title: Effect of a Clinical Practice Guideline for Pediatric Complicated Appendicitis.
abstract: Complicated appendicitis is a common condition in children that causes substantial morbidity. Significant variation in practice exists within and between centers. We observed highly variable practices within our hospital and hypothesized that a clinical practice guideline (CPG) would standardize care and be associated with improved patient outcomes.
  
  
  
  To determine whether a CPG for complicated appendicitis could be associated with improved clinical outcomes.
  
  
  
  A comprehensive CPG was developed for all children with complicated appendicitis at Monroe Carell Jr Children's Hospital at Vanderbilt, a freestanding children's hospital in Nashville, Tennessee, and was implemented in July 2013. All patients with complicated appendicitis who were treated with early appendectomy during the study period were included in the study. Patients were divided into 2 cohorts, based on whether they were treated before or after CPG implementation. Clinical characteristics and outcomes were recorded for 30 months prior to and 16 months following CPG implementation.
  
  
  
  Clinical practice guideline developed for all children with complicated appendicitis at Monroe Carell Jr Children's Hospital at Vanderbilt.
  
  
  
  The primary outcome measure was the occurrence of any adverse event such as readmission or surgical site infection. In addition, resource use, practice variation, and CPG adherence were assessed.
  
  
  
  Of the 313 patients included in the study, 183 were boys (58.5%) and 234 were white (74.8%). Complete CPG adherence occurred in 78.7% of cases (n = 96). The pre-CPG group included 191 patients with a mean (SD) age of 8.8 (4.0) years, and the post-CPG group included 122 patients with a mean (SD) age of 8.7 (4.1) years. Compared with the pre-CPG group, patients in the post-CPG group were less likely to receive a peripherally inserted central catheter (2.5%, n = 3 vs 30.4%, n = 58; P < .001) or require a postoperative computed tomographic scan (13.1%, n = 16 vs 29.3%, n = 56; P = .001), and length of hospital stay was significantly reduced (4.6 days post-CPG vs 5.1 days pre-CPG, P < .05). Patients in the post-CPG group were less likely to have a surgical site infection (relative risk [RR], 0.41; 95% CI, 0.27-0.74) or require a second operation (RR, 0.35; 95% CI, 0.12-1.00). In the pre-CPG group, 30.9% of patients (n = 59) experienced any adverse event, while 22.1% of post-CPG patients (n = 27) experienced any adverse event (RR, 0.72; 95% CI, 0.48-1.06).
  
  
  
  Significant practice variation exists among surgeons in the management of pediatric complicated appendicitis. In our institution, a CPG that standardized practice patterns was associated with reduced resource use and improved patient outcomes. Most surgeons had very high compliance with the CPG.
authors.affiliation: Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: Zachary I
authors.initials: ZI
authors.lastname: Willis
authors.affiliation: Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: Eileen M
authors.initials: EM
authors.lastname: Duggan
authors.affiliation: Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee3Division of Pediatric Surgery, University of Utah, Salt Lake City.
authors.forename: Brian T
authors.initials: BT
authors.lastname: Bucher
authors.affiliation: Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: John B
authors.initials: JB
authors.lastname: Pietsch
authors.affiliation: Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: Monica
authors.initials: M
authors.lastname: Milovancev
authors.affiliation: Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: Whitney
authors.initials: W
authors.lastname: Wharton
authors.affiliation: Monroe Carell, Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.
authors.forename: Jessica
authors.initials: J
authors.lastname: Gillon
authors.affiliation: Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: Harold N
authors.initials: HN
authors.lastname: Lovvorn
authors.affiliation: Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: James A
authors.initials: JA
authors.lastname: O'Neill
authors.affiliation: Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: M Cecilia
authors.initials: MC
authors.lastname: Di Pentima
authors.affiliation: Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: Martin L
authors.initials: ML
authors.lastname: Blakely
mesh_terms: D000293:Adolescent; D001062:Appendectomy / Q000009:adverse effects*; D001064:Appendicitis / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D002406:Catheterization, Peripheral; D002648:Child; D002675:Child, Preschool; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D065186:Interrupted Time Series Analysis; D007902:Length of Stay; D008297:Male; D010359:Patient Readmission / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D012086:Reoperation; D013530:Surgical Wound Infection / Q000209:etiology; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome