Optimized Use of Imaging in Appendicitis Screening

This is a project to standardize the initial evaluation of patients presenting with abdominal pain to identify patients in need of further diagnostic imaging for suspected appendicitis.

OVERVIEW


CONTRIBUTORS


Sub-optimal triage of children with abdominal pain may lead to unnecessary imaging, radiation exposure and resource utilization in children at very low risk for appendicitis, and potential delays in treatment for patients with appendicitis.

TARGETED PROBLEM STATEMENT


  • Improve efficiency and effectiveness of triage of children with suspected appendicitis
  • Reduce cost of unnecessary workups and admissions for patients at low risk of appendicitis
  • Reduce radiation exposure of unnecessary CT scans for patients at low risk of 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


• 100% use of the diagnostic appendicitis screening tool
• 100% compliance with guidelines outlined by the screening tool
• 50% reduction in the number of low-risk children receiving unnecessary diagnostic imaging specifically for a concern for appendicitis
• 10% reduction in the median cost and charges associated with the ED visit (shared across patients with and without documented appendicitis)

SCOPE


IN SCOPE
People: ER physicians
Process: Diagnosis of suspected appendicitis, Initial triage to determine if imaging workup is needed
Tools: Diagnostic appendicitis screening tool

OUT OF SCOPE
• EMR changes
• Use by community providers
• Staffing/FTE changes

PROJECT DETAILS

RESOURCES
  • Sponsor (could be chief of ER, Surgery, CMO, i.e., someone with authority to push standardization and accountability for clinical care)
  • ER or Surgery physician leader/process owner (someone with appendicitis expertise who leads the effort to define clinical standards and guidelines and gets buy-in from peers)
  • Clinical representatives from the ER and Surgery services: (people who best understand the current clinical care processes, participate in defining new standards, and facilitate buy-in from their peers)
  • IT representative: (someone who understands the EMR system and can facilitate implementation of the checklist)
  • Financial analyst (someone who can run a reporting query on the cost of ER visits. This is minimal involvement.)


INPUTS
1. Initial appendicitis screening tool template
2. Any existing guidelines and protocols for suspected appendicitis workup, as reference

INSTRUCTIONS
1. Identify and confirm resources, per above
2. Schedule and hold three working meetings (ideally one to two weeks apart)
  1. Kickoff meeting to review templates and existing reference materials. Tailor screening tool as appropriate. Request offline review. (2-hour meeting)
  2. Share and discuss feedback from peers (1-hour meeting)
  3. 3. Finalize and ratify proposed checklist (30 minutes)
3. Define approach for measuring and reporting on compliance with the use of the screening tool.
4. Review with and hand-off to IT for build out of the screening tool and compliance tracking mechanism in EMR
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.

SAMPLE SCHEDULE
• 1 - 2 months of screening tool design & review
• 3 - 6 months to implement in EMR & roll out

Months 1 - 2: Activities 1 - 3
Months 3 - 8: Activities 4 - 7

OUTCOMES & MEASURES

1. 100% use of the screening tool (Process)
Numerator: # of children in the ER with suspected appendicitis, i.e. presenting with abdominal pain, who receive the screening tool
Denominator: # of children in the ER with suspected appendicitis, i.e. 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: ER or Surgery physician leader/process owner, or delegate
Data collection frequency: Monthly, for six months
Method for displaying the data: Run chart

2. 50% reduction of unnecessary diagnostic workups (Outcome)
Numerator: # unnecessary diagnostic workups, i.e. # of children presenting with abdominal pain in the ER who have scored below the threshold on the scoring tool
Denominator: # diagnostic workups
Data source: EMR. If EMR reporting not easily available, perform chart review or offline database tracking (Excel spreadsheet).
Person responsible for data collection: ER or Surgery physician leader/process owner, or delegate
Data collection frequency: Monthly, for six months
Method for displaying the data: Run chart

3. 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: ER or Surgery physician leader/process owner, or delegate
Data collection frequency: Monthly, for six months
Method for displaying the data: Run chart

4. 25% reduction of median cost and charges for ER visits (Outcome)
Numerator: Median cost for ER visits
Denominator: Baseline median cost for ER visits
Numerator: Median charges for ER visits
Denominator: Baseline median charges for ER visits
Data source: Financial / billing systems
Person responsible for data collection: ER or Surgery physician leader/process owner, or delegate, working with a financial analyst
Data collection frequency: Monthly, for six months
Method for displaying the data: Run chart

IMPLEMENTATION OPTIONS

1. If EMR enhancements are cost prohibitive or too timely, use a paper-based screening tool.
2. Skip the measures for track median cost and charges
3. If resources are not available for chart review to establish baseline, capture rates prospectively.
4. If resources are not available for baseline tracking, assume there is room for improvement and implement the initial screening tool.

CHANGE MANAGEMENT CONSIDERATIONS

This is primarily implemented by the ER department.

Review of the symptoms, descriptions of the symptoms, and consensus should occur between the triage (ER) and intervention (Surgery) services regarding the definitions and language used in the PAS screening tool. The modified version of the PAS used in this projects takes this into consideration, although a sit-down session to review the criteria between service champions should occur.

RISK MITIGATION

1. Risk: Institutional memory may prevent patients from receiving the new diagnostic screening tool.
Mitigation: Continue reinforcing the new diagnostic screening tool with ER physicians.

CONTINUOUS IMPROVEMENT LEARNINGS

In progress