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.
This is a project to provide a composite risk assessment and disposition guidelines for patients presenting with uncertain risk of appendicitis. Create an Appendicitis Diagnostic Tool and disposition guidelines for children clinically presenting with suspected appendicitis who have had laboratory results and imaging.
Description: This is a case study about a set of quality improvement projects implemented by Boston Children's Hospital over a six-month period to improve the care of children presenting to the Emergency Department with suspected appendicitis.
At BCH, 27% of children with suspected appendicitis underwent CT scan, the overuse of which subjected them to as-yet unknown long-term harmful effects of exposure to radiation, including the risk of cancer.
Similarly, 6.5% of children underwent an operation where a normal appendix was found, subjecting them to the morbidity of an unnecessary operation and lost days from school. Similarly, such cases may result in severe anxiety on behalf of parents, as well as lost productivity from days off from work.
TARGETED PROBLEM STATEMENT
Cognizant of the risks of radiation exposure and the morbidity of negative appendectomy, BCH physicians established a standardized diagnostic pathway for patients presenting with abdominal pain where appendicitis was considered in the differential diagnosis. The pathway was composed of three components designed to: 1) streamline the initial screening process to identify patients in need of further diagnostic imaging (US), 2) Improve the quality of ultrasound exams, 3)Increase the diagnostic utility of US and laboratory data, and reduce variability in disposition for patients at low, moderate and high risk for appendicitis
Benefits of such a pathway include:
- Reduced CT utilization for patients with suspected appendicitis
- Reduced rates of negative appendectomy
- Reduce rates of unnecessary admission for serial abdominal examinations and observation
- Improved communication between surgery, emergency medicine and radiology
33% reduction in baseline rate (27%) of CT utilization for children with suspected appendicitis
33% reduction in baseline rate (6.5%) of negative appendectomy
10% reduction in the median cost and charges associated with the ER visit
GOALS / SPECIFIC AIMS
People: Surgery, ER, Radiology (sonography technicians and physicians), IT (optional)
- Process: Diagnosis
- Tools: Initial Diagnostic Screening Tool for patients presenting with abdominal pain, utrasound technique and reporting form, EMR
OUT OF SCOPE
- Processes: intervention, management, transition
- People: Staffing / FTE changes
- Activities: Education/use by community physicians, IRB activities
- Other: Ultrasound techniques and reporting of findings for other conditions
In 2012, Dr. Shawn Rangel undertook an effort to improve appendectomy care at Boston Children's Hospital to reduce the potential for unnecessary exposure to radiation and to reduce the rate of unnecessary operations (negative appendectomy). After determining their current rates of CT scans and negative appendectomies from currently available benchmarks (NSQIP and CHA), BCH physicians were astonished to discover they exceeded the national benchmarked rate on both measures.
Root causes of the high rates of CT scans and negative appendectomies were:
- No standardized criteria to identify which patients presenting with abdominal pain needed further work-up
- Inconsistent quality of ultrasound due to variable imaging techniques and reporting of findings (errors of omission)
- Unclear utility of equivocal US exams (52% of all studies) where neither primary or secondary findings of appendicitis wee found, nor a normal appendix
- Lack of a standard approach/guidelines to assess the composite risk of appendicitis in children based on WBC and US findings together
They developed a set of decision-support guidelines to segment patients into high and low risk profiles for appendicitis, where unnecessary workups could be avoided, to identify which patients were at high risk for negative appendectomy.
They also standardized the ultrasound techniques and reporting of findings based on a national appendicitis-focused, knowledge-sharing quality-improvement collaborative that identified “best practices” for reducing CT utilization and cost while maintaining (or improving) the effectiveness of the diagnostic pathway.
Together, this series of improvements resulted in:
- 50% reduction in the baseline of 28.5% CT utilization rate, or 105 CT scans averted
- 50% reduction in the baseline 5.8% Negative Appendectomy Rate (NAR), or 9 unnecessary operations averted
- 25% reduction in the 8.9% admission rate for serial abdominal exams, or 17admissions averted
Based on achieving reduction targets for CT utilization, negative appendectomy, and inpatient admission utilization rates, and future case volume estimates from 2014 BCH data, we estimate a cumulative annual cost and charge savings of $182,454 and $406,286, respectively
Administrators will look to these outcomes even more than projected cost savings, which are not readily translatable to what they can expect to save.
While this work can be implemented by a single placement service, alignment between ER, Surgical, and Radiology services is most effective to achieving the aims of reducing radiation from CT scans, reducing the negative appendectomy rate, and reducing unnecessary inpatient admissions for serial abdominal exams.
Obtain buy-in from chiefs (and/or their delegates) of the three services. May target radiologists with specific interest or division leadership for ultrasound imaging. This occurs ideally as part of the selection of which projects to undertake.
CHANGE MANAGEMENT CONSIDER-ATIONS
- Institutional memory may prevent patients from receiving the new diagnostic screening tool. Mitigation: Continue reinforcing the new diagnostic screening tool with ER physicians. This is where daily email reminders of the pathway targeting on-call surgeons and staff (including contact info with questions and a schema of the pathway itself) may be helpful
- Institutional memory may have patients continuing to receive CT scans. Mitigation: Continue reinforcing the new diagnostic imaging process via ultrasound with ER physicians.
- Initial quality of ultrasound results may reinforce the preference for CT scans. Mitigation: Continue training of ultrasound technicians and reinforcing use of ultrasound with ER physicians.
- If appendicitis risk profiles based on laboratory and ultrasound are not based on the institution’s own laboratory and ultrasound data, the effectiveness of the tool 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.
- 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.
Over the years, we have gleaned a few vital lessons:
- It critical to define appendicitis risk profiles based on your institutions own laboratory and ultrasound data. This is necessary to take into account differences in patient populations and ultrasound technique which may be considerable across hospitals.
- Coordination between the ER, Radiology, and Surgery is required to implement effective change for diagnosing suspected appendicitis.
- The rate of overuse of CT scans and unnecessary radiation is likely greater than people assume, as was the case at BCH.
- Standard assessment / decision-making tools are highly effective in improving diagnostic accuracy
- Training and reinforcement of new tools, techniques, and reporting of findings are essential components of continuous quality improvement. Auditing of pathway compliance and regular meetings between the surgeon, ED and radiology champions is effective in reinforcing changes in progress, as are regular (daily) reminders to on-call physicians that the pathway exists.