcomes. © 2015 by the Society for Academic Emergency Medicine.
    No preview · Article · Jun 2015 · Academic Emergency Medicine
Show more