Approach to Decreasing Computed Tomography (CT) Utilization for Diagnosing Appendicitis

General Information

Institution Name: Dell Children’s Medical Center of Central Texas

Primary Author & Title: Kavita Bhakta, BSN, RN, RN Coordinator, NSQIP-P Surgical Clinical Reviewer (SCR)

Co-Authors & Titles: Theresa Viduya, MSN, RN, RN Coordinator, NSQIP-P SCR Kathryn Danko, BSN, RN, Children’s Surgery Program Manager Erich Grethel, MD, FACS, FAAP, NSQIP-P Surgeon Champion

Name of the Case Study: Approach to Decreasing Computed Tomography (CT) Utilization for Diagnosing Appendicitis

Problem Detailing

Reducing radiation exposure in the pediatric population has been a quality initiative nationwide for years. Dell Children’s Medical Center (DCMC) joined the Pediatric Surgery Quality Collaborative (PSQC) in 2020. One of the first projects initiated in the collaborative focused on decreasing computed tomography (CT) utilization to diagnose appendicitis. A review of the literature by the collaborative found a study specific to CT utilization for diagnosing appendicitis in the pediatric population that showed a correlation between radiation exposure and increased cancer risk in later adult life.¹ After interviewing participating hospitals that were either high or low outliers, the collaborative created an implementation guideline to assist members in decreasing their CT rates.

Dell Children’s NSQIP-P 2020 Semi-Annual Report (SAR) showed an increased CT rate to diagnose appendicitis compared to the previous report. After further historical review, the institution found the CT rate of 30.3% in 2020 was the highest since data collection for the appendectomy variable in the National Surgical Quality Improvement Program—Pediatric (NSQIP-P) started in 2015.

Dell Children’s Medical Center is a free-standing pediatric hospital located in Austin, Texas. This 240-bed institution has 50 subspecialties and is a designated magnet hospital with a Level I Pediatric Trauma Center, Level I Children’s Surgery Center, and a Level IV Neonatal Intensive Care Unit. In fiscal year 2021 alone, DCMC had an average daily census of 121 patients, over 39,800 Emergency Department visits, and 7,121 surgeries.

DCMC is affiliated with The University of Texas at Austin Dell Medical School and is part of the Ascension Healthcare Company. Ascension is a faith-based nonprofit healthcare system that includes more than 150,000 associates, 40,000 aligned partners, and operates more than 2,600 sites of care in 19 states and the District of Columbia.

Beginning in May 2021, a project team consisting of two RN coordinators, a nurse manager, project manager, and a surgeon champion met to develop a plan to decrease DCMC’s CT rate. The implementation guideline provided by the PSQC encouraged the use of a pediatric appendicitis scoring tool, appendicitis guideline, ultrasound (US) protocol and training, US reporting in electronic health records (EHR), and US strategies for patients with BMI ≥ 30. The team noticed that besides magnetic resonance imaging (MRI) utilization, DCMC already had most implementations advised by the collaborative in place but compliance with some of these factors had decreased over time. The project team organized a larger interdepartmental CT Reduction Team and included the addition of 14 representatives:

• Administration: Director of Trauma Services (1), Interim Surgical Services Director (1)
• Surgery: General Surgeons (2), Surgery Advanced Practice Providers (2)
• Emergency Department: Emergency Medicine Physicians (2), RN (1)
• Radiology Department: Radiologist (1), Radiology Manager (1)
• Imaging Departments Leads: Ultrasound technician (1), CT technician (1), MRI technician (1)

Goal Specification

SMART Goal

Specific: Using the implementation guideline provided by the Pediatric Surgical Quality Collaborative, DCMC aimed to decrease their CT utilization rate to ≤15% while maintaining a negative appendicitis rate of ≤1.75%.

Measurable: NSQIP-P and Institutional Data (Centricity and EHR)

Achievable: PSQC set a goal to have the CT utilization rate decrease to ≤ 15% by the end of the year 2021. The team discussed this goal and determined it was not obtainable as the project started mid-year (July 2021); therefore, DCMC decided to increase the timeline to one year (June 2022).

Relevant: Historically DCMC’s CT rates for diagnosing appendicitis have been lower, as low as 12.8% in 2015. DCMC needed to address the changes that have occurred since this time and also determine any new implementations that could be added to the Acute Appendicitis Guideline to decrease the CT rate.

Timeline: July 2021–June 2022.

Strategic Planning

Monthly meetings were scheduled starting in May during which each department was introduced to the project and end goal. Historical NSQIP-P data was reviewed and showed a decrease in compliance with Pediatric Appendicitis Score (PAS) documentation by the Emergency Department and Surgery. The group found that it would be beneficial to also collect data on all patients that were evaluated for appendicitis and received imaging at DCMC. This larger pool of data allowed the team to monitor the success rates of appendix visualization via US

and CT in patients who did not have appendicitis as both data points are not collected in NSQIP-P. The additional data was collected via Centricity and hand-pulling from EHRs.

Since MRI utilization would be a new amendment to the current institutional Acute Appendicitis Guideline, the team also conducted a literature review to investigate the effectiveness and cost difference between MRI and CT for diagnosing appendicitis. As the actual cost of these procedures is institution based, DCMC connected with their billing department for the internal costs. The team determined that the fast sequence MRI would be just as effective as CT for diagnosing appendicitis and the long-term benefits of decreased radiation exposure outweighed the cost difference.

A “CT Utilization Dashboard” was created for easy data visualization and ad lib monitoring by the team. Data points on the dashboard included monthly CT rate, PAS completion, US visualization rates, ED duration, admissions for observation, and lab counts.

Many of the implementations involved in DCMC’s project were already in place. The institution had an established Acute Appendicitis Guideline, the physicians were using an appendicitis scoring tool, and the ultrasound technicians were trained on visualizing the appendix. Success ultimately came down to focusing on resurfacing these processes and increasing compliance.

Process Evaluation

The representatives took the information from the monthly meetings back to their respective departments and returned with follow-up interventions and goals.

• The Emergency Department stated they will reach 100% compliance with PAS documentation by conducting inservices with attendings and residents, posting reminder flyers at workstations with instructions on simple EHR documentation, and counseling individuals who remained non-compliant at each data
• The Radiology Department made it mandatory to scan patients for a minimum of 15 minutes to visualize the appendix and when available, ask another technician to scan the patient if the appendix was not visualized.
• The Surgery Department encouraged their colleagues to give families the option to admit patients with equivocal exams for observation and next-day repeat US in lieu of a CT, held an inservice with their group to complete PAS documentation, and initiated the institutional process to incorporate MRI utilization for diagnosis of appendicitis.

The institutional Acute Appendicitis Guideline is in the process of being amended to incorporate MRI utilization for diagnosing appendicitis. The guideline is under review for approval by the evidence-based outcomes center committee. Currently, the MRI implementation is in the logistics phase, which includes the development of an MRI protocol and navigating how to incorporate the stat MRI orders from the emergency department into the daily MRI schedule.

Outcome Evaluation

The 2020 NSQIP-P data showed DCMC to have a CT rate of 30.3% with a negative appendicitis rate of 0.7%. According to the 2021 NSQIP-P data, the CT rate decreased to 23.2% with a negative appendicitis rate of 0.9%. PAS completion in both Emergency and Surgical departments and US visualization had an increasing trend over the year. DCMC has also shown an increase in hospital admissions for observation since the project began.

Setbacks

Visualization of the appendix is highly dependent on the experience of the technician.² Staff turnover increased during the coronavirus pandemic, leading to a loss of experienced technicians. The data does show improvement, but the numbers may have been better if staff turnover did not occur.

There was a setback related to visualization of the appendix in patients with a high BMI; the radiology department is troubleshooting to determine if there is anything that can be done differently in these patients besides changing patient position and emptying bladder prior to US scan.

As expected, operationalizing MRI imaging instead of CT brought up some reservations in each involved department. DCMC addressed some of these reservations, such as MRI technician availability and interpretation of results, by seeking advice from other institutions involved in the PSQC who were already utilizing MRI for diagnosing appendicitis. The institutions shared their available resources, some of which included literature supporting MRI utilization, MRI protocol information, and coding. With the knowledge gained from these resources, the team is working through their concerns with hospital administration while emphasizing the importance of reducing radiation exposure to young children.

Cost Evaluation

No additional costs or funding beyond normal hospital operations were needed to implement or maintain the project at the time this case study was written. However, the MRI implementation pilot may reveal future additional costs.

Cost considerations were not the focus of this project. The goal being to reduce the number of CT scans significantly, a cost savings may or may not be balanced out with resources committed to other aspects of the abdominal pain work-up.

Knowledge Acquisition

There were several lessons learned from completion of this QI project, including:

• Leadership is very important for Having an involved leadership group increases buy-in from other stakeholders and provides the support and encouragement for the team to move forward towards project goals.
• Access to data is vital and presentation Information Systems (IS) involvement was necessary to pull data outside of NSQIP-P that was required for this project. Additionally, the creation of a dashboard to visualize the data allowed stakeholders to review data anytime making meetings more efficient resulting in the Project Team receiving more feedback. Of note, not having a dedicated data analyst led to the Project Team having to take on this extra role.

• PSQC has been an excellent networking resource. The network has been very helpful as DCMC moves forward with MRI utilization for diagnosing appendicitis.

End-of-Project Decision-Making

Upon project completion, the dashboard will be available to the entire hospital in Tableau. This will allow for sustainability of data dissemination and continuous monitoring.

The Acute Appendicitis Guideline is currently under review to incorporate MRI utilization. Once implemented and if CT rate continues to decline, DCMC does not see any additional changes to be made until the 3-year guideline review mark. DCMC plans to share the guideline and project results with other interested Ascension hospitals in the surrounding area.

Acknowledgments

Special thanks to Terry Fisher and Dr. Kevin Lally from the PSQC for all your help with this project. The team would also like to thank Dr. Afif Kulaylat and Dr. Michael Moore from Penn State, Dr. Loren Berman from Nemours, and Dr. KuoJen Tsao from Children’s Memorial Hermann for all the MRI resources and guidance they have provided. Lastly, to all in the CT Reduction Team, thank you for all the time and hard work you dedicated to this effort.

References

1. Lee KH, Lee S, Park JH, et al. (2021). Risk of hematologic malignant neoplasms from abdomniopelvic computed tomographic radiation in patients who underwent appendectomy. JAMA Surg, 156(4), 343-351.
2. Kim J, Kim K, Kim J, et al. (2017). The learning curve in diagnosing acute appendicitis with emergency sonography among novice emergency medicine residents. J Clin Ultrasound, 46(5), 305-310.