370 - Effect of an Evaluation Algorithm on CT Utilization in Identifying Appendicitis in Children

Poster Number: 370
Publication Number: 370.312

Kendra L. Sikes, Norton Children's Research Institute, Louisville, KY, United States; Rebecca J. Hart, University of Louisville/Norton Children's Medical Group, Louisville, KY, United States; Yana Feygin, University of Louisville School of Medicine, Louisville, KY, United States; Cody H. Penrod, University of Louisville School of Medicine, Louisville, KY, United States

Background: Appendicitis is a common cause of acute abdominal pain and surgical emergency in children presenting to the PED. Identifying acute appendicitis (AA) in the pediatric emergency department (PED) can be challenging and evaluation methodology is controversial.

Objective: Our objective was to determine if there was a significant change in computed tomography (CT) utilization or length of stay (LOS) among patients evaluated for AA following implementation of an appendicitis evaluation algorithm.

Design/Methods: We conducted a retrospective chart review of patients aged 3-18 years in an urban, tertiary PED with acute abdominal pain, evaluated for appendicitis. Data was collected for 6 months pre- and post-implementation of the evaluation algorithm with a 3-month washout period between September 2018 and November 2019. Main outcomes were comparing rate of CT utilization and LOS and were analyzed using chi-square test and Mann-Whitney U test, respectively. Descriptive analysis of demographics was performed, in addition to logistic regression to assess differences between the two study periods.

Results: A total of 2,872 charts were identified with a chief complaint inclusive of “abdominal pain”. Of these, 1,510 met age requirements but did not meet at least one inclusion criteria; 229 more were excluded upon chart review for a final study sample of 1,133 patients. Of the 1,133 patients, 648 (57.2%,) were female, 747 (65.9%) white and 988 (87.2%) non-Hispanic. Patients pre- and post-implementation had similar baseline characteristic distributions. The majority of patients (770, 68%) were discharged home from the emergency department without a diagnosis of acute appendicitis. Neither CT (25.7% to 24.8%; p=0.794) nor ultrasound (59.5% to 59.7%; p=1.000) utilization significantly changed post-implementation (Table 1). Total ED median LOS increased significantly (333.50 to 362.00 minutes; p=0.011). Significant factors associated with CT utilization included fever, migration of pain and right lower quadrant (RLQ) tenderness (Table 2). Significant factors associated with appendicitis diagnosis included RLQ pain, nausea/vomiting, migration of pain and peritoneal signs.Conclusion(s): Overall, the appendicitis evaluation algorithm did not significantly decrease CT utilization or LOS. Equivocal grade 2 or 3 ultrasound finding rates were high - likely leading to higher rates of CT utilization and increasing LOS.
Pre- and Post-Implementation Imaging and Length of Stay Outcomes
Odds ratios of factors associated with CT utilization and diagnosis of appendicitis