Evaluation of a novel pediatric appendicitis pathway using high- and low-risk scoring systems.

Abstract

OBJECTIVES:

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.

METHODS:

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.

RESULTS:

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%).

CONCLUSIONS:

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.

• Authors: Ross J Fleischman, Miranda K Devine, Marie-Annick N Yagapen, Angela J Steichen, Matthew L Hansen, Andrew F Zigman, David M Spiro
• Journal: Pediatric emergency care (Pediatr Emerg Care) Vol. 29 Issue 10 Pg. 1060-5 (Oct 2013) ISSN: 1535-1815 [Electronic] United States
• PMID: 24076607 (Publication Type: Journal Article, Research Support, Non-U.S. Gov't)

Topics

• Abdominal Pain (etiology)
• Adolescent
• Appendectomy (statistics & numerical data)
• Appendicitis (diagnosis, diagnostic imaging, surgery)
• Child
• Child, Preschool
• Critical Pathways
• Emergencies
• Emergency Service, Hospital (statistics & numerical data)
• Female
• Follow-Up Studies
• Humans
• Length of Stay (statistics & numerical data)
• Male
• Palpation
• Patient Admission (statistics & numerical data)
• Patient Selection
• Physical Examination
• Predictive Value of Tests
• Prospective Studies
• Retrospective Studies
• Risk
• Risk Assessment (methods)
• Sampling Studies
• Sensitivity and Specificity
• Severity of Illness Index
• Symptom Assessment
• Tomography, X-Ray Computed (statistics & numerical data)
• Ultrasonography