Development and Five-year Results of a Pediatric Appendicitis Working Group: Harmonizing Care and Increasing Value
*Yuqi Zhang, *Sam Miller, Michael G Caty, Emily R Christison-Lagay, Robert A Cowles, David H Stitelman, *Beth L Emerson, *Cicero T Silva, *Thomas R Goodman, *Brian Dillon, Lisa Sagnella, Daniel G Solomon, Doruk E Ozgediz
Yale New Haven Hospital, New Haven, CT
Objective: Improvement in pediatric appendicitis care through a multidisciplinary approach and protocols
Design: We convened a multidisciplinary working group between pediatric radiology, interventional radiology, emergency medicine, and pediatric surgery. We reviewed data from Pediatric Health Information Systems (PHIS) to assess priority areas.
Setting: Tertiary center
Patients or other Participants: 1319 patients < 18 who underwent an appendectomy for acute uncomplicated and perforated appendicitis at Yale-New Haven Children’s Hospital
Interventions: Formation of working group
Main outcome measures: Development of care pathways
Results: A standardized definition of perforated appendicitis and protocols were developed. Six different care pathways were reduced to one. Average length of stay decreased from 6 to 4 days (p<0.05) for complicated appendicitis and antibiotic cost decreased for both uncomplicated and complicated appendicitis ($102 vs. $35 and $1,666 vs. $155, respectively) with no increase in complications. Same day discharge in select patients with uncomplicated appendicitis was instituted with no increase in ER re-visits. Currently, selected patients are being discharged directly from the post-anesthesia care unit. Template-based reporting of pediatric ultrasound for appendicitis was initiated to improve diagnostic accuracy in equivocal cases. Finally, a single evidence-based pathway for percutaneous drains placed by interventional radiology reduced care variation and decreased resource utilization, primarily through performing drain injections in only select patients; reducing the mean number of procedures for patients requiring a drain from 1.9 to 1.2 (p=0.2).
Conclusions: A multidisciplinary appendicitis team can develop evidence-based care pathways that reduce unnecessary variability in care and decrease cost without compromising outcomes, thereby increasing value.
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