Introduction

Welcome to the APSA Quality and Safety Committee Intussusception Toolkit. This page is intended to help anyone who is interested in quality improvement pertaining on the management of patients with intussusception.

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.

video link Intussusception systematic review from the APSA 2020 virtual meeting

Intussusception Management

Children’s Hospital Los Angeles

This protocol outlines the diagnosis and management of intussusception based on clinical suspicion. Diagnostic imaging, radiologic reduction, resuscitation and emergent surgical indications are outlined. Emergency department (ED) discharge is also outlined when clinically appropriate

Protocol

• Intussusception protocol

Stakeholders: ED, radiology, general pediatric surgery

Submitted by Lorraine Kelley-Quon

Early Discharge After Intussusception

Boston Children’s Hospital

Boston Children’s developed a standardized clinical assessment and management plan (SCAMP) for pediatric ileocolic intussusception to enable successfully reduced patients meeting certain criteria to be discharged from the emergency department (ED) with two planned follow-up phone calls by surgical personnel after discharge. Of the 118 patient encounters treated through the SCAMP in two pilot studies from February 2013 through December 2017 76% met discharge criteria of whom 88% underwent outpatient management. There were no instances of bowel perforation, necrosis or death in the discharged group. No patients developed bacteremia despite withholding antibiotics for the sole indication of intussusception. We concluded that patients treated via the SCAMP can allow for most patients to be safely discharged from the ED, avoid antibiotics and safely undergo phone based follow-up for concerns of recurrent intussusception [1][2].

Protocol

• Intussusception surgical algorithm

Resources

• Follow-up phone surveys and symptom analysis
• Family education sheets (English, Spanish, Arabic)

Stakeholders: patients, patient families, pediatric surgeons, emergency physicians, primary care physicians, radiologists and nurse practitioners

Challenges and solutions:

1. The biggest challenge in the initial pilot was educating providers, encouraging buy-in and managing compliance. These were addressed via discussions during faculty staff meetings as well as updated education during rotating resident orientation sessions. Reminder emails were also sent to surgical staff at weekly intervals.
2. In the second pilot phase, the biggest challenges were improving the rates of follow-up phone calls by nurse practitioners and rates of distribution of the family education sheet. These were addressed by sending weekly reminder emails to the nurse practitioners to place follow-up calls over the weekend and by adding a question to the follow-up questionnaire to confirm that families received the family education sheet.
3. Currently, we are attempting to redirect appropriate patients to urgent clinic visits instead of the ED. To accomplish this, we are developing a smart phone app to help mediate follow-up.

Submitted by Catherine Chen

Cardinal Glennon

This project was designed to assess the success of ED discharge for patients with radiographically reduced intussusception. Following reduction, patients are observed in the ED and discharged to home if clinically well.

Protocol

Eligible patients (ileocolic intussusception, no prior episodes, age zero to four years, parents deemed capable of identify symptoms of recurrence, live within one hour of the hospital, reliable method of transportation) who undergo successful intussusception reduction are consented for study enrollment. Following successful reduction, patients return to the ED where they are given a PO trial and briefly observed. Patients who remain clinically well are discharged to home and receive phone follow-up.
Patients who do not meet eligibility requirements (peritonitis, persistent pain following reduction, lead point identified, difficult reduction, failed reduction or perforation, severe dehydration) are either taken directly to the operating room or admitted for observation as determined by the
clinical scenario.

Stakeholders: patient/ families, pediatric surgeons, emergency department staff

Challenges and solutions:

Challenges: extended time spent in the ED, availability of appropriate staff to obtain consent, ability to contact families by telephone

Solutions: direct discussion and education of ED staff, currently research fellows cover significant portion of call schedule and are typically
available to obtain consent. Once the study is completed consent will no longer be required, phone follow-up can be challenging as phone numbers frequently change or families not responding to unrecognized numbers. If phone numbers have changed, letters may be sent in the mail. Text messaging systems may be used to overcome the challenges of unrecognized numbers.

Submitted by Colleen Fitzpatrick

Additional implementers: Kavi Chatoorgoon

University of Texas Houston

This project helped to standardize our management of patients with intussusception. The goal was to decrease length of stay and develop a protocol for early discharge from the emergency department. We were also able to define which patients would have a repeat attempt at reduction of intussusception. [2][3]

Protocol

• Intussusception protocol

Stakeholders: pediatric surgery, ED physicians, ED nurses, floor nurses, pediatric radiology

Challenges and solutions:

• Difficulty with adequate beds in the ER with a possible effect on patient flow; Solution: Short ED observation period and admission to observation unit if the ED is backed up
• Determine who can be discharged safely from the ED after enema reduction; Solution: Follow protocol criteria for determination of admission

Submitted by Akemi Kawaguchi

Emergency Physician Management

Children’s Hospital Wisconsin

CHW had previously reported on the management of patients who presented to the emergency department (ED) with ileocolonic (IC) intussusception, ED physicians evaluate children with suspected intussusception with ultrasonography. If IC intussusception is found and there is no clinical concern for bowel ischemia, the patient undergoes pneumatic or contrast reduction. If the reduction is successful and the child tolerates oral challenge of food and liquids successful, he/she is sent home. Surgical consultation is obtained with unsuccessful intussusception reduction, concerns for possible lead point, concerns for bowel ischemia, small bowel to small bowel intussusception AND repeat visits for intussusception.

Protocol

The current CHW protocol empowers the ED physicians to evaluate and radiologists to manage simple IC intussusception. It gives guidelines regarding safe repeated attempts at nonoperative reduction. Patients who are suspected of having recurrence of IC intussusception undergo diagnostic ultrasonography.

Stakeholders: pediatric surgeons, emergency department physicians, emergency department nurses, pediatric radiologists

Challenges and solutions: The pathway whereby simple IC intussusception is managed without surgical consultation was not accepted universally by surgeons who were trained to evaluate and admit all intussusception patients. An institutional retrospective review [4] showed that recurrent intussusception is relatively rare, did not occur hours after reduction and recurrence did not have any adverse effects on patient outcome. These data were reviewed with the ED, surgery, and radiology creating wide acceptance of the protocol. The protocol outlined above represents a modification of the protocol, addressing incomplete reductions.

Resources

Presentation

Submitted by Marjorie Arca

References