Introduction

Welcome to the APSA Quality and Safety committee Appendicitis Toolkit. This page is intended to help anyone who is interested in quality improvement of the management of 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.

Suspected Appendicitis Pathways

Children’s Medical Center Dallas

Resources

Appendicitis clinical guideline

Submitted by Alana Beres

Cohen Children’s Medical Center

Resources

Suspected appendicitis algorithm

Submitted by Richard Glick

St. Joseph’s Children’s Hospital

Appendicitis pathway

Submitted by Grant Geissler

Sunrise Children’s Hospital

Resources

History and physical exam template for suspected appendicitis

Emergency Department FastTrack

Texas Children’s Hospital

TCH developed an emergency department (ED) fast track that included standing delegation orders (SDO) for ultrasound (US) and a surgical hospitalist pilot to decrease ED length of stay (LOS).

We adopted SDO for US based on the Pediatric Appendicitis Score (PAS) as assessed by triage nursing staff in the ED 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

The presentation summarizes the pathway and the decision support that was built to integrate the PAS score into the radiology orders for US. This project was part of a multifaceted intervention addressing LOS in all phases of care as we piloted a shared savings program for appendectomy.

Stakeholders: ED, nursing, surgeons, radiology, perioperative services staff, anesthesia, financial services, hospital administration

Submitted by Monica Lopez

Ultrasound Templates

Children’s Healthcare of Atlanta

CHOA developed and validated an ultrasound (US) template that reported secondary signs and categorized diagnostic confidence and disease severity for acute appendicitis in children.

In order to optimize the utility of US at our institution, we implemented a quality improvement (QI) initiative to increase the reporting of secondary signs (SS) in right lower quadrant US [1][2][3]. Concurrently, we tracked the number of patients undergoing computerized tomography (CT) and the number of patients being admitted for observation.

Resources

• The structured radiology US reporting template
• Standardized reporting of secondary signs poster
• Do secondary signs of appendicitis matter presentation

Outcomes of interest

• high compliance rates of utilizing the standardized US report
• lower CT use
• fewer admissions for observation
• duration of symptoms was associated with more SS
• equivocal US that included hyperemia, fluid collection or appendicolith had 96% specificity and 88% accuracy

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 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 malking.

Submitted by Mehul Raval

Additional implementers: Kurt Heiss

Texas Children’s Hospital

TCH developed and validated an ultrasound scoring system for children with suspected acute appendicitis.

Brief description

We standardized the reporting of appendiceal ultrasound (US) by means of a structured template system aiming to risk stratify patients with suspected pediatric appendicitis and measure the effect of this scoring system on US diagnostic performance measures, follow-up computerized tomography rates and negative appendectomy rates [4][5][6][7].

Resources

The structured radiology US reporting template is detailed in the reference attached.

Stakeholders: emergency department (ED), radiology, surgery

Challenges and solutions: We found that 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 us to identify factors that further discriminate between simple and perforated appendicitis based on US.

Submitted by Monica Lopez

Nonoperative Management of Simple Appendicitis

Nationwide Children’s Hospital

Nationwide developed an algorithm for the nonoperative management of uncomplicated appendicitis.

Brief description

Selection criteria for the nonoperative management of uncomplicated appendicitis were developed. We offer it as a treatment choice to any patient that meets the inclusion criteria.

Resources

Description of inclusion and exclusion criteria

Stakeholders: surgery, emergency department, radiology

Submitted by Peter Minneci

Informed Consent

Texas Children’s Hospital

TCH developed standardized visual aids to use during the informed consent process for appendectomy.

Brief description

We developed a visual aid to promote patient’s and families’ understanding during the informed consent process [8].

Resources

Visual aid

Stakeholders: surgery, anesthesia, perioperative services

Challenges and solutions: ongoing education for rotating residents, adapt process for community campus without learners, promote awareness and use by faculty

Submitted by Mary Brandt

Intraoperative Assessment

St. Joseph’s Childrens Hospital

Resources

Intraoperative assessment and standardization of care for perforated appendicitis worksheet

Submitted by Grant Geissler

Texas Children’s Hospital

TCH developed a program to standardize the intraoperative diagnosis and wound classification.

Brief description

We standardized the intraoperative definitions of disease severity for appendicitis and wound classification with appropriate documentation in the electronic medical record in order to improve accuracy of our institutional appendectomy population outcomes platform.

Protocol

A presentation was developed, distributed and posted in the operating room and other common areas. Education was provided to physicians and nursing staff. See attached slides.

Stakeholders: surgery, anesthesia, perioperative services, hospital quality improvement leadership

Submitted by Monica Lopez

Opioid Reduction

Children’s Healthcare of Atlanta

CHOA developed opioid sparing postoperative pain management

Brief description

We put together a protocol to minimize the use of opioids in the postoperative period. This was part of a comprehensive early recovery after surgery pathway for colorectal surgery in our institution but it has been adopted in the setting of appendectomy as well.

Resources

Pain management protocol

Stakeholders: surgery, anesthesia, perioperative nursing staff

Submitted by Mehul Raval

Pediatric Surgery Associates (las Vegas, NV)

Resources

Recommendations for opioid reduction

Same Day Discharge

Johns Hopkins All Children’s Hospital

Johns Hopkins developed a same day discharge after appendectomy fast track.

Brief description

Successful implementation of a same day discharge fast track for patients with acute and suppurative appendicitis as well as those presenting for an interval appendectomy [9].

Resources

Order set

fast track flow

Stakeholders: surgeons, emergency department (ED) staff, operrting room staff, patients, parents, 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 patient flow process, hand offs and discharge education was extremely important.

Submitted by Raquel Gonzalez

Nemours / Alfred I. duPont Hospital for Children

Nemours/AIDHC developed a same day discharge protocol for uncomplicated appendicitis.

Brief description

Patients with uncomplicated appendicitis are discharged home from the postanesthesia care unit (PACU) [9][10][11][12][13][14][15][16].

Resources

Same day discharge protocol

Stakeholders: surgeons, PACU nurses, operating room nurse managers

Submitted by Loren Berman

Texas Children’s Hospital

TCH developed a same day discharge for appendicitis pathway

Protocol

A standardized care algorithm was developed to allow same day discharge for selected appendectomy patients [10]. This entailed convening a large multidisciplinary team to help define specifics of the protocol.

• eligibility - five to 18 years or age with the intraoperative diagnosis of simple appendicitis (previously we had standardized disease severity definitions among surgeons)
• exclusion criteria - interval appendectomy, advanced appendicitis (e.g. gangrenous, perforated), comorbid condition or social indication for admission

Interventions included an order set featuring conditional orders, standardized patient education pamphlets, physician/advanced practice providers education sessions, a telephone script and standardized same day discharge appendectomy phone follow-up template were created for documentation within our electroninc health record. We tracked direct variable costs from our hospital cost accounting department.

Stakeholders: emergency department physicians, pediatric hospital medicine physicians, community pediatricians, surgeons, anesthesiology, radiology, nursing staff, pharmacy, perioperative nursing leadership, quality/outcomes leadership

Challenges and solutions: We encountered difficulty defining days/hours of eligibility for same day discharge based on postanesthesia care unit (PACU) staffing. We also adapted the protocol to better suit the workflows at community locations where PACU availability differs and the make up of the surgery service differs (no learners).

Submitted by Monica Lopez

University or Texas / Children’s Memorial Hermann Hospital

Resources

Same day discharge for appendicitis presentation

Resident handbook on appendicitis

Submitted by Kuojen Tsao

Decreasing Length of Stay

Texas Children’s Hospital

TCH developed a pathway for decreasing length of stay (LOS) in patients with simple acute appendicitis.

Brief description

We implemented a fast track, nursing driven order set and family educational pamphlet in order to decrease the LOS for patients with simple appendicitis

Protocol

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. The results are noted in the poster.

Stakeholders: nursing, surgeons, perioperative services staff, anesthesia

Challenges and solutions: This was one of the very first quality improvement interventions related to appendicitis in our institution (back in 2012). The multidisciplinary workgroup has continued to partner in developing many other protocols related to optimization of appendicitis management.

Submitted by Monica Lopez

Perforated Appendicitis

Saint Louis University/ Cardinal Glennon Children’s Hospital

This protocol was enacted to develop consistent criteria for the initial nonoperative treatment of perforated appendicitis and to establish a standardized approach to antibiotic management for appendicitis patients.

Protocol

Through multiple discussions with the surgical staff the protocol was developed. An order set was developed and a flow sheet of the algorithm distributed to the surgical residents. Additionally, there has been discussion with the Infectious Disease team regarding choice of antibiotics and this will likely be an area for continued refinement.

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

Challenges and solutions: Finding common ground between the surgeons in protocol development. This was overcome with several rounds of discussion and agreement that there could be deviation from the protocol at attending surgeon discretion (which is now a rare event). This resulted in decreased antibiotic usage on discharge and
decreased duration of antibiotics from an average of 19 to seven days. There was no significant change in rate of complications, rate of readmission or abscess formation (seven versus 11% after protocol).

Submitted by Colleen Fitzpatrick

Nemours / Alfred I. duPont Hospital for Children

All surgeons at our institution were managing complicated appendicitis in very different ways. We reviewed the literature and worked with a multidisciplinary team of surgery, infectious disease and pharmacy to come up with standardized antibiotic protocols, a standardized definition of ruptured versus nonruptured appendicitis and developed electronic health record (EHR) order sets and standardized operative notes to easily identify complicated versus uncomplicated in data review.

Resources

• protocol starting with emergency department (ED) work up to antibiotic administration posted in our ED
• summary of protocol regarding antibiotic use and definitions of ruptured versus nonruptured [17][18][19][20][21].
• surgeon immediate operative note template submitted to the EHR team to develop appendicitis specific operative note in order to quantitatively query operative notes and differentiate between complicated and uncomplicated cases
• presentation of our NSQIP data that I made to our surgery team to encourage more aggressive approach to operating on ruptured appies. Of note, this will not decrease surgical site infection rate because you are operating on more ruptured cases but I believe it does improve care for appendicitis patients overall and this is what the literature suggests
• presentation of our NSQIP data emphasizing morbidity of excess antibiotic therapy (this was used especially to help commit to a definition of complicated appendicitis that does not include gangrenous or localized exudate)

Stakeholders: surgeons, infectious disease, pharmacy, emergency department

Submitted by Loren Berman

Texas Children’s Hospital

TCH developed a clinical pathway for complex appendicectomy patients.

Brief description

Implementation of 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.

Protocol

We followed the pathway for revision of this hospital wide practice guideline which entailed assembling a multidisciplinary content expert team, research specialists, EHR builder, data architect and clinical outcomes specialist.

Two additional questions are addressed in this version of the guideline, we updated the care algorithm after a review of the literature to reach consensus recommendations. We have ongoing appendectomy outcomes review via application tracking of selected measures which generates a balanced scorecard.

Clinical decision support is integrated into work flows by means of admission and postoperative order sets and standardized admission and progress 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

Stakeholders: ED physicians, pediatric hospital medicine physicians, surgeons, radiology, interventional radiology, infectious disease, nursing staff, pharmacy, nutrition, social services, quality/outcomes staff, research staff

Challenges and solutions: We benefited from leveraging an institutional process for developing clinical standards that is mature and very robust. We encountered some difficulty in achieving consensus for some recommendations given the lack of published evidence. We used standardized education sessions for all campuses but need to optimize ongoing monitoring of adherence to protocol.

Submitted by Monica Lopez

References

1. 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]
2. 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]
3. 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]
4. 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]
5. 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]
6. 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]
7. 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]
8. 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]
9. 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]
10. 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]
11. 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]
12. 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]
13. 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]
14. 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]
15. 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]
16. 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]
17. 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]
18. 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]
19. 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]
20. 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]
21. 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]