title: Protocol for suspected pediatric appendicitis limits computed tomography utilization.
abstract: BACKGROUND
  Despite radiation concerns, computed tomography (CT) remains the favored imaging modality at many children's hospitals for appendicitis. We sought to reduce CT utilization for appendicitis in a children's hospital with an algorithm relying on 24-h ultrasound (US) as the primary imaging study.
  
  
  METHODS
  An US-based protocol for suspected appendicitis was adopted at the end of the fiscal year (FY) 2011. Data were collected for 12 mo before and 24 mo after implementation. Imaging test usage and charges were adjusted per annual number of appendectomies. Training of emergency department staff continued over 1 y after protocol implementation.
  
  
  RESULTS
  For FY 2011, 644 abdominal CT and 1088 appendix US were ordered, and 249 laparoscopic appendectomies (LAs) were performed. After protocol implementation, FY 2012: 535 CT, 1285 US, and 265 LA were performed; and FY 2013: 330 CT, 1235 US, and 236 LA were performed. Length of stay decreased from before to after protocol (2.57 ± 0.29 versus 2.15 ± 0.11 d), P < 0.001. CTs per appendectomy decreased 42% from FY 2011 to FY 2013 (2.43 versus 1.40, P < 0.001) and 30% from before to after protocol (2.43 versus 1.70, P < 0.001). A corresponding 27% increase in number of US before to after protocol (4.11 versus 5.20 US/appendectomy, P = 0.004) occurred. CT and US charges decreased $2253 and $6633 per appendectomy for FY 2012 and 2013, respectively.
  
  
  CONCLUSIONS
  Protocol-driven workup with US significantly reduced CT utilization, radiation exposure, and imaging-related charges in children with suspected appendicitis. Ongoing training of emergency department staff is required to ensure protocol compliance.
authors.affiliation: Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida.
authors.forename: Amy E
authors.initials: AE
authors.lastname: Wagenaar
authors.affiliation: Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida.
authors.forename: Jun
authors.initials: J
authors.lastname: Tashiro
authors.affiliation: Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida.
authors.forename: Bo
authors.initials: B
authors.lastname: Wang
authors.affiliation: Department of Pediatrics, Baptist Children's Hospital, Miami, Florida.
authors.forename: Miosotys
authors.initials: M
authors.lastname: Curbelo
authors.affiliation: Department of Pediatrics, Baptist Children's Hospital, Miami, Florida.
authors.forename: Kenneth L
authors.initials: KL
authors.lastname: Mendelson
authors.affiliation: Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida; Department of Pediatrics, Baptist Children's Hospital, Miami, Florida.
authors.forename: Eduardo A
authors.initials: EA
authors.lastname: Perez
authors.affiliation: Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida; Department of Pediatrics, Baptist Children's Hospital, Miami, Florida.
authors.forename: Anthony R
authors.initials: AR
authors.lastname: Hogan
authors.affiliation: Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida; Department of Pediatrics, Baptist Children's Hospital, Miami, Florida.
authors.forename: Holly L
authors.initials: HL
authors.lastname: Neville
authors.affiliation: Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida; Department of Pediatrics, Baptist Children's Hospital, Miami, Florida. Electronic address: Jsola@med.miami.edu.
authors.forename: Juan E
authors.initials: JE
authors.lastname: Sola
mesh_terms: D000293:Adolescent; D000465:Algorithms; D001062:Appendectomy / Q000191:economics; D001064:Appendicitis / Q000000981:diagnostic imaging* / Q000191:economics / Q000601:surgery; D002648:Child; D002985:Clinical Protocols; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital; D005260:Female; D005431:Florida; D019983:Guideline Adherence; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D017410:Practice Guidelines as Topic; D014057:Tomography, X-Ray Computed / Q000191:economics / Q000706:statistics & numerical data*; D014463:Ultrasonography
keywords: Appendicitis; Computed tomography; Pediatrics; Protocol; Ultrasound