J. Tashiro1, B. Wang1, M. Curbelo2, E. A. Perez1,2, A. R. Hogan1,2, H. L. Neville1,2, J. E. Sola1,2 1University Of Miami,Division Of Pediatric Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA 2Baptist Children’s Hospital,Miami, FL, USA
Introduction: Appendicitis is the most common surgical emergency in children. However, diagnosis by history and physical exam can be challenging in children as classical signs and symptoms are often lacking and other childhood conditions can mimic appendicitis. Despite concerns for radiation, computed tomography (CT) is the favored imaging modality at many children’s hospitals for appendicitis. We sought to reduce CT utilization for appendicitis in a children’s hospital by adopting an algorithm (Figure 1), relying on 24-hour ultrasound (US) as the primary imaging study.
Methods: A standardized protocol was adopted at the end of fiscal year (FY) 2011 using US as the primary imaging study for diagnosing appendicitis in the emergency department (ED). Pediatric surgery service assumed patient care after US had been performed. A prospectively recorded database was analyzed 12 months prior to and 24 months after the employment of the protocol. The usage for each imaging test was adjusted per number of appendectomies performed. Training of ED staff continued for over 1 year after protocol implementation. Statistical analysis was performed using PASW Statistics V.21. Student t test was used to compare continuous data. Significance was determined at P value < 0.05.
Results: For FY 2011, 644 abdominal CT, and 1088 appendix U/S were ordered from the ED and 249 laparoscopic appendectomies (LA) were performed. After implementation of the protocol, FY 2012: 535 CT, 1285 appendix U/S, and 265 LA were performed; and FY 2013: 330 CT, 1235 appendix U/S, and 236 LA were performed. Paired t-test comparing monthly incidence of appendectomy between the three years did not show any significant difference. Length of stay decreased from FY 2011 to FY 2013 (2.57 ± 0.29 vs. 1.90 ± 0.15 days) and from pre- to post-protocol (2.57 ± 0.29 vs. 2.15 ± 0.11 days), both p<0.001. There was a 42% decrease in number of abdominal CT utilized per appendectomy performed from FY 2011 to FY 2013 (2.43 vs. 1.40, p<0.001) and 30% from pre- to post-protocol (2.43 vs. 1.70, p<0.001). In addition, a corresponding 27% increase in number of appendix US pre- to post protocol (4.11 vs. 5.20 US/appendectomy, p=0.004) occurred.
Conclusion: Protocol driven workup with US significantly reduced CT utilization and thereby radiation exposure in children with suspected appendicitis. Ongoing training of ED staff after implementation is required to ensure protocol compliance.
