Evaluation of a novel pediatric appendicitis pathway using high- and low-risk scoring systems.
OBJECTIVE
This study aimed to determine the test characteristics of a pathway for pediatric appendicitis and its effects on emergency department (ED) length of stay, imaging, and admissions.


METHODS
Children age 3 to 18 years with suspicion for appendicitis at 1 tertiary care ED were prospectively enrolled, using validated low- and high-risk scoring systems incorporating history, physical examination, and white blood cell count. Low-risk patients were discharged or observed in the ED. High-risk patients were admitted. Those meeting neither low-risk nor high-risk criteria were evaluated by surgery, with imaging at their discretion. Chart review or telephone follow-up was conducted 2 weeks after the visit. A retrospective study before and after was also performed. Charts of a random sample of patients evaluated for appendicitis in the 8 months before and after the pathway implementation were reviewed.


RESULTS
Appendicitis was diagnosed in 65 of 178 patients. Of those with appendicitis, 63 were not low-risk (sensitivity, 96.9%; specificity, 40.7%). The high-risk criteria had a sensitivity of 75.3% and specificity of 75.2%. We reviewed 292 visits before and 290 after the pathway implementation. Emergency department length of stay was similar (253 minutes before vs 257 minutes after, P = 0.77). Computed tomography was used in 12.7% of visits before and 6.9% of visits after (P = 0.02). Use of ultrasound was not significantly different (47.3% vs 53.7%). Admission rates were not significantly different (45.5% vs 42.7%).


CONCLUSIONS
The low-risk criteria had good sensitivity in ruling out appendicitis. The high-risk criteria could be used to guide referral or admission. Neither outperformed the a priori judgment of experienced providers.
From the *Department of Emergency Medicine, Oregon Health and Science University; and †Division of Pediatric Surgery, Kaiser Permanente Northwest, Portland, OR.
Ross J
RJ
Fleischman
Miranda K
MK
Devine
Marie-Annick N
MA
Yagapen
Angela J
AJ
Steichen
Matthew L
ML
Hansen
Andrew F
AF
Zigman
David M
DM
Spiro
D015746:Abdominal Pain / Q000209:etiology*; D000293:Adolescent; D001062:Appendectomy / Q000706:statistics & numerical data; D001064:Appendicitis / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D019091:Critical Pathways; D004630:Emergencies; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D010173:Palpation; D010343:Patient Admission / Q000706:statistics & numerical data; D018579:Patient Selection; D010808:Physical Examination; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012189:Retrospective Studies; D012306:Risk; D018570:Risk Assessment / Q000379:methods*; D012494:Sampling Studies; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D063189:Symptom Assessment; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data; D014463:Ultrasonography