Appendicitis

Introduction

Welcome to the APSA Quality and Safety committee Appendicitis Toolkit. This page is intended to help anyone who is interested in Quality Improvement (QI) of the management of patients with appendicitis.

Available toolkit projects are listed below. Many of the approaches described are evidence-based - some are not. These approaches have not been approved by APSA.

Quality Improvement Methods to Facilitate Implementation of Clinical Practice Guidelines for Appendicitis

Lurie Children’s Hospital initiated a QI project implementing PDSA cycles to develop an evidence-based clinical practice guideline (CPG) for appendicitis. Through their process, the added value of care (increased quality rating and decreased cost) following implementation of the CPG. A multidisciplinary QI team was formed which included pediatric surgery team members (surgeons, APN/PA/midlevel providers, nurses), emergency medicine personnel (physicians and nurses), anesthesiology team members, infectious disease personnel, pharmacists, perioperative business office members, clinical informatics representatives, Epic information support personnel, a process improvement liaison, a patient and family advocate, child life personnel, and social workers. The team met on a monthly basis to identify barriers to decreased length of stay (LOS) using fishbone and key driver diagrams.

Within the Division of Pediatric Surgery, monthly meetings were held to review evidence and process measures, and develop an evidence-based CPG with local context definitions where evidence was lacking. Moreover, an appendectomy operative note (including specific SmartTexts for grading appendicitis severity) and standardized order sets were developed, and underwent iterative revisions. The simple appendicitis CPG was launched March, 2019. The complicated appendicitis CPG was launced in June, 2019. Dissemination was ensured by announcements at division meetings, regular meetings, and provision of bulletin notices to display in workrooms. Improved ease of search/word finding was available for EMR interface features. Monthly meetings continued through the implementation process to gather feedback and iteratively perform PDSA cycles.

Protocol:

Resources:

Stakeholders: pediatric surgery (surgeons, APN/PA/mid-level providers, nursing, division leadership), emergency medicine personnel (physicians, nursing), anesthesiology team members, infectious disease personnel, pharmacists, perioperative business office, clinical informatics representatives, Epic information support personnel, process improvement liaison, patient &andfamily advocate, child life personnel, social workers

Challenges and Solutions:

Links to published data (used to develop the protocol):

Submitted by: Martha-Conley E Ingram, MD

Additional implementers: Mehul Raval, MD, MS, Abbey Studer

Decreasing CT Use in Appendicitis Patients

St. Joseph’s Children’s Hospital in Tampa developed a quality initiative focused on decreasing unnecessary CT scans while determining a diagnosis of appendicitis through assessment with the pediatric appendicitis score (PAS) and use of radiation-free diagnostic imaging. This initiative resulted from a review of the institution’s NSQIP Pediatric Semiannual Report that revealed a higher than average CT utilization and high negative appendectomy rate to CT utilization. A thorough literature review of best practices, current protocols for the diagnosis of appendicitis in ER, and imaging modalities used to diagnose cases in 2017, was undertaken. Moreover, surgeons reached out to other institutions to inquire about protocols being utilized. Thereafter, a multidisciplinary team was created which included emergency room physicians, radiologists and pediatric surgeons to create an algorithm for the diagnosis and treatment of appendicitis. The algorithm was presented at appropriate committees and was subsequently adopted as a best practice medical standard by the Health System.

Protocol:

Resources:

Stakeholders:

Challenges and Solutions:

Challenges:

Solutions:

Links to published data (used to develop the protocol):[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15]

Submitted by: Grant Geissler, MD

Additonal Implementers: Kirsten Yancy, RN, BSN, CPN

In order to optimize the utility of ultrasound (US) at Children’s Healthcare of Atlanta (CHOA), a QI initiative was implemented consisting of the development and validation of a right lower quadrant ultrasound template that reported secondary signs (SS) and categorized diagnostic confidence and disease severity for acute appendicitis. Concurrently, the patients undergoing CT A/P and those being admitted for observation were also being tracked. The outcomes of interest included: high compliance rates of utilizing the standardized US report, lower CT A/P use, fewer admissions for observation, duration of symptoms was associated with more SS, and equivocal US that included hyperemia, fluid collection, or appendicolith had 96% specificity and 88% accuracy.

Protocol:

Resources:

Stakeholders: emergency department (ED), radiology, surgery, QI team

Challenges and Solutions: This QI initiative led to high compliance rates of utilizing the standardized US report and resulted in lower CT A/P use and fewer admissions for observation. We found that our colleagues in radiology were amenable to using the US template and had relatively easy/rapid implementation. We also found that both the ED and Surgery faculty/staff thought that the templated reports provided more detail and facilitated improved decision making.

Links to published data (used to develop the protocol):[16][17][18]

Submitted by: Mehul Raval, MD, MS

Additional implementers: Kurt Heiss, MD

Texas Children’s Hospital (TCH) also developed and validated an ultrasound scoring system for children with suspected acute appendicitis. The goal of standardizing the reporting of an appendiceal US by means of a structured template system was to risk-stratify patients with suspected pediatric appendicitis, and measure the effect of this scoring system on US diagnostic performance measures, follow-up CT exam rates and negative appendectomy rates.

Protocol:

Resources:

Stakeholders: emergency department (ED), radiology, surgery

Challenges and Solutions: The use of a risk stratification scoring system and structured template for reporting US exam results for suspected pediatric appendicitis improved communication of appendicitis likelihood to all the teams involved in the care of the patient. It did not seem to affect ED process measures such as total ED length of stay. Further analysis of data generated from this study allowed identification of factors that further discriminate between simple and perforated appendicitis based on the US.

Links to published data (used to develop the protocol): [19][20][21][22]

Submitted by: Monica Lopez, MD

Texas Children’s Hospital (TCH) also adopted Standing Delegation Orders (SDO) for US based on PAS scores assessed by ED triage nursing staff in order to minimize LOS in the ED phase of care. A surgical hospitalist pilot was launched concurrently with the goal of facilitating prompt surgical evaluations in the ED.

Protocol:

Resources:

Stakeholders: emergency department (ED), surgery, radiology, anesthesia, nursing, perioperative services, financial services, hospital administration

Submitted by: Monica Lopez, MD

At Nemours/Alfred I. DuPont Hospital for Children, a retrospective review was performed to identify patient characteristics associated with non-diagnostic ultrasounds in children with suspected appendicitis. Patients with a moderate PAS were likely to have non-diagnostic ultrasound, whereas, patients with high PAS were ikely to have appendicitis diagnosed on ultrasound. A hybrid approach to imaging patients with suspected appendicitis based on PAS was developed in which low PAS requires no imaging studies, moderate PAS get an MRI vs. no imaging, according to index of suspicion, and high PAS undergo an ultrasound. The current appendicitis imaging order (for MRI or ultrasound) has an embbeded PAS calculator, and requires input of the PAS.

Protocol:

Resources:

Stakeholders: surgery, radiology, ED

Challenges and Solutions:

Submitted by: Loren Berman, MD

In the evaluation of appendicitis, imaging is often obtained to confirm the diagnosis. While US is often considered a first-line imaging modality, there may be reasons, such as equivocal imaging or issues related to availability/reliability, that may prompt cross-sectional imaging (i.e., CT or MRI). Additionally, although US is often cited to have high diagnostic performance for appendicitis, recent studies have questioned its true sensitivity in clinical practice. At Penn State Children’s Hospital, the desire to avoid the potential radiation associated with CT scan, and the ready availability of MRI (Children’s Hospital within a General Health System sharing MRI resources) led to an investigation of MRI in the diagnostic evaluation of pediatric appendicitis. Based on the diagnostic accuracy and reliability of MRI in diagnosing or excluding appendicitis, characterizing alternative pathology, and facilitating ED disposition, as well as acceptable clinical time-related parameters (e.g., time from request to scan, imaging duration, time from request to interpretation), an appendicitis pathway was implemented and evaluated utilizing MRI as the primary imaging modality.

Key Results:

● 30 month institutional experience (n=510), 98% of patients ≥ 5 years old

● No IV/oral contrast MRI protocol

● Diagnostic Performance

o Sensitivity: 96.8%

o Specificity: 97.4%

o Positive Predictive Value: 92.4%

o Negative Predictive Value: 98.9%

● Time Parameters (median):

o Time from request to scan: 71 minutes

o Imaging duration: 11 minutes

o Time from last sequence to interpretation: 31 minutes

o Time from request to interpretation: 2 hrs

Protocol:

Resources:

Stakeholders: pediatric surgery, pediatric radiology, pediatric ED, ultrasound and MRI technologists

Challenges and Solutions: The program required buy-in from all pediatric surgeons, ED physicians, radiologists and technologists. Initially, coordination between the ED and technologists for scheduling MRI times, and interpretation was challenging, but improved as the MRI sequences were refined, timely MRI requests and scanning time became more predictable, and familiarity with the protocol grew. Additionally, skill in interpretation of appendicitis on MRI had to be developed and refined.

Links to published data (used to develop the protocol): [8][23][24][25][26][27][28][29][30][31]

Submitted by: Afif Kulaylat, MD, MSc

Nonoperative Management of Simple Appendicitis

Nationwide Children’s Hospital developed a clinical algorithm for the non-operative management of uncomplicated appendicitis. It is offered as a treatment choice to any patient that meets the inclusion criteria.

Protocol:

Resources:

Stakeholders: surgery, ED, radiology

Challenges and Solutions:

Submitted by: Peter Minneci, MD

Informed Consent

Texas Children’s Hospital developed a standardized visual aid during the appendectomy informed consent process to promote patient and family understanding.

Resources:

Stakeholders: surgery, anesthesia, perioperative services

Challenges and Solutions:

Links to published data (used to develop the protocol): [32]

Submitted by: Mary Brandt, MD

Intraoperative Disease Severity & Wound Classification

Texas Children’s Hospital (TCH) developed a program to standardize the intraoperative definitions of disease severity for appendicitis and wound classification with appropriate documentation in the electronic medical record in order to improve the accuracy of the institutional appendectomy population outcomes platform. As such, a pamphlet was developed and distributed/posted in operating rooms and other common areas. Education was provided to physicians and nursing staff.

Protocol:

Resources:

Stakeholders: surgery, anesthesia, perioperative services, hospital QI leadership

Challenges and Solutions:

Links to published data (used to develop the protocol):

Submitted by: Monica Lopez, MD

St. Joseph’s Children’s Hospital in Tampa also recognized the need for standardization, given the potential for significant variation in techniques amongst surgeons in the treatment of perforated appendicitis. After reviewing an article from the Journal of Pediatric Surgery [33], they developed a standardized intraoperative and postoperative management plan for these patients. In over 3 years, they were able to improve their complicated appendicitis SSI rates from the lower 25th percentile to the exemplary upper 25th percentile.

Protocol: St. Joseph’s Children’s Hospital Intraoperative Assessment & Standardization of Care for Pediatric Patients with Perforated Appendicitis

Resources:

Stakeholders: pediatric surgeons

Challenges and Solutions: Requires collaboration and a thorough consistent approach

Links to published data (used to develop the protocol): [33]

Submitted by: Grant Geissler MD

Same Day Discharge & Efforts to Decrease Length of Stay

Johns Hopkins All Children’s Hospital implemented an evidence-based protocol for same day discharge after appendectomy patients presenting with simple appendicitis. Protocol implementation resulted in decrease use of inpatients resources, reduced need for patient handoffs, and an increase in hospital savings. A multidisciplinary approach to this initiative was key to its success.

Protocol: JHACH Fast Track SECU Order Set

Resources: JHACH Fast Track Patient Flow

Stakeholders: surgeons, ED staff, perioperative personnel, patients and family, hospital administration

Challenges and solutions: Protocol implementation was centered on a multidisciplinary approach involving various specialties (surgery, ED, anesthesia), as well as departments (ED, perioperative services). Education regarding awareness on changes in the patient flow process, handoffs and discharge education was extremely important to ensure success.

Links to published data (used to develop the protocol): [34]

Submitted by: Raquel Gonzalez, MD, MHCM

Nemours/Alfred I. DuPont Hospital for Children also developed a protocol for same day discharge for patients with uncomplicated appendicitis; safely and successfully discharging them from the PACU.

Protocol:

Resources:

Stakeholders: surgeons, PACU nurses, OR nurse managers

Links to published data (used to develop the protocol): [34][35][36][37][38][39][40][41]

Submitted by: Loren Berman, MD

Texas Children’s Hospital standardized a care algorithm to allow same day discharge for selected appendectomy patients. This entailed convening a large multidisciplinary team to help define specifics of the protocol. Eligible patients were those between 5-18 years of age, with an intraoperative diagnosis of simple appendicitis. The group had previously standardized disease severity definitions amongst surgeons. Exclusion criteria were: interval appendectomy, advanced appendicitis (gangrenous, perforated), comorbid conditions or social indications for admission. Interventions included an order set featuring conditional orders, standardized patient education pamphlets, physician/APP education sessions, and the creation of a telephone script and standardized same day discharge appendectomy phone follow-up template to facilitate documentation in the EMR. Direct variable costs were tracked from the hospital cost accounting department.

Protocol:

Resources:

Stakeholders: ED physicians, pediatric hospital medicine physicians, community pediatricians, surgeons, anesthesiologists, radiologists, nursing staff, pharmacists, perioperative nursing leadership, quality/outcomes leadership

Challenges and solutions:

Submitted by: Monica Lopez, MD

Moreover, Texas Children’s Hospital also implemented a fast track, nursing-driven order set and family educational pamphlet in order to decrease the LOS for simple appendicitis. The order set featured nursing-driven interventions including early ambulation, early diet order, and conditional discharge orders. The family educational handout was designed to moderate parental expectations and standardize provider communication to the patients and their families.

Protocol:

Resources:

Stakeholders: nursing staff, surgeons, perioperative services staff, anesthesia personnel

Challenges and solutions:

Submitted by: Monica Lopez, MD

University of Texas Southwestern (UTSW) Children’s Medical Center Dallas developed a fast track process for patients with simple appendicitis in order to standardize care, facilitate early discharge, decrease cost, and free up hospital beds. This was a one year prospective observational study to assess safety and feasibility, as well as parental satsifaction. IRB approval was obtained. During the evaluation of a child with suspected non-perforated appendicitis and no underlying comorbidities, the surgical team discusses and encourages postoperative discharge with the family. The child is then taken from the ER to the OR, if available, without any formal admission to hospital. After undergoing an uneventful standard appendectomy, the patient is discharged from the PACU using a same day surgery discharge order set, which outlines activity, diet, follow up (2 weeks by phone), restrictions, and ER warnings. The parents are given a phone number to contact with questions. The pain regimen consists of alternating acetaminophen and ibuprofen for 24 hours, then as needed. For a child admitted overnight, and undergoing appendectomy in the morning, the discharge occurs from the PACU or from the inpatient room, with the same order set.

Protocol:

Resources:

Stakeholders: patient and families, surgeons, ER personnel, OR staffing, anesthesiologists, PACU providers, hospital administrators

Challenges and Solutions:

Links to published data (used to develop the protocol):[39][42]

Submitted by: Alana Beres, MD

At the University of Rochester, a clinical practice guideline was implemented following appendectomy for simple appendicitis. The protocol went live in late September, 2019, and was used in children ≤ 15 years old. The clinical practice guideline recommended discharge when the patient was tolerating a regular diet, ambulating, the pain was controlled on nonopioid oral medications, and if there were no additional concerns. A surgeon of the week service model was implemented in November, 2019, and the use of an urgent operating room started January, 2020. Patients from January, 2018 through September, 2019 (pre-guideline group) were compared to patients from October, 2019 through June, 2021 (post-guideline group). Data was gathered prospectively and stored in our NSQIP-P database.

Protocol: University of Rochester Postoperative Simple Appendicitis Clinical Practice Guideline

Resources:

Stakeholders: pediatric surgery, pediatric surgical services (perioperative and operating room staff), pediatric appendicitis patients and families, pediatric ED personnel, infectious disease physicians, hospital leadership

Challenges and Solutions:

Please refer to the key driver diagram for additional drivers and solutions.

Links to published data (used to develop the protocol):

Submitted by: Derek Wakeman, MD

Perforated Appendicitis

Saint Louis University/Cardinal Glennon Children’s Hospital enacted a protocol to develop consistent criteria for the initial nonoperative treatment of perforated appendicitis and to establish a standardized approach to antibiotic management for appendicitis patients. Through multiple discussions with the surgical staff, the protocol and order set were developed. Moreover, a flowsheet of the algorithm was distributed to the surgical residents. In addition, there has been a discussion with the infectious disease team regarding the choice of antibiotics and this will likely be an area for continued refinement.

Protocol:

Stakeholders: appendicitis patients and families, pediatric surgery team – faculty, fellows, residents, nurse practitioners

Challenges and solutions:

Submitted by: Colleen Fitzpatrick, MD

At Nemours / Alfred I. DuPont Hospital for Children, all surgeons were managing complicated appendicitis in very different ways. A literature review was performed, and in collaboration with a multidisciplinary team consisting of of surgeons, infectious disease specialists, and pharmacists, a standardized definition of ruptured versus non-ruptured appendicitis was developed, as well as standardized antibiotic protocols. An EMR order set and standardized operative notes were constructed to easily identify complicated versus uncomplicated in data review.

Protocol:

Resources:

Stakeholders: surgeons, infectious disease physicians, pharmacists, emergency department personnel

Links to published data (used to develop the protocol): [43][43][44][45][46]

Submitted by: Loren Berman, MD

Texas Children’s Hospital implemented a revised evidence-based practice guideline for complex appendectomy patients which features clinically based criteria only for discharge readiness and limits the duration of antibiotics. The TCH Evidence-Based Outcomes Center pathway was followed for revision of this hospital-wide practice guideline which entailed assembling a multidisciplinary Content Expert Team, research specialists, IT/IS EMR builders, data architects, and clinical outcomes specialists. Two additional PICO questions were addressed in this version of the guideline. Moreover, the care algorithm was updated after a review of the literature to reach consensus recommendations. Ongoing appendectomy outcomes are reviewed via EDW-based application tracking of selected measures which generates a balanced scorecard. Clinical decision support is integrated into workflows by means of order sets and standardized admission and progreess notes with SmartForm elements that prompt the practitioner to elicit discharge criteria elements on a daily basis.

Methodology: interrupted time series design- three-month preintervention, three-month transition, three month postintervention periods.

Outcome measures: length of stay, infection rate (intra-abdominal abscess), direct variable costs.

Balance measures: 30-day readmission, emergency department (ED) visits.

Process measures: order set utilization, progress note utilization rates.

Protocol:

Resources:

Stakeholders: ED physicians, pediatric hospital medicine physicians, surgeons, radiology personnel, interventional radiologists, infectious disease personnel, nursing staff, pharmacists, nutritionists, social services, quality/outcomes staff, research staff

Challenges and solutions:

Submitted by: Monica Lopez, MD

The postoperative management of pediatric patients with perforated appendicitis is an area of active research. Practice patterns have shifted from extended durations of IV antibiotics to shorter courses of oral antibiotics over time. The optimal antibiotic duration for perforated appendicitis is unknown, and the benefits of further antibiotics must be weighed against the risks of drug resistance and side effects. At UC Davis Children’s Hospital, an appendicitis clinical practice guideline (CPG) was created through extensive discussion among the pediatric surgical team, based on evidence from the literature. The implementation required approval by all members of the pediatric surgery team, and was distributed to residents and nurse practitioners on the service. The CPG has gone through multiple iterations to optimize the post-operative management of patients. Interim results are reviewed by the research team to evaluate outcomes as the CPG is modified. Most recently, the CPG was modified to discontinue further antibiotics for children with perforated appendicitis meeting clinical criteria for discharge, in the presence of a normal white blood cell count without a left shift. The effect of this modification was studied by comparing antibiotic duration and adverse events pre and post modification, finding a significant decrease in antibiotics prescribed on discharge, without an increase in adverse events. Further modifications are in process based on these results, and will be updated on this platform, accordingly.

Protocol:

Resources:

Stakeholders: UC Davis Children’s Hospital pediatric surgeons and nurse practitioners, surgical residents, infectious disease physicians, patients and families

Challenges and solutions: Weighing the benefits of shortened antibiotic durations with the risks of increased infectious adverse events is an ongoing management challenge.

Links to published data (used to develop protocol or demonstrating success of protocol):[47][48][49]

Submitted by: Christina Theodorou, MD

Additional implementers: Erin G. Brown, MD

Though evidence-based clinical pathways for the diagnosis and treatment of pediatric appendicitis have been established, protocols guiding management of percutaneous abscess drains are lacking. Yale New Haven Children’s Hospital implemented a standardized protocol for management of percutaneous abscess drain placement in patients with perforated appendicitis; clinical practice prior to implementation was variable and often included routine use of fluoroscopic drain studies or diagnostic imaging. The standardized protocol for abscess drain management is based on clinical parameters and drain output with demonstration of reduced number of IR procedures without an adverse impact on clinical outcomes.

Protocol:

Resources:

Stakeholders: pediatric surgeons & APPs, pediatric nursing staff, interventional radiologists, appendicitis patients and families

Challenges and solutions:

Links to published data (used to develop protocol or demonstrating success of protocol): [50]

Submitted by: Lindsay Eysenbach, MD

Additional implementers: Daniel Solomon, MD

At the University of Rochester, a high rate of surgical site infections (SSI) after appendectomy for complicated appendicitis led to a QI initiative to improve outcomes and reduce healthcare resource utilization for these patients. The intraoperative and postoperative care after appendectomy for pediatric complicated appendicitis was standardized. Moreover, an intraoperative culture of purulent fluid at the time of appendectomy for complicated appendicitis was added. By standardizing the care for children with complicated appendicitis, including performing intraoperative culture during appendectomy, postoperative SSI’s became less frequent and ED visits/readmissions decreased significantly. Post-operative SSIs decreased from 27% before implementation of the clinical practice guideline to 12% post-implementation. In aggregate, these outcomes prevent morbidity for children after appendectomy and add significant value to the healthcare system.

Protocol:

Resources:

Stakeholders: pediatric surgical team (MD’s and APN’s), nurses (floor, OR), ED providers, infectious disease and epidemiology physicians, pharmacists, QI staff, families

Challenges and solutions:

Links to published data (used to develop protocol or demonstrating success of protocol): [51]

Submitted by: Derek Wakeman, MD

Additional implementers: Marjorie Arca, MD

Opioid Sparing Pain Protocols

Children’s Healthcare of Atlanta (CHOA) initiated a protocol to minimize use of opioids in the postoperative period. This was part of a comprehensive ERAS pathway for colorectal surgery at their institution, but has been adopted in the setting of appendectomy as well.

Protocol:

Resources:

Stakeholders: surgery, anesthesia, perioperative nursing staff

Challenges and Solutions: Obtain pharmacy review and consensus among surgeons

Submitted by: Mehul Raval, MD, MS

Additional implementers: Matthew Santore, MD

In order to discover actual patient use and need of opioids after routine laparoscopic appendectomies, Yale New Haven Children’s Hospital spearheaded an appendectomy quality improvement project where parents and/or patients were called 1-3 weeks after surgery to discuss analgesia and medication use. This led to an opioid-based suggestion titled; "An Evidence Based Guideline for Post-Appendectomy Analgesia: No More Than Three Oxycodone".

Protocol:

Resources:

Stakeholders: pediatric surgery patients and families, pediatric surgery providers and prescribers, appendectomy patients, communities suffering from opioid abuse

Challenges and Solutions:

Links to published data (used to develop the protocol): [52]

Submitted by: Mollie Freedman-Weiss, MD

Post Discharge Care

Appendectomy was found to be the procedure most commonly associated with post-operative emergency room (ER) revisits at Nemours Children’s Health, a multi-institution healthcare system. A considerable number of these are minor, potentially avoidable visits related to the procedure. Therefore, at Nemours/Alfred I. DuPont Hospital for Children, a text messaging system was developed to proactively message patient caregivers on post discharge days 2, 6,10 and 14 with a simple question on if they have any concerns regarding the recovery of their child. If they did, they were directed to an affiliated primary physician via a video conference or the surgeon’s office. The goal was to decrease unplanned ER revisits for minor postoperative complaints such as superficial wound issues or mild medical problems unrelated to the procedure. A dashboard was created to track patients and outcomes (revisits). A formal chart review was performed of all patients that returned to see, if and how, the system could have performed better. Monthly meetings involving all stakeholders were conducted to review the data obtained from the application and dashboard to assess performance and ways to improve.

Protocol:

Resources:

Stakeholders: surgeons, telehealth physicians, Nemours software engineers, management team

Links to published data (used to develop the protocol):

Submitted by: Roshan D’Cruz, MD

Recent Research

[48][53][54][55][56][57][58]

References

  1. Samuel M. Pediatric appendicitis score. J Pediatr Surg. 2002;37(6):877-81.  [PMID:12037754]
  2. Blitman NM, Anwar M, Brady KB, et al. Value of Focused Appendicitis Ultrasound and Alvarado Score in Predicting Appendicitis in Children: Can We Reduce the Use of CT? AJR Am J Roentgenol. 2015;204(6):W707-12.  [PMID:26001260]
  3. Hall EJ, Brenner DJ. Cancer risks from diagnostic radiology. Br J Radiol. 2008;81(965):362-78.  [PMID:18440940]
  4. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Surg Infect (Larchmt). 2010;11(1):79-109.  [PMID:20163262]
  5. Bachur RG, Levy JA, Callahan MJ, et al. Effect of Reduction in the Use of Computed Tomography on Clinical Outcomes of Appendicitis. JAMA Pediatr. 2015;169(8):755-60.  [PMID:26098076]
  6. Kotagal M, Richards MK, Flum DR, et al. Use and accuracy of diagnostic imaging in the evaluation of pediatric appendicitis. J Pediatr Surg. 2015;50(4):642-6.  [PMID:25840079]
  7. Brenner D, Elliston C, Hall E, et al. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol. 2001;176(2):289-96.  [PMID:11159059]
  8. Aspelund G, Fingeret A, Gross E, et al. Ultrasonography/MRI versus CT for diagnosing appendicitis. Pediatrics. 2014;133(4):586-93.  [PMID:24590746]
  9. Goldman RD, Carter S, Stephens D, et al. Prospective validation of the pediatric appendicitis score. J Pediatr. 2008;153(2):278-82.  [PMID:18534219]
  10. Herliczek TW, Swenson DW, Mayo-Smith WW. Utility of MRI after inconclusive ultrasound in pediatric patients with suspected appendicitis: retrospective review of 60 consecutive patients. AJR Am J Roentgenol. 2013;200(5):969-73.  [PMID:23617477]
  11. Neff LP, Ladd MR, Becher RD, et al. Computerized tomography utilization in children with appendicitis-differences in referring and children's hospitals. Am Surg. 2011;77(8):1061-5.  [PMID:21944524]
  12. Fahimi J, Herring A, Harries A, et al. Computed tomography use among children presenting to emergency departments with abdominal pain. Pediatrics. 2012;130(5):e1069-75.  [PMID:23045569]
  13. Humes, D.J., Simpson, J. (2012). Clinical Presentation of Acute Appendicitis: Clinical Signs—Laboratory Findings—Clinical Scores, Alvarado Score and Derivate Scores. In: KEYZER, C., Gevenois, P. (eds) Imaging of Acute Appendicitis in Adults and Children. Medical Radiology(). Springer, Berlin, Heidelberg. https://doi.org/10.1007/174_2011_211
  14. Saucier A, Huang EY, Emeremni CA, et al. Prospective evaluation of a clinical pathway for suspected appendicitis. Pediatrics. 2014;133(1):e88-95.  [PMID:24379237]
  15. Foundation, A. B. I. M. (2015, February 26). ACS - CT in evaluation of appendicitis in children: Choosing wisely. Choosing Wisely | Promoting conversations between providers and patients. Retrieved April 21, 2022, from http://www.choosingwisely.org/clinician-lists/american-college-surgeons-computed-tomography-to-evaluate-appendicitis-in-children
  16. Partain KN, Patel AU, Travers C, et al. Association of Duration of Symptoms and Secondary Signs in Ultrasound for Pediatric Appendicitis. Am Surg. 2016;82(9):e266-8.  [PMID:27670544]
  17. Partain KN, Patel A, Travers C, et al. Secondary signs may improve the diagnostic accuracy of equivocal ultrasounds for suspected appendicitis in children. J Pediatr Surg. 2016;51(10):1655-60.  [PMID:27039121]
  18. Partain KN, Patel AU, Travers C, et al. Improving ultrasound for appendicitis through standardized reporting of secondary signs. J Pediatr Surg. 2017;52(8):1273-1279.  [PMID:27939802]
  19. Fallon SC, Orth RC, Guillerman RP, et al. Development and validation of an ultrasound scoring system for children with suspected acute appendicitis. Pediatr Radiol. 2015;45(13):1945-52.  [PMID:26280638]
  20. Abbas PI, Zamora IJ, Elder SC, et al. How Long Does it Take to Diagnose Appendicitis? Time Point Process Mapping in the Emergency Department. Pediatr Emerg Care. 2016.  [PMID:26945196]
  21. Telesmanich ME, Orth RC, Zhang W, et al. Searching for certainty: findings predictive of appendicitis in equivocal ultrasound exams. Pediatr Radiol. 2016;46(11):1539-45.  [PMID:27282824]
  22. Mangona KLM, Guillerman RP, Mangona VS, et al. Diagnostic Performance of Ultrasonography for Pediatric Appendicitis: A Night and Day Difference? Acad Radiol. 2017;24(12):1616-1620.  [PMID:28826614]
  23. Kulaylat AN, Moore MM, Engbrecht BW, et al. An implemented MRI program to eliminate radiation from the evaluation of pediatric appendicitis. J Pediatr Surg. 2015;50(8):1359-63.  [PMID:25783291]
  24. Moore MM, Kulaylat AN, Brian JM, et al. Alternative diagnoses at paediatric appendicitis MRI. Clin Radiol. 2015;70(8):881-9.  [PMID:26072983]
  25. Moore MM, Kulaylat AN, Hollenbeak CS, et al. Magnetic resonance imaging in pediatric appendicitis: a systematic review. Pediatr Radiol. 2016;46(6):928-39.  [PMID:27229509]
  26. Moore MM, Brian JM, Methratta ST, et al. MRI for clinically suspected pediatric appendicitis: case interpretation. Pediatr Radiol. 2014;44(5):605-12.  [PMID:24442340]
  27. Moore MM, Gustas CN, Choudhary AK, et al. MRI for clinically suspected pediatric appendicitis: an implemented program. Pediatr Radiol. 2012;42(9):1056-63.  [PMID:22677910]
  28. Mushtaq R, Desoky SM, Morello F, et al. First-Line Diagnostic Evaluation with MRI of Children Suspected of Having Acute Appendicitis. Radiology. 2019;291(1):170-177.  [PMID:30747595]
  29. Dillman JR, Trout AT. MRI for First-Line Evaluation of Children Suspected of Having Acute Appendicitis. Radiology. 2019;291(1):178-179.  [PMID:30776248]
  30. Desoky S, Udayasankar UK. Unenhanced MRI for Abdominal Pain in the Pediatric Emergency Department: Point-Safe and Comprehensive Assessment While Reducing Delay in Care. AJR Am J Roentgenol. 2021;216(4):874-875.  [PMID:32876486]
  31. Brian JM, Moore MM. Unenhanced MRI for Abdominal Pain in the Pediatric Emergency Department: Counterpoint-Choice Should Consider Access, Patient, and Cost. AJR Am J Roentgenol. 2021;216(4):876-877.  [PMID:32876483]
  32. Rosenfeld EH, Lopez ME, Yu YR, et al. Use of standardized visual aids improves informed consent for appendectomy in children: A randomized control trial. Am J Surg. 2018;216(4):730-735.  [PMID:30060912]
  33. Yousef Y, Youssef F, Homsy M, et al. Standardization of care for pediatric perforated appendicitis improves outcomes. J Pediatr Surg. 2017;52(12):1916-1920.  [PMID:28935397]
  34. Farach SM, Danielson PD, Walford NE, et al. Same-day discharge after appendectomy results in cost savings and improved efficiency. Am Surg. 2014;80(8):787-91.  [PMID:25105399]
  35. Yu YR, Smith CM, Ceyanes KK, et al. A prospective same day discharge protocol for pediatric appendicitis: Adding value to a common surgical condition. J Pediatr Surg. 2017.  [PMID:29103787]
  36. Aguayo P, Alemayehu H, Desai AA, et al. Initial experience with same day discharge after laparoscopic appendectomy for nonperforated appendicitis. J Surg Res. 2014;190(1):93-7.  [PMID:24725679]
  37. Cairo SB, Raval MV, Browne M, et al. Association of Same-Day Discharge With Hospital Readmission After Appendectomy in Pediatric Patients. JAMA Surg. 2017;152(12):1106-1112.  [PMID:28678998]
  38. Putnam LR, Levy SM, Johnson E, et al. Impact of a 24-hour discharge pathway on outcomes of pediatric appendectomy. Surgery. 2014;156(2):455-61.  [PMID:24962193]
  39. Gee K, Ngo S, Burkhalter L, et al. Safety and feasibility of same-day discharge for uncomplicated appendicitis: A prospective cohort study. J Pediatr Surg. 2018;53(5):988-990.  [PMID:29510871]
  40. Gurien LA, Burford JM, Bonasso PC, et al. Resource savings and outcomes associated with outpatient laparoscopic appendectomy for nonperforated appendicitis. J Pediatr Surg. 2017;52(11):1760-1763.  [PMID:28347529]
  41. Devin CL, D'Cruz R, Linden AF, et al. Reducing resource utilization for patients with uncomplicated appendicitis through use of same-day discharge and elimination of postoperative antibiotics. J Pediatr Surg. 2020;55(12):2591-2595.  [PMID:32482411]
  42. Ngo S, Gee K, Burkhalter L, et al. Parental satisfaction with same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis. Paediatr Child Health. 2019;24(5):318-322.  [PMID:31379433]
  43. Fraser JD, Aguayo P, Leys CM, et al. A complete course of intravenous antibiotics vs a combination of intravenous and oral antibiotics for perforated appendicitis in children: a prospective, randomized trial. J Pediatr Surg. 2010;45(6):1198-202.  [PMID:20620320]
  44. Adibe OO, Barnaby K, Dobies J, et al. Postoperative antibiotic therapy for children with perforated appendicitis: long course of intravenous antibiotics versus early conversion to an oral regimen. Am J Surg. 2008;195(2):141-3.  [PMID:18070723]
  45. St Peter SD, Aguayo P, Fraser JD, et al. Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial. J Pediatr Surg. 2010;45(1):236-40.  [PMID:20105610]
  46. St Peter SD, Tsao K, Spilde TL, et al. Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial. J Pediatr Surg. 2008;43(6):981-5.  [PMID:18558169]
  47. Bonasso PC, Dassinger MS, Wyrick DL, et al. Evaluation of white blood cell count at time of discharge is associated with limited oral antibiotic therapy in children with complicated appendicitis. Am J Surg. 2019;217(6):1099-1101.  [PMID:30639131]
  48. Ingram MC, Harris CJ, Studer A, et al. Distilling the Key Elements of Pediatric Appendicitis Clinical Practice Guidelines. J Surg Res. 2021;258:105-112.  [PMID:33010554]
  49. Theodorou CM, Lee SY, Lawrence Y, et al. The Utility of Discharge Antibiotics in Pediatric Perforated Appendicitis Without Leukocytosis. J Surg Res. 2022;275:48-55.  [PMID:35219251]
  50. Eysenbach LM, Caty MG, Christison-Lagay ER, et al. Outcomes following adoption of a standardized protocol for abscess drain management in pediatric appendicitis. J Pediatr Surg. 2021;56(1):43-46.  [PMID:33143877]
  51. Wakeman D, Livingston MH, Levatino E, et al. Reduction of surgical site infections in pediatric patients with complicated appendicitis: Utilization of antibiotic stewardship principles and quality improvement methodology. J Pediatr Surg. 2022;57(1):63-73.  [PMID:34657739]
  52. Freedman-Weiss MR, Chiu AS, Worhunsky D, et al. An Evidence-Based Guideline Supporting Restricted Opioid Prescription after Pediatric Appendectomy. J Pediatr Surg. 2020;55(1):106-111.  [PMID:31699433]
  53. Wakimoto M, Miller R, Shafy SZ, et al. Safety of Same-Day Discharge Compared to Overnight Observation Following Laparoscopic Appendectomy in the Pediatric-Aged Patient: A National Surgical Quality Improvement Program Project. J Laparoendosc Adv Surg Tech A. 2019;29(7):965-969.  [PMID:31099710]
  54. Knaapen M, van der Lee JH, Heij HA, et al. Clinical recovery in children with uncomplicated appendicitis undergoing non-operative treatment: secondary analysis of a prospective cohort study. Eur J Pediatr. 2019;178(2):235-242.  [PMID:30421265]
  55. Nordin AB, Diefenbach K, Sales SP, et al. Gangrenous appendicitis: No longer complicated. J Pediatr Surg. 2019;54(4):718-722.  [PMID:30551843]
  56. Raval MV, Kwan AB, Travers CD, et al. Importance of Compliance Audits for a Pediatric Complicated Appendicitis Clinical Practice Guideline. J Med Syst. 2018;42(12):257.  [PMID:30406316]
  57. Anandalwar SP, Cameron DB, Graham DA, et al. Association of Intraoperative Findings With Outcomes and Resource Use in Children With Complicated Appendicitis. JAMA Surg. 2018;153(11):1021-1027.  [PMID:30046808]
  58. Schoel L, Maizlin II, Koppelmann T, et al. Improving imaging strategies in pediatric appendicitis: a quality improvement initiative. J Surg Res. 2018;230:131-136.  [PMID:30100029]
  59. Alkhoury F, Burnweit C, Malvezzi L, et al. A prospective study of safety and satisfaction with same-day discharge after laparoscopic appendectomy for acute appendicitis. J Pediatr Surg. 2012;47(2):313-6.  [PMID:22325382]
  60. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986;15(5):557-64.  [PMID:3963537]
  61. Carpenter JL, Orth RC, Zhang W, et al. Diagnostic Performance of US for Differentiating Perforated from Nonperforated Pediatric Appendicitis: A Prospective Cohort Study. Radiology. 2017;282(3):835-841.  [PMID:27797677]
  62. Kotagal M, Richards MK, Chapman T, et al. Improving ultrasound quality to reduce computed tomography use in pediatric appendicitis: the Safe and Sound campaign. Am J Surg. 2015;209(5):896-900; discussion 900.  [PMID:25771132]
  63. Rice HE, Brown RL, Gollin G, et al. Results of a pilot trial comparing prolonged intravenous antibiotics with sequential intravenous/oral antibiotics for children with perforated appendicitis. Arch Surg. 2001;136(12):1391-5.  [PMID:11735866]

Media

JHACH Fast Track Patient Flow

Yale Opioid Use in Appy Results - A Closer Look

University of Rochester Simple Appendicitis Key Driver Diagram

University of Rochester Postoperative Simple Appendicitis Clinical Practice Guideline

University of Rochester Same Day Discharge Appendectomy Run Chart

© 2026 American Pediatric Surgical Association and Unbound Medicine, Inc. All Rights Reserved.
All content is protected by copyright and may not be used for AI model training or other unauthorized purposes.