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:

  • Global Statement:
    • Incorporating rigorous QI initiatives in complex healthcare teams can be challenging. For this particular project, one of the main obstacles was the volume of diverse providers (pediatric surgeons, emergency department providers, nursing, and ancillary staff) who could potentially be involved with the care of a given patient with appendicitis. Early engagement of these stakeholders to develop the CPG was critical for buy-in and success. Further, harnessing division meetings to disperse information, identifying influential stakeholders to champion the intervention, and soliciting regular feedback were all important mechanisms of implementing and revising the intervention.
  • Specific Challenges:
    • Developing order set usability for practitioners: Initially, we found that our proposed simple same day discharge order set was not used by practitioners soon after launch. Through individual interviews and conversations about the order sets with nursing, mid-level providers, and residents, we found that the mid-level providers and residents did not like that the order set allowed nursing to discharge patients without notifying the surgical team. We changed the order set to include a conditional discharge order with specific criteria (“discharge in 4 hours after Pediatric Surgery team has seen patient” or “discharge in the morning after rounds”) to keep practitioners in communication with nursing for same day discharge.
    • Developing standard op note language that all 16 providers can use: one of the main goals of a standardized operative note was to deliver standardized descriptions and intraoperative grading of pediatric appendicitis that could be used among all surgeons in our practice. The importance of having standard documentation descriptions for both coding/billing purposes and for ensuring reliability in postoperative antibiotic stewardship cannot be overemphasized. Along with this, however, we found that all surgeons had individual systems and preferences with how they wrote or dictated operative reports. Challenges in developing this tool included both finding a common language that all providers could agree upon, and getting surgeon feedback on the operative note to make it more usable. Obtaining feedback required individual interviews and regular reporting at division meetings to bring all surgeons into a common practice. Ultimately, we developed a smart text that auto-populated in the operative note and included the grade category and associated descriptors.

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:

  • Medical Director of Pediatric Surgery, Grant Geissler, MD
  • Pediatric Emergency Medicine Physician, Worth Barbour, MD
  • Pediatric Radiologist, Timothy Bonsack, MD
  • Pediatric Hospitalist, Christina Canody, MD
  • Pediatric Surgical Program Coordinator, Kirsten Yancy, RN
  • Evidence Based Medicine Members: Paul Lewis, MD and Pamela Morell, RN

Challenges and Solutions:

Challenges:

  • Documentation of the PAS score by the ER physician in the EMR
  • Education to all ER physicians
  • Education to community ER physicians about best practice for the diagnosis of appendicitis

Solutions:

  • Working with the IT department to embed the PAS score in EMR documentation, providing education to ER physicians on consistently documenting the PAS score
  • Working on presenting the insitutional best practice medical standard to each Health System Hospital
  • Looking at opportunities for community education- work still in progress

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:

  • ED hesitant to discharge kids without any imaging, even in low/moderate PAS groups.
  • Institutions must have experience and easy access to MRI 24x7.

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:

  • Ongoing education for rotating residents
  • Adapt a process for community campus without learners
  • Promote awareness and use by faculty

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:

  • Difficulty defining days/hours of eligibility for same-day discharge based on the PACU staffing.
  • Adaptation of the protocol to better suit the workflows at community locations where PACU availability, as well as the makeup of the surgery service differs (no learners).

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:

  • This was one of the very first QI interventions related to appendicitis that was implemented (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, 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:

  • The initial challenge was getting all of the pediatric surgeons to be willing to change their practice. This was solved by one surgeon adopting the same day discharge, and others seeing it was possible. Doing it as a research intiiative encouraged other surgeons to partipcate since outcomes were being monitored.
  • The next challenge was in the PACU since the staff was not used to managing these children as same day surgery patients. This initially generated many calls and confusion. The solution was to have conversations about WHY. Now, if we don’t discharge the patient from PACU, it generates a phone call! Complete change of practice.
  • An additional challenge was with the parents/guardians as they often were told that their child would have to stay postoperatively, and this was their expectation. Modifying the preoperative conversation allowed the team to set the expectation of same day discharge.

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:

  • Getting provider and healthcare team buy-in. Dr. Wakeman had been trying to send patients home the same day for several years. However, without a standardized pathway and agreement from all surgeons and residents, patients rarely were discharged the same day after an appendectomy for simple appendicitis.
    • Involved attending surgeons in the creation and consensus approval of the protocol.
    • Provided education to the rotating residents and familiarized them with the guideline.
    • Provided nursing education, especially to PACU nurses, who became familiar with same day discharge requirements.
    • Improved the same day discharge process. In the past, these patients had their operations overnight or were admitted to the floor for surgery the next day. These patients start boarding in the PACU while overnight, awaiting surgery the next morning. Given the familiarity of the PACU with the discharge certain criteria, this likely helped improve same day discharge.
  • Obtaining parent and patient buy-in.
    • Normalized same day discharge during patient discussions, which became the norm/expectation.
  • OR availability.
    • Implemented the availability of an urgent OR to be available in the morning for add-on cases (shared with orthopedics).
    • Implemented a surgeon of the week model where one surgeon is available and responsible for all cases that are added on overnight. In the past, surgeons often performed appendectomies during nighttime hours to prevent the case from interfering with their schedule the following day.

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:

  • Finding common ground between the surgeons in protocol development. This was overcome with several rounds of discussion and agreement that there could be a 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 the rate of complications, rate of readmission, or abscess formation (7% versus 11% after protocol).

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:

  • Leveraging a mature and very robust institutional process for developing clinical standards was very beneficial.
  • Some difficulty was encountered in achieving consensus for some of the recommendations given the lack of published evidence.
  • Standardized education sessions were provided for all campuses, however, ongoing monitoring of adherence to the protocol needs to be optimitized.

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:

  • University of Rochester Postoperative Complicated Appendicitis Clinical Practice Guideline (Clinical practice guideline, which standardizes intra- and post-operative care for complicated appendicitis. It includes obtaining an intraoperative culture of purulent fluid at the time of appendectomy. The length of time on IV antibiotics is standardized, and a fast track for children doing well after appendectomy was created. Children receive piperacillin/tazobactam post-operatively for at least 72 hours. If they remain afebrile (temperature < than 37.9 °C) for at least 48 hours, a WBC is obtained, if < than 12K cells/μL, children are transitioned to oral antibiotics. Oral antibiotics are customized to the intraoperative culture results; amoxicillin/clavulanate is the default. Those who did not meet discharge criteria by post-operative day 5-7 had an abdominal/pelvic ultrasound (US) performed to assess for drainable abscesses. Further treatment is based on US results and the child’s clinical status.)

Resources:

  • University of Rochester Complicated Appendicitis SSI Key Driver Diagram (Depicts a diagram of key drivers contributing to SSI development after appendectomy for complicated appendicitis. Ideas of change are listed which are believed to mitigate the drivers of SS.)
  • University of Rochester Perioperative Antibiotic Guideline for Pediatric Appendicitis (Guideline created in consultation with a pharmacist and infectious disease/epidemiology specialist, to standardize antibiotics to treat appendicitis and assist providers in deciding, if and when, to redose antibiotics before incision in the operating room.)
  • University of Rochester OR Monitor Send Culture Reminder (Photo of one of the two monitors in the OR. The label at the bottom of the screen helps the surgical team remember to send an intraoperative culture of purulent fluid at the time of laparoscopic appendectomy for complicated appendicitis. Compliance with this process measure has been high (~98%).)
  • University of Rochester Appy Op Note (Example of an operative note template for laparoscopic appendectomy. The "findings" section has been standardized across surgeons in the group, so that information is readily available for our NSQIP surgical clinical reviewer. This process ensures accurate information is entered into NSQIP. Complicated appendicitis is confirmed by a visible hole in the appendix, fecalith found outside the appendix, intra-abdominal abscess, or purulent fluid in more than one abdominal quadrant; gangrenous appendicitis without any of the aforementioned elements is not considered CA. In equivocal cases, surgeons are encouraged to inspect the appendix for a visible hole on the back table.)
  • University of Rochester Postoperative Complicated Appy Note (Template note for the physician attestation for the daily progress notes after appendectomy for complicated appendicitis. The note helps standardize care post-operatively. Non-opioid medications are scheduled to minimize opioids post-operatively.)
  • University of Rochester APSA Abstract -The utility of intraoperative peritoneal cultures during appendectomy for complicated appendicitis (Abstract accepted for presentation at the 2021 APSA meeting. The abstract contains some of our preliminary results. The g-chart demonstrates the time between SSIs. After implementation of the clinical practice guideline, including intra-operative cultures, SSIs became less frequent.)

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:

  • Standardizing care for complicated appendicitis required agreement among all surgeons in the group. All surgeons met as a group to obtain consensus in an effort to get “buy-in”.
  • In November 2019, in an antibiotic stewardship effort, the combination of ceftriaxone and metronidazole was selected to treat children with complicated appendicitis. Due to concerns about not treating certain microorganisms, the process of obtaining an intra-operative culture of purulent fluid was instituted as well. In the first two months of this practice, three of nine cultures had growth of Pseudomonas aeruginosa. In January 2021, the IV antibiotic of choice was transitioned back to piperacillin/tazobactam.
  • Within the first few months of the practice of obtaining intra-operative cultures, a culture was not collected for two children. To overcome this issue, a label on the two monitors in the main OR’s was placed to serve as a visual aid to remind the surgical team to send a culture. Since doing so, compliance with the culture has been 100%.
  • Many of the intraoperative cultures had growth of organisms that were unexpected, including growth of extended-spectrum beta-lactamase positive (ceftriaxone-resistant) strains of Escherichia coli. There was also growth of strains of Escherichia coli and other organisms that were not susceptible to our default oral antibiotics (amoxicillin/clavulanate). At times, two antibiotics were required at discharge to treat all organisms appropriately. Consultation from infectious disease specialists was obtained on several occasions to help decide the best antibiotic regimen for discharge. On one occasion, a child was discharged home on IV antibiotics because the isolated organisms were not susceptible to any oral antibiotics.

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:

  • After IRB approval, the greatest challenges included: ensuring all appendectomy patients had the “smart phrase” entered into their discharge instructions and reaching parents by phone.
    • To solve the first problem, the implementer enlisted help from those on the surgical team who do not rotate off the service-- the pediatric surgery fellow, the APRNs, and the attendings. Moreover, the implementer also often personally checked the pediatric surgery list in the morning and evening to add the welcome letter to each patients’ discharge paperwork.
    • For the second issue of patient contact, the implementer left a message with a call-back number (using a work cell phone) and answering the corresponding unidentified phone numbers which resulted in many parents calling back. Moreover, various attempts of contact were made for non-responders, resorting to different times during the day to try and accommodate different family schedules.

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]

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Media

JHACH Fast Track Patient Flow

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Yale Opioid Use in Appy Results - A Closer Look

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University of Rochester Simple Appendicitis Key Driver Diagram

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University of Rochester Postoperative Simple Appendicitis Clinical Practice Guideline

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University of Rochester Same Day Discharge Appendectomy Run Chart

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Last updated: September 12, 2022