Attending Yale School of Medicine / Yale New Haven Children's Hospital Yale University School of Medicine New Haven, Connecticut, United States
Background: The diagnosis of appendicitis in children is facilitated by the use of computed tomography (CT). However, emerging practice patterns have demonstrated comparable diagnostic accuracy in diverse care settings through use of clinical decision rules, basic laboratory results and ultrasound (US) in order to minimize childhood exposure to ionizing radiation. Further, recent publications report an increased odds of CT use in this diagnostic workup when children are seen in their community’s general emergency department (GED), where 90% of children seek emergency medical care.
Objective: The primary aim of this quality improvement (QI) initiative was to decrease CT rate in children ages 3-18 years presenting to a community GED system for an appendicitis evaluation by 50% (from 32% to 16%), in one year. Further, we aimed to reduce the proportion of patients obtaining a CT scan prior to an US by 25%, increasing US use by 15%, and decreasing the incidence of non-diagnostic US scans by 20%. Finally, we tracked the balancing measures of transfer and “over-transfer” rates to the participating children’s hospitals.
Design/Methods: Colleagues within a State Emergency Medical Service for Children community of practice formed the QI team. They represented multiple stakeholders across three institutions. The team generated project aims through review of the prior year’s practice trends and implemented changes using the Model for Improvement framework (Fig 1). Interventions included a GED pediatric appendicitis clinical pathway (Figs 2a&b), US report templates and case audit and feedback. Statistical process control tracked project outcomes. Additionally, we compared frontline GED provider perceptions of knowledge gains, practice changes, and teamwork.
Results: The 12-month baseline revealed a GED CT scan rate of 32%, US rate of 63%, non-diagnostic US rate of 77%, transfer to a children’s hospital rate of 23%, and an “over-transfer” rate of 0%. Project interventions achieved and sustained the primary aim as CT scan rate decreased to 4.5% (Fig 3) without measurable impact on balancing measures (Figs 4a-c). Additionally, frontline GED providers reported positive perceptions of knowledge gains and standardization of practice. Conclusion(s): Engaging regional colleagues in a pediatric specific QI initiative significantly decreased CT scan use in children cared for in a community GED system. The emphasis on community of practice may guide future improvement work in the state and beyond.
Figure 1 - Key Driver Diagram:
*GED = General Emergency Department; US = Ultrasound; CT = computed tomography
Figures 2a and 2b:
Initial and Revised GED Pediatric Appendicitis Care Pathway
Figure 3 - Main Outcome:
Annotated Primary Outcome SPCC p-chart – The Rate of CT use for Pediatric Appendicitis evaluations in the GED System
* = Project Launch in October, 2019
Figures 4a – c:
SPCC p-charts for the process measures of US rates and Non-diagnostic US rates and the balancing measure of transfer rates to the children’s hospitals.
Authors/Institutions: Michael P. Goldman, Yale University School of Medicine, New Haven, Connecticut, United States; William Lynders, Middlesex Health, Middletown, Connecticut, United States; Michael Crain, Middlesex Health, Middletown, Connecticut, United States; Mariann N. Kelley, Connecticut Children's Medical Center, Hartford, Connecticut, United States; Daniel M. Solomon, Yale University School of Medicine, New Haven, Connecticut, United States; Doruk Ozgediz, University of California San Francisco, San Francisco, California, United States; Adam Berkwitt, Yale University School of Medicine, New Haven, Connecticut, United States; Sayad A. Bokhari, Yale University School of Medicine, New Haven, Connecticut, United States; Gunjan Tiyyagura, Yale University School of Medicine, New Haven, Connecticut, United States; Marc Auerbach, Yale University School of Medicine, New Haven, Connecticut, United States; Beth Emerson, Yale University School of Medicine, New Haven, Connecticut, United States