M. E. Ingram1,2, C. Harris1,2, A. Studer2, S. Martin2, L. Berman3, A. Alder4, M. V. Raval1,2 1Feinberg School Of Medicine – Northwestern University,Department Of Surgery,Chicago, IL, USA 2Ann & Robert H. Lurie Children’s Hospital of Chicago,Department Of Surgery,Chicago, IL, USA 3Nemours Children Hospital,Department Of Surgery/Division Of Pediatric Surgery,Orlando, FL, USA 4Children’s Medical Center,Department Of Surgery/Division Of Pediatric Surgery,Dallas, Tx, USA
Introduction:
Use of clinical practice guidelines (CPG) have been shown to reduce care delays, optimize resource utilization, and improve patient outcomes. We conducted a systematized review to identify key elements that should be included in an evidence-based CPG for pediatric appendicitis.
Methods:
Our systematized review identified pediatric appendicitis CPGs, developed by US Children’s hospitals from 2000-2019, using PubMed, Web of Science, Clinical Trials.gov, Google searches, the American Pediatric Surgical Association Quality and Safety Toolkit, and by manual search/personal communications. All guidelines, pathways, and algorithms were reviewed to determine the major decision-points defining the respective guideline or pathway.
Results:
CPGs from 22 institutions were reviewed and content saturation was achieved for specific CPG elements after reviewing a median of 8 guidelines. We found 16 key elements, spanning triage, operative, post-operative, and late phases of care, should be included in development of an evidence-based CPG for pediatric appendicitis (Figure 1). Elements with high accord among CPGs included deciding on a standardized operative approach and delay of postoperative imaging until day 7 after appendectomy. For simple appendicitis, all CPGs agreed to stop postoperative antibiotics, advance diets, and encourage activity. Five CPGs included same-day discharge for simple appendicitis. Elements with most heterogeneity in decision-making included antibiotic type (broad-spectrum vs. second-generation cephalosporin +/- metronidazole) and duration postoperatively (for perforated appendicitis); location of administration of first dose (Emergency Department or in preop); criteria determining perforation pathway (clinical exam vs operative findings); and utility of postoperative labs (i.e. white blood count and C-reactive protein). Among published pre- and post-implementation studies surrounding pediatric appendicitis CPGs, average length of stay decreased by one day or more, hospital costs of care decreased by up to 30% for perforated appendicitis, and rates of adverse events were found to decrease by an average of 40% across all studies (reported RR 0.4-0.8).
Conclusion:
Development of an evidence-based CPG for pediatric appendicitis requires attention to 16 key elements. Despite nuanced differences in execution of specific elements, pre- and post-implementation studies of CPGs demonstrate improved patient outcomes and decreased costs of care. Future meta-analysis of these studies will be useful in further optimizing care of pediatric appendicitis.
