Pediatric appendicitis care: An evolving project in patient quality and safety

In 2003, Children's Hospital's Pediatric General and Thoracic Surgery team began an appendicitis quality improvement project to standardize the protocol used in the hospital, and that work continues today.

Appendicitis is the most common surgical emergency in the pediatric population. However, until as recently as 2003, there were no uniform guidelines on how to treat these patients at Children's Hospital. The general and thoracic surgeons at the hospital recognized that clinical pathways improve patient care by reducing variability, increasing efficiencies and decreasing costs. Clinical pathways were created for the postoperative treatment of appendicitis. Accurate and operative classification of the degree of disease was mandated for all surgeons (acute vs. ruptured), and they agreed to follow a clinical pathway depending on the degree of disease. A predetermined length of antibiotic therapy (single agent antibiotic therapy for acute and triple agent antibiotic therapy for ruptured) and advancement of diet and pain control measures were delineated for each patient based on disease degree. Once the protocols were established, outcomes such as length of stay and postoperative morbidity were measured. The team then compared outcomes to other comparable hospitals within the Pediatric Health Information System (PHIS)*, looking for areas of improvement.

Children's Hospital's protocolized approach compared favorably with other hospitals and published literature in terms of postoperative complications. However, the team found longer length of stay for patients with ruptured appendicitis. New literature showed that single antibiotic therapy was safe in ruptured appendicitis and that improvement in clinical status (no fever, normal heart rate and return of intestinal function) is a good indicator that intravenous antibiotics and hospitalization may be discontinued. In 2008, the team approach to ruptured appendicitis was modified in accordance with recommendations based on a systematic review of the literature. The team postulated that changing from multiple antibiotics to a single antibiotic agent for ruptured appendicitis also would decrease length of stay and overall cost.

The team continued to monitor outcomes for this disease. The change to single antibiotic therapy decreased length of stay for patients with ruptured appendicitis, but led to higher postoperative infection rates. In 2010, the antibiotic therapy for acute and ruptured appendicitis was changed to another single agent antibiotic that has more gram-negative and anaerobic coverage. This change decreased the postoperative infection rates while maintaining the decreased length of stay and decreased antibiotic and nursing costs.

For outcomes information for our hospital, including more than a dozen specialty areas, visit chw.org/quality.