title: It is not what you do, it is the way that you do it: impact of a care pathway for appendicitis.
abstract: OBJECTIVE
  Appendicitis is the most common surgical emergency in children. However, management varies widely. The aim of this study was to assess the impact of introducing a care pathway on the management of childhood appendicitis.
  
  
  METHODS
  Data were collected prospectively for 3 successive cohorts: All patients operated for suspected appendicitis were included. The pathway was modified after interim analysis of group B data. P < .05 was significant.
  
  
  RESULTS
  Six hundred patients were included. When compared with group A, group C patients were more likely to receive preoperative antibiotics (P < .0001), undergo formal pain assessment (P < .0001), and be operated before midnight (P = .025). There was a significant decrease in readmission rates from 10.0% to 4.2% (P = .023) despite an increase in cases of gangrenous and perforated appendicitis (P = .010).
  
  
  CONCLUSIONS
  The introduction of a care pathway resulted in improved compliance with antibiotic regimens, more frequent pain assessment, and fewer post-midnight operations. Postappendicectomy readmission rates were reduced despite an increase in disease severity. This was achieved by critical reevaluation of outcomes and pathway redesign where appropriate.
authors.affiliation: Department of Paediatric Surgery, Royal Liverpool Children's NHS Trust, L12 2AP Liverpool, UK. salmond@liv.ac.uk
authors.forename: Sarah L
authors.initials: SL
authors.lastname: Almond
authors.forename: Megan
authors.initials: M
authors.lastname: Roberts
authors.forename: Victoria
authors.initials: V
authors.lastname: Joesbury
authors.forename: Sue
authors.initials: S
authors.lastname: Mon
authors.forename: Jeff
authors.initials: J
authors.lastname: Smith
authors.forename: Nevila
authors.initials: N
authors.lastname: Ledwidge
authors.forename: Sailaja
authors.initials: S
authors.lastname: Pisipati
authors.forename: Amir
authors.initials: A
authors.lastname: Khan
authors.forename: Basem A
authors.initials: BA
authors.lastname: Khalil
authors.forename: Elvina
authors.initials: E
authors.lastname: White
authors.forename: Colin T
authors.initials: CT
authors.lastname: Baillie
authors.forename: Simon E
authors.initials: SE
authors.lastname: Kenny
mesh_terms: D000293:Adolescent; D000704:Analysis of Variance; D019072:Antibiotic Prophylaxis / Q000379:methods*; D001062:Appendectomy / Q000009:adverse effects / Q000379:methods*; D001064:Appendicitis / Q000175:diagnosis / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D019091:Critical Pathways; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods; D007813:Laparotomy / Q000009:adverse effects / Q000379:methods; D008297:Male; D010359:Patient Readmission / Q000706:statistics & numerical data; D011182:Postoperative Care; D011183:Postoperative Complications / Q000453:epidemiology / Q000517:prevention & control; D011300:Preoperative Care; D011336:Probability; D011446:Prospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016896:Treatment Outcome