title: Clinical practice guidelines for pediatric appendicitis evaluation can decrease computed tomography utilization while maintaining diagnostic accuracy.
abstract: OBJECTIVE
  The objective of this study was to compare usage of computed tomography (CT) scan for evaluation of appendicitis in a children's hospital emergency department before and after implementation of a clinical practice guideline focused on early surgical consultation before obtaining advanced imaging.
  
  
  METHODS
  A multidisciplinary team met to create a pathway to formalize the evaluation of pediatric patients with abdominal pain. Computed tomography scan utilization rates were studied before and after pathway implementation.
  
  
  RESULTS
  Among patients who had appendectomy in the year before implementation (n = 70), 90% had CT scans, 6.9% had ultrasound, and 5.7% had no imaging. The negative appendectomy rate before implementation was 5.7%. In patients undergoing appendectomy in the postimplementation cohort (n = 96), 48% underwent CT, 39.6% underwent ultrasound, and 15.6% had no imaging. The negative appendectomy rate was 5.2%. We demonstrated a 41% decrease in CT use for patients undergoing appendectomy at our institution without an increase in the negative appendectomy rate or missed appendectomy. The results were even more striking when comparing the rate of CT scan use in the subset of patients undergoing appendectomy without imaging from an outside hospital. In these patients, CT scan utilization decreased from 82% to 20%, a 76% reduction in CT use in our facility after protocol implementation.
  
  
  CONCLUSIONS
  Implementation of a clinical evaluation pathway emphasizing examination, early surgeon involvement, and utilization of ultrasound as the initial imaging modality for evaluation of abdominal pain concerning for appendicitis resulted in a marked decrease in the reliance on CT scanning without loss of diagnostic accuracy.
authors.affiliation: Division of Pediatric Emergency Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, SC 29425, USA. mail: ruscott@musc.edu
authors.forename: W Scott
authors.initials: WS
authors.lastname: Russell
authors.forename: Abigail M
authors.initials: AM
authors.lastname: Schuh
authors.forename: Jeanne G
authors.initials: JG
authors.lastname: Hill
authors.forename: Andre
authors.initials: A
authors.lastname: Hebra
authors.forename: Robert A
authors.initials: RA
authors.lastname: Cina
authors.forename: Charles D
authors.initials: CD
authors.lastname: Smith
authors.forename: Christian J
authors.initials: CJ
authors.lastname: Streck
mesh_terms: D000006:Abdomen, Acute / Q000000981:diagnostic imaging / Q000209:etiology*; D000293:Adolescent; D001062:Appendectomy / Q000706:statistics & numerical data*; D001064:Appendicitis / Q000150:complications / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D019091:Critical Pathways; D057210:Delayed Diagnosis; D003951:Diagnostic Errors; D004502:Education, Medical, Continuing; D004635:Emergency Medicine / Q000193:education; D005260:Female; D019983:Guideline Adherence; D006776:Hospitals, Pediatric / Q000592:standards; D006786:Hospitals, Urban / Q000592:standards; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007902:Length of Stay; D008297:Male; D010348:Patient Care Team; D010372:Pediatrics / Q000193:education; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012189:Retrospective Studies; D062606:Tertiary Care Centers / Q000592:standards; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*; D014463:Ultrasonography; D019564:Unnecessary Procedures