Improving high-value care of ileocolic intussusception in a pediatric ED

Ileocolic intussusception is one of the most common causes of intestinal obstruction in young children. Presenting symptoms often include episodic abdominal pain, fussiness, and emesis, all of which, unfortunately, are common and nonspecific complaints. The “classic triad” of abdominal pain, palpable mass, and bloody stool is present in less than 40 percent of cases.¹ The management of intussusception for hemodynamically stable patients without evidence of perforation includes attempted reduction with an air- or liquid-contrast enema. However, wide practice variation with respect to diagnostic imaging, prophylactic antibiotic administration, and hospitalization exists across the U.S.

The issue at Seattle Children’s Hospital

Seattle Children’s Hospital, WA, is the tertiary care referral center for Alaska, Idaho, Montana, and Washington. The urgent care clinics and emergency department (ED) provide care to approximately 75,000 patients annually. The hospital has pediatric specialists on staff in nearly every subspecialty.

Until the development of the clinical standard work pathway, Seattle Children’s Hospital had a guideline for diagnosis and management of ileocolic intussusception in the ED. Components of the guideline were used with varying consistency among surgery and emergency medicine providers. Abdominal radiographs were recommended as the initial screening step for intussusception. However, numerous studies have demonstrated that ultrasound has far superior sensitivity and specificity in the diagnosis of intussusception.² We found that many children were undergoing radiography only to then have an ultrasound done, regardless of the results of the X ray. It was also standard practice to administer cefoxitin to all patients diagnosed with intussusception prior to enema reduction. This practice was used consistently at Seattle Children’s Hospital, but wide practice variation exists across the country.  Also, all patients with intussusception were admitted to the surgical service regardless of whether reduction was achieved with enema. Many institutions in the U.S. routinely discharge patients after successful reduction, although variation exists.

Putting the quality improvement activity in place

This project was developed as part of the clinical standard work (CSW) process that Seattle Children’s Hospital uses to address a range of clinical practices. CSW is a documented approach to management and treatment of a particular population or diagnosis that providers and staff are expected to follow when patients meet a specific set of inclusion criteria. The approach is rooted in evidence when available. When evidence is unavailable, the treatment plan is determined by team consensus. The management approach is supported by methods and/or standardized tool(s) that are integrated into the workflow, such as an order set, checklist, or algorithm. A designated pathway owner tracks, evaluates, and follows identified process and outcome measures specific to the condition to ensure the continual improvement of the care for this condition.

If a project is approved for CSW consideration, the following guidelines are used to inform prioritization and resourcing:

• Does it improve the value of care to the patient?
• Does the patient population represent a significantly growing volume?
• Do current practices for the condition vary widely?
• Is there an imminent patient safety concern?
• Does division/department leadership support this standardization?
• Is there an anticipated large effect as a result of this project?

Planning and development process

Representatives from pediatric surgery and radiology were recruited to join a working team led by a pediatric emergency medicine (PEM) physician. A clinical nurse specialist, CSW consultant, clinical effectiveness project manager, librarian, clinical informatician, ultrasound technician, pharmacist, and clinical effectiveness analyst also were recruited.

The planning and implementation stages are listed in the sidebar on this page.

The PEM project leader developed clinical questions with a focus on quality of care within the ED. Therapeutic measures, such as enema and surgery, were deemed to be outside the scope of this project. Questions were refined using input from other team members and include the following:

• What is the best initial radiologic diagnostic modality for intussusception? What is the role of radiography, if any?
• What clinical features can be used to assess a risk level for intussusception?
• What is the optimal antibiotic management of these patients?
• Does a surgery consultation need to be obtained prior to enema reduction?
• Is there a need for lab evaluation after confirmation of intussusception?
• What is the optimal sedation and/or analgesia for these patients?
• What is the appropriate disposition for patients with intussusception post-reduction (admission versus discharge home)?

Charts of patients with intussusception were reviewed in order to understand the existing process and flow, including time to diagnostic and therapeutic measures. Data from patients evaluated for intussusception also were reviewed to determine practice variation in evaluation.

Studies were identified by searching electronic databases using search strategies developed and executed by a medical librarian. The searches for all aspects of intussusception were performed in June 2016. The following databases were searched:

• On the Ovid platform: Medline and the Cochrane Database of Systematic Reviews
• Other platforms: Embase, National Guideline Clearinghouse, Turning Research Into Practice, and Cincinnati Children’s Evidence-Based Care Guidelines

Clinical questions regarding intussusception were searched from 2006 to date. A search with no evidence categories, study, or publication-type limitations was conducted for pediatric patients up to 18 years of age. A second search, limited to certain evidence categories, such as relevant publication types, clinical queries filters for diagnosis and therapy, index terms for study types and similar limits, was conducted with no age specifications. All retrieval was limited to English language. In Medline and Embase, appropriate Medical Subject Headings and Emtree headings were used respectively, along with text words, and the search strategy was adapted for other databases using their controlled vocabularies, where available, along with text words.

Studies were evaluated by two independent reviewers for quality and ability to address our clinical questions. Selected studies were then evaluated for quality using the GRADE (grading of recommendations assessment, development, and evaluation) method.

Recommendations

Based on our literature review and/or consensus among PEM, radiology, and surgery experts, we arrived at the following recommendations:^3-6

Initial radiologic diagnostic modality

• Order ultrasound for the diagnostic evaluation of intussusception.
• Do not order X ray for diagnostic evaluation for the concern of intussusception for patients who are hemodynamically stable with nonacute abdomen due to low sensitivity and specificity.
• Consult surgery and order two-view abdominal X ray if concern for perforation in patients who are hemodynamically unstable and with peritoneal signs.

Clinical features that can be used to assess a risk level for intussusception

• Not enough evidence to address.

Optimal antibiotic management

• Antibiotics are not recommended for routine treatment of intussusception in a patient who is hemodynamically stable and without peritoneal signs.

Need for surgery consult prior to enema

• Consult surgery for patients who are diagnosed with intussusception prior to enema reduction. The surgery resident will evaluate the patient prior to enema and verbally consult with their fellow/attending (expert opinion).

Need for lab evaluation after confirmation of intussusception

• Do not obtain routine labs if not clinically indicated (expert opinion).

Optimal sedation and/or analgesia

• Consider oral acetaminophen for pain.
• Consider oral oxycodone for moderate to severe pain for confirmed intussusception.
• Consider intravenous (IV) analgesia in patients who have an IV and moderate to severe pain.

Appropriate disposition for patients with intussusception post-reduction (admission versus discharge to home)

• Do not admit children (who are hemodynamically stable and without peritoneal signs, with reliable caregivers, and access to medical care) after intussusception that has been successfully reduced on the first attempt. The patient must, however, successfully tolerate oral challenge with clear liquids prior to discharge.
• Admit patients to general surgery after successful reduction if unable to tolerate oral intake or have no reliable follow-up.
• Admit patients to general surgery if first attempt at reduction is unsuccessful or a complication occurs.

Using a low-fidelity simulator, we simulated the steps in evaluation and management of a patient with intussusception from arrival in the ED through discharge to home. This process included completed key components of workflow, such as patient transport between the ED and the radiology suites, communication between physicians (PEM, radiology, and surgery residents and attendings), nurses, and radiology technicians. Clarifications and revisions to workflow protocols were made at this time.

Modifications to the pathway were made after careful review of results of simulation. Leadership from the three specialties also provided feedback for incorporation into the protocols. Refer to the Seattle Children’s Hospital ED intussusception final pathway.

Description of the quality improvement activity

Education was rolled out one month before implementation of the CSW pathway. Policy changes, changes to electronic order sets, and new information for the education of families and outside providers were all developed but did not go live until the start date of the pathway, October 10, 2016.

Educational efforts included a learning center module consisting of online didactic presentation followed by multiple-choice questions related to content created for attending physicians in PEM, pediatric surgery, and radiology. Learning modules were released one week before the project went live, and physician members of the project team presented the new pathway at PEM, pediatric surgery, and radiology faculty meetings.

Changes in orders included the addition of ultrasound abdomen intussusception to the ED abdominal pain PowerPlan and creation of an ED-confirmed intussusception PowerPlan. We also updated the surgical unit guideline of care, the intussusception discharge instructions to reflect the new care pathway, and the Seattle Children’s website, a resource for families and health care providers outside of our institution.

Resources used and skills needed

The core members of our team are listed in the sidebar on this page.

No additional costs were incurred beyond normal hospital operations to implement and maintain the project beyond routine funding of the clinical effectiveness program. No additional funding was provided for this project.

Results

To date, 67 cases of intussusception have presented since the pathway was implemented. Two patients were excluded from management per pathway due to clinical concerns for hemodynamic instability and possible perforation. An additional 10 patients were taken off pathway due to reduction failure with the first attempted enema and then admitted to the general surgery service for further management. Six patients were admitted despite successful reduction by enema. Eight patients have had recurrence of intussusception since implementation of the pathway, with five occurring within 48 hours of the initial reduction.

Prior to pathway implementation, 100 percent of patients with intussusception received antibiotics before enema reduction. Since implementation, no patient qualifying for treatment per pathway has received antibiotics before their first enema reduction. Two patients, however, did receive cefoxitin after a successful reduction during admission to the surgery service, one with bloody stools and another who had a history of intussusception in the past. Another received antibiotics after there was concern for perforation during an unsuccessful enema. An additional three patients were treated after an unsuccessful first enema without concern for perforation.

In the year before implementation, 61.3 percent of patients being evaluated for intussusception had an ultrasound as the first diagnostic test. Since implementation, 91.1 percent have ultrasound as the initial study. In the three years before implementation, 62.5 percent of patients with negative evaluations for intussusception had an X ray performed at some point in their ED visit. After implementation, only 5.1 percent of these patients have had a radiograph.

The mean total direct costs for pathway patients being treated for intussusception decreased from $6,740 in the year before implementation to $2,803. There has been no change in the mean direct cost for patients with negative evaluations.

Tips for others

Project design and implementation requires buy-in from key stakeholders, including emergency medicine, surgery, and radiology. We found that reviewing the literature and coming to a consensus was best achieved during in-person meetings. Having adequate support of project managers, librarians, and data managers allowed for timely progress with pathway development and implementation.

We now are monitoring the effects of our project implementation, as well as searching for new clinical data that may warrant changes to our current pathway. We review new literature every three months. The core team members also meet quarterly to review core metrics, including the following:

• Percent of patients with intussusception who receive antibiotics
• Percent of patients with intussusception who have laboratory evaluation
• Percent of patients with intussusception reduced on first enema attempt who are discharged home from the ED within four hours of reduction
• Percent of patients who have ultrasound rather than radiograph for the evaluation of suspected intussusception

Our clinical nurse specialist monitors the electronic feedback system for any reports pertaining to patients with intussusception. Timely reminders of the pathway are provided to clinicians, nursing staff, and radiology technicians when deviations from protocols are observed. Pathway revisions are scheduled for five-year cycles, but may occur more frequently if new evidence for practice changes emerges or deficiencies in current practices are identified.

References

1. Weihmiller SN, Buonomo C, Bachur R. Risk stratification of children being evaluated for intussusception. Pediatrics. 2011;127(2):e296-e303 [Epub ahead of print].
2. Henderson AA, Anupindi SA, Servaes S, et al. Comparison of 2-view abdominal radiographs with ultrasound in children with suspected intussusception. Pediatr Emerg Care. 2013;29(2):145-150.
3. Gray MP, Li SH, Hoffmann RG, Gorelick MH. Recurrence rates after intussusception enema reduction: A meta-analysis. Pediatrics. 2014;134(1):110-119.
4. Ito Y, Kusakawa I, Murata Y, et al. Japanese guidelines for the management of intussusception in children, 2011. Pediatr Int. 2012;54(6):948-958.
5. Al-Tokhais T, Hsieh H, Pemberton J, Elnahas A, Puligandla P, Flageole H. Antibiotics administration before enema reduction of intussusception: Is it necessary? J Pediatr Surg. 2012;47(5):928-930.
6. Broomfield D. Role of plain abdominal radiograph in the diagnosis of intussusception. Emerg Med J. 2008;25(2):106-107.