EvidenceBasedPracticeandInnovativeHealthcareRedesigntoReduceIonizingRadiationExposureinChildrenwithAbdominalPainandAcuteAppendicitis

SujitIyerM.D.,PatrickBoswell,ShaheenHussainiMD,JulieSanchezM.D,ToryMeyerM.D.

Purpose

Inthelast10yearsalone,thenumberofcomputedtomography(CT)scansusedinyoungchildrenhastripledinthediagnosticevaluationofcommonpediatriccomplaints.1Thisisdespiteoverwhelmingevidencethatexposuretoionizingradiationintheyoungchildincreasestheoveralllifetimecancerrisk.2–4NationalorganizationshaverecommendedthateffortsshouldbemadetousedifferentimagingmodalitieswhenpossibleandreduceCTradiationsettingstominimizeradiationexposureintheyoungchildwithimmatureorgansandsmallersize.5–7Despitethesewellknownfactsandthepotentialharmtopatients,theorganizationofmanyhealthcaresystemshavecreatedbarriersthatmakereductioninCTutilizationratedifficult.Weaimedtodevelopasystematicapproachtoreviewthebestevidenceonthediagnosticevaluationforachildwithpotentialappendicitisandreorganizeourhealthcaredeliverysystemtopredictablyreduceradiationexposure.WesoughttobringtogetherstakeholdersfrommultipledisciplinesandthroughiterativePDSAcyclesdrivedowntheCTutilizationrateinthediagnosisofacuteappendicitis.Inconjunctionweaimedtovalidatethepredictivestrengthsandlimitationsoftheclinicalexamandnon-radiatingimagingmodalities(ultrasound)whilealsodecreasingthenumberofchildrenwithmisseddiagnosesofappendicitisontheirinitialemergencydepartment(ED)encounter.

Methods

Ourinstitutionhadpreviouslydevelopedaprovenmethodtoreviewbestevidencebasedpracticeandimplementanevidencebasedguidelineacrossourinstitutionforcommonconditions(e.g.asthma)andsustainimprovedpatientoutcomes.Webeganwithareviewofourcurrentratesofpre-operativeCTutilizationrate,ourratesof“noimaging”priortooperations,andcomparedtheseratestootherlargechildren’shospitalsthroughtwocollaborativedatasharingnetworks(NSQIPandPHIS).Areviewofourpracticeandbaselineimagingutilizationratesshowedopportunitiesforimprovementinfourmajorareas.Thisincludeduseofanagreedclinicalscoringtooltodefineriskstratification,creatingastandardmethodofreportingultrasound(US)resultstoclearlydelineateequivocalfindings,standardizingthecriteriafororderingaCTscaninourdepartment,andtrackingbalancingmeasuresofthenumberofpatientswhoweremissedwiththediagnosisofappendicitisontheirinitialEDencounterinourmedicalsystem.

UsingGRADEmethodologystakeholdersdevelopedclinicalquestionstargetinghighvariabilityinclinicalpractice.8Anevidencereviewofover75articlesthenledtothecreationofamultidisciplinarypathwaytowardstheapproachofachildwithconcernforappendicitisintheED.HighlightsofthispathwayincludedtheimplementationofthePediatricAppendicitisScore(PAS)foreverychildwithanevaluationforappendicitisintheED,settingexpectationsonsurgicalconsultationforequivocalcasesandforhighriskcasesthatcouldproceedtoanoperationwithnoimaging,incorporatingultrasoundastheinitialimagingtestforpatients,standardizingradiologyreportsandtechniqueonabdominalultrasounds,and

standardizingpaincontrol,labsandfluidresuscitationforthesechildrenduringtheirEDstay.9–14(Figure1,Table1)

Implementationandeducationofstaffincludedthedevelopmentofa“yellowsheet”thatmandatedthatallpediatricpatientswithapotentialappendicitishaveaPASscoredocumentedonthechart.RegularchartreviewsweredonetoincreasecomplianceofthistooluntilEDprovidersmetthis>90%ofthetime.ToensurethePASscorewasachievingthesamepredictabilityasfoundintheliterature,achartreviewofover600chartswasdonetofolloweachpatient’sPASscoretotheirfinaldiagnosis.Similarmethodologyofchartreviewandscorevalidationwasdonetoensure>90%complianceoftheUSscoringtoolbyradiologists.Finally,theemergencydepartmentimplementedasystemtorevieweverypatientforeverydiagnosisthatreturnedtotheEDforasecondvisitwithin72hoursoftheirinitialvisit(i.e“bouncebackrate”).Patientswithadiagnosisofappendicitiswerepulledouttobereviewedbythestakeholdersoftheworkgrouptodefineopportunitiesforimprovementandtogiveinpersonfeedbacktoproviders.

Theworkgroupdefined5keymetricstocreateadashboardforallhospitalstafftoreviewontheperformanceoftheinstitutionontheevaluationandmanagementofchildrenwithappendicitis.(Table2).PHISdatawasusedretrospectivelytoseehowthebounce-backrateforpatientswithappendicitisinourinstitutionchangedcomparedtootherlargechildren’shospitalsinthenation.

Results

Implementationofourevidencebasedpathwayshowedareductionofpre-operativeCTutilizationfromahighof30%downtoasustainedmedianof11%.Concurrentlypre-operativeUSutilizationraterosefrom47%toahighof70%(Figure2).Comparedtothetop45children’shospitalsinthenation(PHISdatabase),ourhospitalsustainedalowerCTutilizationthanourpeersandincreasedpre-operativeUSutilizationratestomatchthoseofpeerinstitutions.(Figure3)

ValidationofthepredictabilityandriskstratificationofthePASscoreshowedsimilarperformancetothatquotedintheliterature13.(Figure4)Theappendectomyrateinthehighestriskpatientsapproached95-100%,while0%ofpatientswithalowriskscore(<3)hadanappendectomy.Thisoccurredwhilewereducedthebounce-backrateofpatient’smisseddiagnosisofappendicitisontheirfirstvisitanddroveourranktobethesecondbestperforminghospitalinthenationcomparedtoourpeersinthismetric(Figure5).

ImplementationofastandardUSscoringtoolbyradiologyfurthershowedthatpatientswithconfirmedappendicitisorconfirmednormalUSachievedexcellenttruepositive(96.3%)andfalsenegativerates(0.72%)(Figure6)

Throughoutthisprojectourinstitutionwasabletoachievebestinclassperformanceonallmetricsinourdashboard(Figure7)

Conclusion

UseofanevidencebasedmethodtocreatemultidisciplinaryconsensusonbestmanagementforchildrenwithpossibleappendicitiscanreducingionizingradiationexposurewhilealsodecreasingtherateofmisseddiagnosisofappendicitisontheinitialEDencounter.ContinuousfeedbacktoprovidersanditerativePDSAcyclescanalsohardwireintheimplementationofnewsystemsofriskstratification(PASscore)thatvalidatetheuseoftheclinicalexamandencourageastreamlinedapproachinusingdiagnosticimaging.StandardizedreportingofUSimagingfindingsandtyingthemtothefinalappendectomyresultsfurthergaveprovidersconfidenceintheuseofmodalitiesotherthanCTscan.

DespitethefactthatevidencehadsupportedtheuseofUSoverCTscanintheliteratureforoveradecade,itwastheorganizedprocessdrivenbymeaningfuldataandengagedstakeholdersthatallowedforsustaineddeliveryofreducedradiationwhilealsoensuringadequatediagnosisontheinitialEDencounter.WhileCTscanutilizationoverallwasdecreased,itismeaningfultonotethatpreviousliteraturehasalsoshownthatuseofUSalonedoeshaveclinicallimitations15

IterativePDSAcyclesalsoshowedthatinordertoreducevariationacrossthehospitalsomekeyelementsneededtobepresent.Thisincludedengagedstakeholdersfromalldisciplinesthatencounterthesepatients,meaningfuldatatovalidatetheuseofanewprocesstoreluctantprovidersandhardwiredsystemchangesthatusedoldsystems(papersheetstotrackpatients)wheninstitutionalEMRsystemscouldnotprovidetimelyandadaptivechangestoimplementanewprocess.

Furtherstepsinthisprojectnowincludeafocusonpediatricpatientsevaluatedforappendicitisatinstitutionsoutsideofourchildren’shospitalsforpossibleappendicitis.Chartreviewhasshownthatonaveragethesepatientshadarateofpre-operativeCTutilizationrateof70%priortotransfertoourhospitalforappendectomy(Figure8).ThisnumberofpatientslikelyrepresentsonlyafractionofthepediatricpatientsundergoingCTscansincethisreviewwasonlyofpatientswhoultimatelyhadappendicitis.Ourworkgroupiscurrentlyengagingstakeholdersacrossthehealthcarenetworkininstitutionswithlittlepediatricexpertisetocreateastandardizeriskstratificationsystemacrossthecitytofunnelthosepatientsneedingimagingorimmediateoperativerepairtoourinstitution.Ournextaimistodemonstratethatwecanreplicatesimilarresultsanddrivedownpre-operativeCTutilizationratesatnon-children’shospitalfacilities.

Figure1–EvidenceBasedPathwayforPossibleAcuteAppendicitisinChildren

Table1–StandardizedRadiologyUSScoringToolforLimitedPediatricAbdominalUltrasound

Table2–AdherenceMeasuresforPediatricAppendicitisPathway

Figure2–ProperativeiCTandUSutilizationrates

Figure3–Comparativepre-operativeCTandUSutilizationrateswithPHISpediatrichospitalnetwork

Figure4–ValidationofthePediatricAppendicitisScore

Figure5–DCMCEDBouncebackratecomparedtopeerPHIShospitals

Figure6–ValidationofStandardizedPediatricAbdominalUSScoringSystem

Figure7–DCMCWorkgroupAppendicitisDashboard

Figure8–PreoperativeCTandUSutilizationrateforAppendectomyDiagnosis,Children’sHospitalvsNon-Children’sHospitals

WorksCited

1. MigliorettiDL,JohnsonE,WilliamsA,etal.TheUseofComputedTomographyinPediatricsandtheAssociated

RadiationExposureandEstimatedCancerRisk.JAMAPediatr2013;167(8):700–7.

2. BayssonH,JournyN,RouéT,Ducou-LepointeH,EtardC,BernierM-O.[ExposuretoCTscansinchildhoodandlong-termcancerrisk:Areviewofepidemiologicalstudies].BullCancer(Paris)2016;103(2):190–8.

3. BrennerD,EllistonC,HallE,BerdonW.Estimatedrisksofradiation-inducedfatalcancerfrompediatricCT.AJRAmJRoentgenol2001;176(2):289–96.

4. PearceMS,SalottiJA,LittleMP,etal.RadiationexposurefromCTscansinchildhoodandsubsequentriskofleukaemiaandbraintumours:aretrospectivecohortstudy.LancetLondEngl2012;380(9840):499–505.

5. RosenMP,DingA,BlakeMA,etal.ACRAppropriatenessCriteria®rightlowerquadrantpain--suspectedappendicitis.JAmCollRadiolJACR2011;8(11):749–55.

6. AmericanCollegeofRadiology|ChoosingWisely[Internet].[cited2017Jan19];Availablefrom:http://www.choosingwisely.org/societies/american-college-of-radiology/

7. AspelundG,FingeretA,GrossE,etal.Ultrasonography/MRIversusCTfordiagnosingappendicitis.Pediatrics2014;133(4):586–93.

8. GRADEhome[Internet].[cited2017Jan19];Availablefrom:http://www.gradeworkinggroup.org/

9. MittalMK,DayanPS,MaciasCG,etal.Performanceofultrasoundinthediagnosisofappendicitisinchildreninamulticentercohort.AcadEmergMedOffJSocAcadEmergMed2013;20(7):697–702.

10. PogorelićZ,RakS,MrklićI,JurićI.ProspectivevalidationofAlvaradoscoreandPediatricAppendicitisScoreforthediagnosisofacuteappendicitisinchildren.PediatrEmergCare2015;31(3):164–8.

11. MaccoS,VrouenraetsBC,deCastroSMM.Evaluationofscoringsystemsinpredictingacuteappendicitisinchildren.Surgery2016;160(6):1599–604.

12. SchneiderC,KharbandaA,BachurR.Evaluatingappendicitisscoringsystemsusingaprospectivepediatriccohort.AnnEmergMed2007;49(6):778–784,784.e1.

13. KharbandaAB,TaylorGA,FishmanSJ,BachurRG.Aclinicaldecisionruletoidentifychildrenatlowriskforappendicitis.Pediatrics2005;116(3):709–16.

14. FallonSC,OrthRC,GuillermanRP,etal.Developmentandvalidationofanultrasoundscoringsystemforchildrenwithsuspectedacuteappendicitis.PediatrRadiol2015;45(13):1945–52.

15. SulowskiC,DoriaAS,LangerJC,ManC,StephensD,SchuhS.Clinicaloutcomesinobeseandnormal-weightchildrenundergoingultrasoundforsuspectedappendicitis.AcadEmergMedOffJSocAcadEmergMed2011;18(2):167–73.