What Was Done?
Global Problem Addressed
Use of the computed tomography (CT) scan as a diagnostic step when acute appendicitis is suspected in children has generated several concerns.1, 2 The unwanted effect of radiation on future cancer risk is a particular concern in childhood, in part because exposure is cumulative and lifelong and in part due to the increased sensitivity of the young patient to ionizing radiation.1, 2 Other concerns about the CT scan include the common practices of administering oral contrast, which is both time-consuming to allow the contrast to reach the appendix and noxious to the patient who is suffering an acute gastrointestinal illness.1, 2 Also, the often-used intravenous contrast has risks, including allergic reaction and contrast-induced neuropathy.1, 2 Finally, sedation is sometimes required to obtain adequate images from pediatric patients, which further increases the risk of performing CT scan, especially in the setting of an acute gastrointestinal illness with the potential for aspiration of gastric contents.1, 2
PICC for prolonged IV antibiotic administration can cause discomfort for children, is associated with higher costs, and exposes patients to the potential for catheter associated complications, including thrombosis, infection, or line breakage. 3-5 Extrapolation from evidence-based guidelines has suggested that in well nourished patients older than one year, the risks associated with postoperative parenteral nutrition (PN) outweigh its benefits unless specific criteria have been met, including (1) the presence of gastrointestinal dysfunction preventing adequate oral or enteral intake of nutrients for longer than seven days and (2) a duration of PN therapy for longer than five days.6
Identification of Local Problem
Golisano Children's Hospital began participation in the American College of Surgeons (ACS) National Surgical Quality Improvement Program Pediatric (NSQIP-P) appendectomy pilot in December 2012. This pilot focused on resource utilization in the care of pediatric appendicitis patients. Through participation in this pilot, we were identified as a high utilizer of preoperative CT scans and total parenteral nutrition (TPN). The first appendectomy pilot report released in July 2014 indicated that our CT utilization was 30 to 35 percent in comparison with the aggregate rate of 21.9 percent. TPN utilization was noted to be 60 percent in comparison with the aggregate rate of 19.1 percent. In December 2014, the second report was released; our PICC line utilization was 25 percent in comparison with the aggregate rate of 19.7 percent. Of note, our PICC line utilization was above the aggregate rate but was not a high outlier.
How Was the Quality Improvement (QI) Activity Put in Place?
Context of the QI Activity
Golisano Children's Hospital (GCH) is a 124-bed facility located in Rochester, NY.
The hospital serves as the referral center for all seriously ill or injured children in the 17-county Finger Lakes regions. With more than 200 pediatric specialists, GCH has a spectrum of care that spans more than 40 specialty areas, which serve more than 85,000 children and their families each year. Approximately 21,300 surgeries per year are performed covering numerous subspecialties, including the only Western New York (WNY) center offering pediatric cardiac surgery. GCH also has the largest pediatric ICU in western and central New York, which averages 825 admissions per year.
In 2010, GCH began participating in ACS NSQIP-P as one of the beta sites. ACS NSQIP-P provides GCH with the ability to benchmark with other ACS NSQIP Pediatric hospitals and identify areas for quality improvement as well as network with participating hospitals to identify best practices.
As ACS NSQIP-P is our primary pediatric surgery benchmarking tool, a high CT and TPN utilization ranking in the ACS NSQIP-P appendectomy pilot was the motivation that drove our QI efforts to improve and standardize the care of pediatric patients undergoing appendectomies at GCH.
Planning and Development Process
Key stakeholders (radiology, general surgery, pediatric surgery, quality professionals, and the emergency department) were identified, and the first meeting was scheduled. This meeting entailed review of the appendectomy pilot data as well as discussion regarding the importance of beginning a QI project to reduce CT utilization. During this, meeting the group found that there were varying opinions and thoughts on who was ordering CTs and why CTs were being ordered. The follow-up meeting focused on retrospective analysis of appendectomy cases that were performed, and group agreement on the need to develop an appendectomy pathway to standardize care of appendectomy patients. Of note, reduction of CT utilization was the main focus of this group. Although GCH has also demonstrated a decrease in TPN and PICC utilization in this study, neither of these areas were specifically targeted.
The appendectomy pathway GCH chose to adopt, modify, and utilize was the pathway in use at lntermountain Primary Children's Hospital.7 The current appendectomy pathway utilized at GCH was modified to include obtaining ultrasound of ovaries when indicated on females older than 11, PAS and ultrasound scoring combined for total score, and whether to consider acute appendicitis, perforated appendicitis with abscess, or perforated appendicitis based on total score.
The radiologist reporting template was adopted from the template in use at Seattle Children's.8 This template was also modified and included visualization of the appendix, size of appendix, compressibility, inflammatory change present, fluid present, hyperemia present, presence of lymph nodes, and abnormal bowel loops observed.
There was consensus among all practitioners involved to adopt the use of the modified appendectomy pathway, pediatric appendicitis and ultrasound scoring and radiologist reporting template.
Description of the Quality Improvement Activity
The appendectomy pathway was developed based on evidence-based literature and included the pediatric appendicitis score (PAS) and the ultrasound score (USS). The PAS is a scoring tool that had already been developed and proven to be an effective tool for evaluating rule out appendicitis patients.9 The USS tool was developed through the retrospective review of appendectomy patients and is scored based on secondary appendicitis signs visualized on ultrasound. The pathway was then sent out to the group for review and approval. Following approval of the pathway, a template for the ultrasound scoring was developed by radiology and implemented into the electronic medical record (EMR). This template provided a standardized tool for documentation of ultrasound reads and facilitated the scoring as well. Education was provided to emergency department (ED) staff, surgical residents, and radiology staff. The quality improvement professionals provided education to the ED staff and surgical residents, including in-person PowerPoint presentations and review of the pathway and scoring tool. The radiologist in the group provided education to the radiology staff via in person review of the ultrasound scoring tool and communication via e-mail. The appendectomy pathway was then initiated in April 2016. Data were prospectively analyzed and education and feedback were provided to the group.
Resources Used and Skills Needed
Staff
The preoperative appendectomy CT utilization work group consisted of 10 staff members, all of whom were identified as key stakeholders in this project. Participants of this group reviewed the appendectomy pilot and retrospective appendectomy data during meetings and regular business hours. Quality improvement professionals, pediatric surgery, general surgery, and ED providers were key stakeholders in implementing the preoperative appendectomy pathway and scoring tool.
Costs
No costs beyond normal hospital operations were necessary. Value analysis approval was not required for any portion of this project. No additional funding was utilized.
What Were the Results?
Comparing the pre-pathway phase (2014-2015) with the post-pathway phase (2016-November 2017), there was a 43 percent reduction in preoperative CT utilization in the post-appendectomy pathway phase. There was a decrease in peripherally inserted central catheter (PICC, 36%) and total parenteral nutrition (TPN, 54%) utilization after implementing our appendectomy pathway. Both CT and TPN utilization reductions were statistically significant with a p-value < 0.05. These reductions are equivalent to a cost savings of $62,317 (Table 1).
Results were measured by utilizing and retrospectively reviewing appendectomy data found for the specified time period (2014-November 2017) in the Case Details and Custom Fields Reports found on the ACS NSQIP-P database as well as prospective case-by-case review performed by the pediatric general surgery quality assurance liaison. Aggregate rates provided in the appendectomy pilot reports were used for benchmarking and measuring success of the appendectomy pathway in reducing preoperative CT utilization.
As mentioned previously, CT utilization reduction was the primary goal of the appendectomy pathway. However, in analyzing the appendectomy data for this project, we also noted a decrease in PICC and TPN utilization. As providers at GCH provide evidence-based care to patients, it can be speculated that the decrease in PICC and TPN utilization during this project may be attributed to this. Current literature supports transitioning patients from IV to oral antibiotics prior to discharge, which is the current practice at GCH, may have attributed to the decrease in PICC utilization as well as the decrease in TPN utilization.10 Length of stay (LOS) in appendectomy patients has also decreased at GCH, which may also be attributed to the reduced resource utilization.
