Radiology

The use of a pediatric appendicitis pathway in a large integrated health system reduced computed tomography imaging in the ED

a b s t r a c t

Background: Appendicitis is the most common cause of an acute surgical abdomen in children. Diagnosis is often challenging as few pediatric patients present with Classic symptoms. Clinicians are thus dependent on imaging to reach an accurate diagnosis. Although Computerized tomography has high sensitivity and specificity, it has the disadvantage of imparting ionizing radiation. Ultrasound (US) is readily available and has comparable accu- racy to CT when performed by experienced sonographers. We sought to examine the impact of a system-wide process improvement plan on CT use and other metrics in pediatric patients who presented to the Emergency Department (ED) with suspected appendicitis.

Methods: This is a retrospective study of the impact of a Pediatric appendicitis Pathway (PAP) within a large in- tegrated hospital system with 12 EDs including 3 designated hub EDs. Patients were placed in an initial risk cat- egory utilizing the Pediatric Appendicitis Score (PAS), and received US of the appendix at a hub ED if indicated by the PAS. Patients presenting to community EDs who required US appendix were transferred to hub EDs for im- aging. Patients presenting in the 6-month pre-implementation period were compared to patients presenting in a 14-month post-implementation period on CT and US utilization, negative and missed appendectomy rates, and ED length of stay .

Results: 1874 patients (401 pre-PAP and 1473 post-PAP) were included in the study. At the hub EDs the rate of CT imaging for suspected appendicitis was reduced from 31% to 17% with a resultant increase in US utilization from 83% (333/401) to 90% (1331/1473) (p < 0.001). At community general EDs (404 pre-PAP and 449 post-PAP), the rate of CT was decreased from 45% (181/404) to 32%(144/449) (p < 0.001)) There was no significant change in the Negative appendectomy rate pre-PAP (1/59 = 1.7%) and post-PAP (4/168 = 2.4%) (p = 0.99) at the hub EDs. There were no missed appendicitis cases after PAP implementation compared to 1 case in the pre-PAP period. Overall LOS was similar pre and post-PAP, however LOS was longer in patients that required transfer from com- munity general EDs to hub EDs (median 264 vs 342 min, p < 0.001).

Conclusions: A PAP that stratified patients into risk groups using the PAS and encouraged the use of US as a first line imaging modality, reduced the number of CT performed in a large integrated health system without signif- icant changes to clinical outcomes. Furthermore, transferring select patients for an US as opposed to obtaining an initial CT in community general EDs was feasible and reduced CT use in the pediatric population.

(C) 2021

  1. Background

* Corresponding author at: Emergency Services Institute, E19, Cleveland Clinic Health System, 9500 Euclid Avenue, Cleveland, Ohio 44195, United States of America.

E-mail address: [email protected] (B.S. Fertel).

Acute appendicitis is the most common cause of an acute surgical abdomen in children [1]. Diagnosis is often challenging with initial mis- diagnosis reported in up to 57% of pediatric patients [2]. Computerized tomography (CT) of the abdomen/pelvis with intravenous (IV) contrast is considered the gold standard for diagnosis which has resulted in a

https://doi.org/10.1016/j.ajem.2021.07.064

0735-6757/(C) 2021

significant increase in CT utilization over the years [3-5]. However, de- spite the increased use of CT, the rate of negative appendectomy has not changed significantly [6,7].

As CT is known to impart ionizing radiation, which can lead to harm [ 8-10], there has been a push to avoid the use of CT in pediatric patients. With the availability of ultrasound, both the American Col- lege of Radiology Appropriateness Criteria and the American College of Surgeons-choosing wisely campaign give ultrasound (US) the highest appropriateness rating of ‘usually appropriate’ as the first line Imaging study in pediatric patients with suspected appendicitis [8,9].

US of the appendix is operator-dependent and requires the use of a graded compression technique [10,11]. One approach used to improve image attainment is to have on site radiologists who can assist with the dynamic acquisition of US images to improve sensitivity and speci- ficity [12,13]. To enhance the diagnosis of appendicitis by US, Wiersma et.al identified secondary sonographic signs of appendicitis that include intrapelvic fluid collection, hyperechogenic mesenteric fat, and local di- lated small bowel loops. These secondary signs were used to develop a new grading system which increased accuracy to 97% [14]. While not universally adapted, the importance of secondary signs have been de- scribed in other studies [15].

Published clinical decision tools that stratify patients with suspected appendicitis utilizing the Pediatric Appendicitis Score (PAS) have suc- cessfully demonstrated decreased utilization of CT without negatively impacting diagnostic accuracy or patient outcomes [16-23]. To date, most of those studies were done in single center academic pediatric emergency departments in free-standing children’s hospitals with

onsite pediatric radiologists who could perform real time dynamic scan- ning. There is a lack of information about the use of PAS in decision tools in other ED settings.

Within our healthcare system, it was identified that community and free-standing EDs would often order CT as a first-line imaging method to either confirm or rule out appendicitis, due to the both the large amount of non-diagnostic US and the reluctance of pediat- ric surgeons to rely on US asa definitive study. This was likely a func- tion of the fact that sonographers at community general EDs in our health system might only see one case of pediatric acute appendicitis per month, challenging their ability to maintain a high skill level. Fur- thermore, there were no on-site radiologists to aid in image acquisi- tion and studies were not consistently read by pediatric radiologists. Even at the Hub EDs (EDs at hospitals with a full complement of ser- vices including pediatrics) where more US studies were ordered due to a larger pediatric census, a confirmatory CT was often requested by the surgery service. Due to the size of our healthcare system, only hub hospitals had pediatric surgical specialists available and there- fore those with confirmed appendicitis were transferred for surgical management. Prior to the implementation of our pediatric appendi- citis pathway, no patients were transferred from ED to ED nor were any patients routinely admitted for serial abdominal exams.

We hypothesized that a system wide Pediatric Appendicitis Pathway (PAP) (Fig. 1) would lower rates of CT use without increas- ing the negative appendicitis or missed appendicitis rate. The PAP risk stratified patients at the bedside, included standardized imaging modalities, encouraged ultrasound as a first-line diagnostic test, and dispositioned patients to appropriate surgical or medical care.

Image of Fig. 1

Fig. 1. Pediatric appendicitis pathway.

  1. Methods
    1. Study design

This was a retrospective cohort study of the impact of a pediatric ap- pendicitis pathway and concurrent process improvement measures with pre- and post-data collection and analysis. Institutional review board approval was obtained.

    1. Setting

This study was performed across the EDs of a large integrated health system that has 90,000 pediatric visits annually spread across multiple sites with varying resources and expertise. There are approximately 250 cases of acute appendicitis annually across the health system. The system is comprised of 3 hub EDs and 9 community general (serving all ages) EDs (Table 1). Of the three hub EDs, one is located at the main academic quaternary hospital, which contains an integrated children’s hospital. The other 2 hub EDs are located in community hos- pitals that have separate pediatric EDs with dedicated pediatric medical staff.

Consultative pediatric surgical services are only available at the 3 hub EDs and therefore, regardless of location of diagnosis, patients were admitted to a hub hospital for surgical management. Those requir- ing admission for serial exams were admitted to the pediatric hospitalist service at all three locations (Table 1).

Pediatric radiology coverage with real-time interpretation by a BC/ BE/fellowship trained pediatric radiologist was provided remotely at all times for all sites.

    1. Participants

All patients less than 18 years old who presented to the ED with suspected appendicitis were included in the study. Patients with chronic abdominal pain, trauma, inflammatory bowel disease, prior ab- dominal surgery, history of liver or bowel transplant, or who underwent a CT at an outside hospital prior to presentation were excluded from the study.

    1. Interventions

A pediatric appendicitis pathway (Fig. 1) and associated imaging process improvement measures were introduced in November 2018 in an attempt to reduce CT use and streamline appendicitis diagnosis and care. This PAP contained interventions focused on the ED clinician at the bedside assessing the patient and initiating a workup, the radiol- ogy team acquiring and interpreting images, and the ED and surgery teams acting on the results of the imaging and determining disposition.

      1. Assessment/Workup

The PAP was developed in part to assist clinicians at the bedside in the evaluation and risk stratification of pediatric patients with suspected appendicitis. The pathway was modeled after the one pro- posed by Depinet et.al through joint efforts between the Departments of Emergency Medicine, Pediatric Hospital Medicine, Radiology and Pe- diatric Surgery [18]. Part 1 of the PAP consisted of an initial risk assess- ment with PAS and subsequent ultrasound for patients in the equivocal and high-risk groups. The clinician was instructed to utilize the clinical portions of the pathway at the bedside to determine risk category. The goal was to ultimately help direct pediatric patients to appropriate im- aging recommendations. The PAP also emphasized the importance of ultrasound as the first-line imaging modality.

An additional component of the PAP was the transfer of pediatric pa- tients from community Emergency Departments so that they could re- ceive imaging at a hub hospital. Under the PAP, pediatric patients who presented to community ED locations were first evaluated by clinicians using history and physical exam to determine risk. If the clinician then determined that the patient scored into the equivocal and/or high-risk PAS category, the patient was transferred by ambulance or private vehi- cle (parent and clinician preference dependent on patient’s clinical sta- bility) to a hub ED. Although laboratory values are a component of the PAS (white blood cell and absolute Neutrophil count), Laboratory workup and IV insertion were deferred to prevent delays to the hub ED unless the patient was unstable or in significant pain. The average distance between hub and community general ED was 10 miles (20 min). The longest distance was 26 miles (35 min). Upon arrival at the hub ED, Transferred patients were expedited with pre-arrival registra- tion, immediate rooming, rapid clinical evaluation, and US ordering. Transferred patients were only charged for one ED visit.

At the Hub ED, a final PAS was calculated once labs were obtained. If there was a discrepancy between Physical exam findings, the physician at the Hub ED was the arbiter. While rare, some patients who were transferred were discharged without Ultrasound imaging.

      1. Imaging

A number of imaging improvement measures were implemented with the PAP. To enhance the quality of the US appendix studies, sonographers at the hub EDs received additional training in the acquisi- tion of images of the appendix, the US appendix imaging protocol was standardized, and it was mandated that at least 20 min was spent by the sonographer to find the appendix before reporting non- visualization. Quality checks were done periodically and individual feedback was provided to the sonographer. Moreover, pediatric appen- dix US were only performed at hub EDs to concentrate expertise and im- prove accuracy.

An additional intervention implemented was that all US appendix studies were interpreted by a board-certified and fellowship trained pe- diatric radiologist using a standardized template with a newly imple- mented grading system for diagnosis of appendicitis (Fig. 1). This

Table 1

Facility information.

Annual pediatric visits

Staffing

Pediatric Surgery coverage, pediatric US technicians

Location of admission for pediatric appendicitis

Pediatric ICU

Hub EDs (n = 3)

Community pediatric EDs

40,000

PEM provider, general pediatricians, EM physicians, pediatric

Yes

Pediatric service with

No

(n = 2)

Academic quaternary (all age)

6000

residents, PAs, NPs

EM physicians, EM residents, PAs, and NPs

Yes

surgical consult

Pediatric Surgery Service

Yes

ED (n = 1)

Community general (all age)

5000 per

EM physicians, EM residents, PAs, and NPs

No

None

No

EDs (n = 9)

ED

EM: Emergency medicine, ICU: intensive care unit, NP: nurse practitioner, PA: physician assistant, PEM: pediatric emergency medicine, US: ultrasound.

grading system was comprised of 1) Normal appendix, 2) The appendix is not visualized/depicted in its entirety. There are no secondary sono- graphic signs to suggest appendicitis, 3) The appendix is not visual- ized/depicted in its entirety. Secondary signs of appendicitis are identified, 4) Findings of acute appendicitis [14]. Prior to the interven- tion, US appendix studies were read by both general and pediatric radiologists.

      1. Disposition

Once labs and US were obtained, in cases of diagnostic uncertainty, the PAP directed clinicians to: 1) admit the patient for serial abdominal exams and repeat US evaluation 8 h later, thus avoiding CT use, or 2) use CT imaging in the ED based on shared decision making with the patient/ family and surgical specialist. Serial abdominal exams were performed by the inpatient pediatric team including pediatric residents and pediat- ric hospitalists. When CT abdomen/pelvis was obtained, it was per- formed with IV contrast without the need for oral contrast. IV contrast was not used if the patient had an elevated GFR or allergy to contrast dye.

As stated above, patients with confirmed appendicitis were admit- ted to the surgery service at the academic hub hospital and the pediatric service with surgical consult at the non- academic hub hospitals.

      1. Additional process improvement measures

Periodic reminders to use the PAP were communicated through email and live sessions at department staff meetings. A care path using flowsheets was built in the Electronic Medical Record (EMR) (Epic Systems Verona WI) to facilitate data capture and guide clinicians in the steps of the pathway. Joint case reviews were held and clinicians who were outliers in their CT ordering patterns were given specific feedback via email. There were no concurrent interventions other than those listed above as part of the pathway.

    1. Outcome measures

The primary outcome was the rate of CT abdomen/pelvis for suspected appendicitis in pediatric patients at hub and community sites. Balancing outcomes were negative appendectomy rate and the number of cases of missed appendicitis. Negative appendectomy was defined as an instance when an appendix was removed for concerns of appendicitis, however final pathology revealed a normal appendix [6]. Missed appendicitis was defined as a patient with abdominal pain who was discharged at an initial visit who then returned to an ED within our system in the subsequent 48 h and underwent an appendectomy with pathology confirmation of appendicitis.

Secondary outcomes included CT use as first line imaging at the hub

and community general EDs, US appendix utilization, rate of admissions for serial abdominal exams, appendectomy status and complications, as well as ED length of stay for the two groups. If a patient was trans- ferred, the total length of stay was calculated from arrival at the first ED to departure from the second ED. complicated appendicitis was defined as gangrenous or perforated appendix, or Intra-abdominal abscess for- mation prior to the appendectomy that was described at pathology or operative report [24].

    1. Data collection

Data were retrospectively collected on patients who presented in the post-PAP period from November 2018 to December 2019, and on a control cohort of patients who presented in the pre-PAP period from May 2018 to October 2018. Study data were collected and managed using REDCap electronic data capture tools hosted at the health system. To obtain the data, an automated EMR search was performed and then the data were manually reviewed. The first data set included all pa- tients aged 0-18 years that presented to hub EDs with one or more of the following criteria: 1) diagnosis code of Right lower quadrant pain

or acute appendicitis (ICD-10 codes includes G89.29, K35.20, K35.21, K35.30, K35.31, K35.32, K35.33, K35.80, K35.890, K35.891, K65.1,

R10.31, R10.813, R10.823), 2) underwent an US of the appendix,

3) had a CT of the abdomen/pelvis, 4) was transferred from a commu- nity ED in the past 24 h for any reason, 5) had documentation of the PAP in the EMR (predefinED flowsheets), or 6) had a prior appendec- tomy. All charts were then manually reviewed by one of two authors who were un-blinded to the study protocol. Charts were reviewed to determine if the patient was being evaluated for suspected appendicitis or other pathology and charts were excluded if the patient had any pre- existing history of defined Abdominal pathology listed above, a CT per- formed for other suspected diagnosis, or if they were transferred to a hub ED for reasons other than abdominal pain (i.e. testicular pain). If one reviewer was uncertain, the second reviewer was consulted, and a joint decision was made. 17% of charts were dual-abstracted and reviewed by both reviewers. If there was a discrepancy it was adjudi- cated by a third emergency physician reviewer. The second data set in- cluded all patients aged 0-18 that received CT abdomen/pelvis at community general EDs for suspected appendicitis with the above EMR search criteria, with transferred patients excluded to avoid dupli- cation with the hub ED data. As above, the identical chart review meth- odology was utilized.

    1. Analysis

Data were described using medians and first and third quartiles [Q1, Q3] for continuous variables and counts and percentages for categorical variables. Demographic variables and clinical characteristics of patients were compared between pre- and post-PAP, and between transferred and non-transferred patients using t-tests or Wilcoxon rank sum tests for continuous and ordinal characteristics, and Chi-square or Fisher’s exact tests for categorical characteristics. All tests were two-tailed and performed at a significance level of 0.05. SAS 9.4 software (SAS Institute, Cary, NC) was used for all analyses. Strengthening the Reporting of Ob- servational Studies in Epidemiology (STROBE) recommendations were followed [25].

  1. Results

There were 1874 pediatric patients who were evaluated for possible appendicitis in hub EDs between May 2018 and December 2019 (Fig. 2). Of these, 401 were evaluated pre-PAP (May 2018-October 2018) and 1473 post-PAP (November 2018-December 2019). Demographic char- acteristics for age and gender were similar for the pre- and post-PAP groups. Median [Q1, Q3] age was 11 years [7, 14] pre- and 10 years [7, 14] post-PAP (p = 0.36). Female patients composed 53% of pre- and 54% of post-PAP period patients (p = 0.67).

For the primary outcome, rate of CT performed to screen for appen- dicitis at the hub EDs decreased from 31% (125/401) to 17% (251/1473) after PAP implementation (P < 0.001). Concurrently, US use increased from 83% (333/401) to 90% (1331/1473) (P < 0.001).

In subgroup analysis, we found that the use of CT as a first line imag- ing modality decreased from 11% to 3% at the hub EDs and subsequent CT after an US decreased from 20% to 14% (Table 2). At the 2 pediatric hub EDs the overall CT rate decreased from 30% to 16% whereas at the academic quaternary hub ED the CT rate decreased from 42% to 25%. Al- though CT use as a first line imaging was reduced at both locations post- PAP, there were more CTs ordered at the academic quaternary ED in both the pre and post-PAP periods compared to the pediatric hub EDs (Table 3). Additionally, at the community general EDs the rate of CT for suspected appendicitis decreased from 45% (181/404) pre-PAP to 32% (144/449) post-PAP (p < 0.001).

The negative appendectomy rate was similar pre-PAP and post-PAP (1.6% vs 2.4%, p = 0.99). None of these cases underwent CT scanning, and details of the cases are shown in the Supplementary Table 1.

1874

(Pre-PAP: 401,

Post-PAP: 1473)

Number of patients analyzed

1891

Number of patients excluded after manual chart review

3765

Hub Emergency Departments

2492

Community General Emergency

Departments

6257

Total number of patients met the inclusion criteria on automated EMR data collection

853

(Pre-PAP: 404,

Post-PAP: 449)

Number of patients analyzed

1639

Number of patients excluded after manual chart review

Fig. 2. Data collection flow chart.

Table 2

Analysis of outcomes by era at the hub EDs.

Pre-PAP (N = 401)

Post-PAP (N = 1473)

p-value

There was only one known missed case of appendicitis during the pre- PAP period and none in the post-PAP period (Table 2).

In the post-PAP period, there was a mean of 29 patients transferred

Any CT used 125 (31) 251 (17) <0.001b

Any US used 333 (83) 1331 (90) <0.001b

First imaging modality <0.001b

No imaging 22 (5) 102 (7)

US or US/CT 333 (83) 1331 (90)

US/CT 79 (20) 211 (14)

CT 46 (11) 40 (3)

Total ED length of stay(min) 284 [213, 400] 282 [216, 381] 0.80a

Directly presented to hub ED 284 [213, 400] 264 [205, 354] 0.060a

Transferred from community ED N/A 342 [266, 439]

Admission for serial abdominal exam 49 (12) 249 (17) 0.023b

Appendectomy 59 (15) 168 (11) 0.072b

Complicated appendicitis 9 (15) 44 (26) 0.088b

Negative appendectomy 1 (2) 4 (2) 0.99c

Missed appendicitis 1 (0.2) 0 (0) 0.21c

Statistics presented as Median [Q1, Q3], N (column %).

p-values: a = Wilcoxon Rank Sum test, b = Pearson’s chi-square test, c = Fisher’s Exact test.

ED: Emergency department, CT: Computerized tomography, US: ultrasound, PAP: Pediat- ric Appendicitis Pathway.

monthly from community general EDs to hub EDs for evaluation of suspected appendicitis. None of these patients had an adverse event during or as a consequence of the transfer. Among the patients trans- ferred, the rate of appendectomy was 14% (51/377) which was similar to the rate of appendectomy in patients who presented initially to the hub ED 11% (117/1096) (p = 0.13) (Table 2).

In the pre-PAP period, 12% of patients were admitted for serial ab- dominal exams, compared to 17% in the post-PAP (p = 0.023) (Table 2). Among patients admitted for serial abdominal exams, only two of them were diagnosed with appendicitis, both in the post-PAP period.

Overall median [Q1, Q3] LOS of this population was 284 min [213, 400] pre-PAP vs. 282 min [216, 381] post-PAP. In those who presented to the hub EDs, LOS decreased to a median of 264 min [205, 354] post- PAP (p = 0.060). With regards to transferred patients, the median LOS

Table 3

Imaging modality by hub ED sub-type.

Pediatric EDs

Academic Quaternary ED

(N = 365)

(N = 36)

Pre-PAP

Post-PAP

p-value

Pre-PAP Post-PAP

p-value

CT as first imaging modality, n (%)*

37 (11)

27 (2)

0.005c

9 (30) 13 (12)

<0.001c

Any CT used, n (%)

110 (30)

222 (16)

0.15b

15 (42) 29 (25)

0.023b

Any US used, n (%)

312 (85)

1237 (91)

<0.001b

21 (58) 94 (80)

<0.001b

Statistics presented as N (column %).

p-values: b = Pearson’s chi-square test, c = Fisher’s Exact test.

CT: Computerized tomography ED: Emergency department, US: ultrasound, PAP: Pediatric Appendicitis Pathway.

median was 342 min [266, 439] which was significantly higher than those who directly presented to hub EDs (p < 0.001) (Table 2).

The rate of complicated appendicitis was 15% pre-PAP and 26% post- PAP, which was not statistically significant (p = 0.088) (Table 2).

  1. Discussion

While CT has become more ubiquitous in the Emergency Depart- ment, improved awareness of the harm of ionizing radiation, especially in children, has resulted in a decrease in pediatric CT imaging over the past decade [26]. We have shown that in a large community based inte- grated health system with varying resources and expertise, a Pediatric Appendicitis Pathway was able to reduce CT use and subsequent radia- tion exposure for pediatric patients being evaluated for appendicitis. This reduction was accomplished without sacrificing diagnostic accu- racy. The use of US appendix increased concurrently. Of note there was no specific BMI or other exclusion criteria that precluded ultra- sound imaging for diagnosis of pediatric appendicitis.

Similar results were shown in another health system that consists of 4 community general EDs staffed by general emergency physicians, however those hospitals had onsite surgical and US capabilities without the need for transfer [27]. Our study adds to the literature and demon- strates that even in a system without these readily available, a pathway that includes transfer is feasible and can reduce CT use.

When comparing the Pediatric EDs and academic quaternary ED, overall CT utilization was higher at the academic quaternary ED both pre- and post-PAP. We speculate that the presence of specially trained pediatric-specific staff who are more comfortable managing pediatric patients may contribute to these lower rates as the academic ED was staffed exclusively by general EM physicians who may have been un- easy about missing a diagnosis [28]. Of note, a zero CT rate is detrimental as there are patients who require a CT based on shared decision making, non-visualization of appendix on US, as well as other clinical characteristics.

The rate of negative appendectomy was not significantly changed after implementation of the pathway and is similar to previous pediatric studies reinforcing the safety of this pathway [29-31]. However, all but 2 patients with a negative appendectomy had abnormalities of the appen- dix which consisted of lymphoid hyperplasia or fibrous obliteration of the appendix. These are known imaging and clinical mimics of appendi- citis and referral for appendicitis is often appropriate. As mentioned pre- viously regarding CT rates, a zero negative appendectomy rate is likely undesirable as the tradeoff between sensitivity and specificity may lead to missed cases.

The pathway emphasized initial imaging with US, which is inher- ently user dependent. To minimize the effect of this challenge, we im- plemented a unique hub ED transfer system to ensure that all pediatric US imaging was performed by technicians skilled in pediatric US. We also required that all the US appendix images were read by pe- diatric radiologists who were off-site. The success of the pathway illus- trates the feasibility of Remote interpretation, thus maximizing the benefits of having the images interpreted by pediatric radiologists.

There was some initial concern among our clinicians that patients

seen at the community general EDs would be transferred to the hub EDs indiscriminately. Our data showed that the appendicitis rate was similar in both groups, suggesting that the initial PAS utilizing the clin- ical history and exam can help guide appropriate transfer decisions and fears of unnecessary transfer were unfounded.

Transferring patients between EDs can add additional costs to the encounter in the form of an ambulance and/or second ED visit charges. To ameliorate this, we worked with our revenue cycle team to avoid having transferred patients incur an additional charge for a second ED visit. The billing system was set to flag multiple same day visits and en- sure that only one bill was sent. This is an important consideration that may not be applicable in every health system or if transferring to an- other system.

Although we expected an increase in admissions for serial abdomi- nal exams with the decreased use of CTs, this rate was not statistically different pre and post-PAP.

When considering all patients together, length of stay was not differ- ent pre- and post-PAP. Although not statistically significant, median LOS was decreased post-PAP for patients who directly presented to hub EDs. This might be due to the decreased rate of CT utilization which often re- quires laboratory work up, IV placement and a wait for the CT scanner which was shared with the adult ED that was a Level 2 trauma center. As expected, there was a slightly longer ED LOS for those who presented to a community general ED, which was offset by the benefit of reduced radiation and without increased morbidity. To minimize the overall delay already encumbered by a drive to another ED, we implemented a rapid triage system with rapid ordering of the ultrasound. Shared de- cision making between patients and family with explanation of risks and benefits (time vs. radiation) helped inform the decision whether to transfer to avoid radiation or obtain the CT at the non-hub ED. We en- courage these conversations in those who seek to employ a similar pathway. Further studies are needed to investigate patient and provider satisfaction about the process.

    1. Limitations

There are several limitations to our study. First, the data was col- lected retrospectively which inherently has selection and recording bias. It is possible that there were patients that were screened for ap- pendicitis but were not included in the cohorts due to lack of searched characteristics. It is also possible that some of the patients that were discharged home could have re-presented to an unaffiliated hospital and were then diagnosed with appendicitis. Moreover, the success of the pathway was heavily dependent on appropriate utilization which may be limited by education constraints. Finally, the lack of an on-site radiologist precluded the ability to scan in-person with the ultrasound technologist if needed and may have biased towards more CT, however this is becoming more standard and representative of real world expe- rience in many health systems.

  1. Conclusion

In conclusion, a standardized pediatric appendicitis pathway and con- current process improvement was able to reduce the number of abdo- men/pelvis CTs in pediatric patients without a resulting increase in cases of missed appendicitis or negative appendectomy. Concentrating US capa- bilities at a hub ED and transferring patients for US is both feasible and rea- sonable and does not adversely impact Clinically meaningful metrics.

Grants/financial support

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

None of the authors have any disclosures or conflicts of interest.

Acknowledgements

We would like to acknowledge Dr. Courtney M. Smalley, MD for her contribution to this manuscript, and Dr.’s Brian Kenney, MD (Na- tionwide Children’s) and Brad Sobolewski, MD (Cincinnati Children’s) for their assistance with the development of the pathway.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2021.07.064.

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