Optimizing the Use of Computed Tomography for Appendicitis Diagnosis in the Pediatric Emergency Department Through the Quality Improvement Methodology.

Background: Acute appendicitis is one of the most common causes of an acute abdomen among pediatric patients. The diagnosis of appendicitis is challenging due to the nonspecific presentation. Diagnosis is based on historical, physical, and serologic information as well as right lower quadrant ultrasound (RLQ US). In equivocal patients, or those with a high degree of suspicion, computed tomography (CT) of the abdomen and pelvis with intravenous (IV) contrast can be utilized to rule in appendicitis. However, optimizing diagnostic protocols to minimize ionizing radiation exposure while maintaining diagnostic accuracy is important.

Methods: We performed a monthly retrospective analysis of CT usage among pediatric patients with suspected acute appendicitis presenting to the pediatric emergency department (ED) from June 2023 to December 2023. We used quality improvement methodology to decrease CT use with monthly Plan-Do-Study-Act (PDSA) cycles with an aim to decrease CT use by 50%. The main intervention was coordination between the ED and surgical providers to require surgical consult before ordering a CT. We quantified the number of patients who received a surgical consult before CT, the number of RLQ US performed, the number of CTs performed, and the number of appendectomies, specifically the number with perforation.

Results: A total of 249 patients under 18 years of age presented to the pediatric ED with symptoms of acute appendicitis during the study period. All 249 patients underwent an initial RLQ US. The number of CTs performed decreased from a baseline of 14 in June to a nadir of four in September (71% decrease, p=0.029). There was a decrease in the percentage of patients who underwent a CT scan after an RLQ US from 36.5% in June to 11.8% in September after our intervention. In June, a total of 38 RLQ US were performed and 14 patients underwent additional CT (36.5%) and in September a total of 34 US were performed and 14 patients underwent additional CT (11.8%). There was an increase in the surgical consults rate from a baseline of seven surgical consults with 14 total CTs in June 2023 (50%) to seven consults with a total of seven CTs performed (100%) in December 2023. There was no increase in appendiceal perforation rates.

Conclusion: Multidisciplinary discussions between pediatric ED physicians and pediatric surgeons reduced CT usage, and corresponding radiation exposure and cost, in the evaluation of appendicitis.