Appendicitis Diagnostic Tool & Guidelines

This is a project to provide a composite risk assessment and disposition guidelines for patients presenting with uncertain risk of appendicitis. 

OVERVIEW


CONTRIBUTORS


Variation in practice and unclear guidelines for disposition of children with non-diagnostic ultrasounds (appendix not visualized) and no secondary signs of appendicitis appendicitis leads to impaired ability to appropriately rule out patients for appendicitis, thus subjecting many children without appendicitis to unnecessary radiation exposure, overnight hospitalization and increased cost and resource utilization, including the risk of negative appendectomy.

TARGETED PROBLEM STATEMENT


  • Improved consistency and accuracy of diagnosis 
  • Reduce rate of negative appendectomy
  • Reduce rate of unnecessary overnight observation for low-risk patients
  • Reduce rate of unnecessary CT scans for both high and for low-risk patients
  • Improved consistency in disposition for patients at low, moderate, and high risk for appendicitis

OPPORTUNITY


Create a standard appendicitis screening tool that applies to every patient with suspected appendicitis in the ER. 

Description of Solution


GOALS/SPECIFIC AIMS

  • 50% reduction in the baseline rate of CT utilization for children with suspected appendicitis
  • 50% reduction in the baseline rate of inpatient admission for serial abdominal exams
  • 50% reduction in the baseline rate of negative appendectomies (removal of pathologically normal appendices)
  • SCOPE

    IN SCOPE
  • People: ER physicians, Radiology, Surgery, IT, Data analysts
  • Process:Diagnosis of suspected appendicitis, Analyzing results
  • Tools: Appendicitis Diagnostic Tool

  • OUT OF SCOPE
  • Treatment/intervention
  • Use by community providers
  • Staffing/FTE changes
  • PROJECT DETAILS

    RESOURCES
    1. Sponsor (could be chief of Radiology, Surgery, ER, CMO, i.e., someone with authority to push standardization and accountability for clinical care)
    2. Physician leader/process owner (someone with appendicitis expertise who leads the effort to define clinical standards and guidelines and gets buy-in from peers)
    3. Clinical representatives--radiologist, surgeon, ED: (people who diagnose appendicitis and facilitate buy-in from their peers)

    INPUTS
    1. Appendicitis Diagnostic Tool template
    2. Disposition guidelines template
    3. Any existing guidelines and protocols for suspected appendicitis workup, as reference

    INSTRUCTIONS
    1. Identify and confirm resources, per above
    2. Gather and analyze data on suspected appendicitis patients
    1. Schedule 1 meeting with data analyst (1-hour)
    2. Analyst gathers data offline
    3. Review data with analyst (1-hour meeting)
    4. Analyst scrubs data
    5. Analyst compiles final report
    3. Schedule and hold 2 working meetings with ER and Surgery.
    1. Review data as a group. Define thresholds for the Appendicitis Diagnostic Tool. (2 hours).
    2. Tailor disposition guidelines based on your thresholds (2 hours).
    4. Define approach for measuring and reporting on compliance with the use of the screening tool.
    5. As close to roll out as possible, schedule and hold training sessions with ER physicians and information sessions with Surgery. Ideally, this occurs one to two weeks prior to roll out.
    6. For the first four to six weeks, monitor compliance with the use of the screening tool weekly.
    7. Transition compliance monitoring to the QI team for regular reviews after this.

    OUTCOMES & MEASURES

    1. 100% use of the appendicitis Diagnostic Tool (Process)
    Numerator: # of children in the ER with suspected appendicitis who scored over the threshold on the initial Appendicitis screening tool and who received the Appendicitis Diagnostic tool
    Denominator: # of children in the ER with suspected appendicitis who scored over the threshold on the initial Appendicitis screening tool
    Data source: EMR. If EMR reporting not easily available, perform chart review or offline database tracking (Excel spreadsheet).
    Person responsible for data collection: Physician leader/process owner or delegate
    Data collection frequency: Monthly, for six months
    Method for displaying the data: Run chart

    2. Achieve a 50% reduction in the baseline rate of inpatient admission (8.9%) for serial abdominal exams. (Outcome)
    Numerator: # unnecessary inpatient admissions of children in the ER with suspected appendicitis who have scored below the threshold on the scoring tool
    Denominator: # children in the ER with suspected appendicitis who have scored below the threshold on the scoring tool who were admitted
    Data source: EMR. If EMR reporting not easily available, perform chart review or offline database tracking (Excel spreadsheet).
    Person responsible for data collection: Physician leader/process owner or delegate
    Data collection frequency: Monthly, for six months
    Method for displaying the data: Run chart

    3. Achieve a 50% reduction from the baseline rate of negative appendectomies (removal of pathologically normal appendices). (Outcome)
    Numerator: # negative appendectomies
    Denominator: # appendectomies performed
    Data source: EMR. If EMR reporting not easily available, perform chart review or offline database tracking (Excel spreadsheet).
    Person responsible for data collection: Physician leader/process owner or delegate
    Data collection frequency: Monthly, for six months
    Method for displaying the data: Run chart

    4. Maintain rate of accurate diagnoses (no increase in rate of misdiagnosis) (Balancing)
    Numerator: # children in the ER presenting with abdominal pain who had delayed diagnoses + number of negative appendectomies
    Denominator: # children in the ER presenting with abdominal pain
    Data source: EMR. If EMR reporting not easily available, perform chart review or offline database tracking (Excel spreadsheet).
    Person responsible for data collection: Physician leader/process owner or delegate
    Data collection frequency: Monthly, for six months
    Method for displaying the data: Run chart

    IMPLEMENTATION OPTIONS


    1. If budget is limited for data collection and analysis, focus on the cases with equivocal ultrasound findings.
    2. If resources are not available for chart review to establish baseline, capture rates prospectively for several months to establish data before beginning this project.

    CHANGE MANAGEMENT CONSIDERATIONS

    1. An audit and analysis of US results, laboratory data and pathology results are necessary in order to establish the hospital specific composite risk profiles.
    2. Alignment between ER physicians and surgeons is necessary to develop the Appendicitis Diagnostic Tool (criteria, thresholds) and guidelines (what happens when each threshold has been reached).

    RISK MITIGATION


    1. If the criteria and threshold of the appendicitis diagnostic tool are not optimized for the institution, the accuracy of diagnosis will be compromised, and the rates of negative appendectomy and inpatient admissions may not improve.
    Mitigation: Continue analyzing data and adjusting thresholds to improve outcomes.
    2. To the extent the Appendicitis Diagnostic Tool is not adopted by ER physicians and surgeons, the accuracy of diagnosis will be compromised, and the rates of negative appendectomy and inpatient admissions may not improve.
    Mitigation: Track adoption rates and continue reinforcing the use of the Appendicitis Diagnostic Tool.

    CONTINUOUS IMPROVEMENT LEARNINGS

    In progress.