Appendicitis is one of the most common causes of urgent abdominal surgery among children. In the U.S., approximately 53,000 children undergo appendectomy each year for acute appendicitis.1,2 Despite substantial research and vigorous debate, no consensus has been reached on the optimal postoperative management of these children. Therefore, the approach to postoperative care varies widely among pediatric surgeons, presenting an opportunity for quality improvement (QI) endeavors.3,4
Appendectomy is a targeted procedure for the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) Pediatric Project, with readily available institution-specific and national statistics. Following the first year of participation, the University of California Davis (UC Davis) Children’s Hospital, Sacramento, was identified among the highest quartile for length of stay for pediatric patients undergoing appendectomy, despite having a lower postoperative complication rate than other institutions.
UC Davis patients had an average length of stay of 3.6 days versus 2.6 days nationally. This disparity was more pronounced for patients with complicated appendicitis, who had an average length of stay of 6.5 days in contrast to 4.7 days nationally. Because the prolonged average length of hospitalization could not be attributed to postoperative complications, the most likely contributors were variability in postoperative management and inconsistent criteria for discharge.
Context of the QI activity
The UC Davis Medical Center is a tertiary referral center with a large catchment area that includes parts of northern California, southern Oregon, Nevada, and Idaho. It also serves as the primary teaching hospital for the UC Davis Medical School, with a range of residency and fellowship programs. The adjoining UC Davis Children’s Hospital offers comprehensive pediatric care, is the region’s only ACS-verified Level I pediatric trauma center, and is the only ACS-verified Level I Children’s Surgery Center on the West Coast. During the year prior to the implementation of this initiative (July 2015 to June 2016), 128 children underwent appendectomy for acute appendicitis; 58 (42 percent) were found to have complicated appendicitis.
The UC Davis office of graduate medical education encourages QI endeavors, particularly multidisciplinary and interdepartmental projects, and offers grant funding through a competitive application process. Grant recipients are provided both financial and technical support to assist implementation. Intermittent updates are required to ensure progress is being made.
Planning and development process
Clinical practice guidelines have been described at other institutions, and their use, in general, has been endorsed by the American Pediatric Surgical Association.5 Guidelines used at several other institutions were obtained and a literature review performed to inform the development of a unique, local clinical practice guideline. The directors of pediatric antimicrobial stewardship provided recommendations for the postoperative antibiotic regimen, taking into consideration the local antibiogram.
A first draft of the local clinical practice guideline was presented along with local performance metrics to the pediatric surgery department during a weekly departmental meeting. The lead research fellow met with each pediatric surgeon in one-on-one meetings to elicit detailed concerns and discuss potential alternatives to specific elements. The guideline was revised based on the accumulated feedback and subsequently received unanimous approval. The final approved guideline defined complicated appendicitis by specific intraoperative findings, established clear discharge criteria, and specified the postoperative antibiotic regimen (see Figure 1).
Figure 1. Initial clinical practice guideline for postoperative management of pediatric appendicitis
Description of the QI activity
Once the clinical practice guideline was approved, it was disseminated by e-mail to all members of the pediatric surgery team, including surgeons, residents, nurse practitioners, and pharmacists. Laminated “badge buddy” cards of the guideline were distributed. The guideline was also posted in each of the resident work rooms and call rooms. An e-mail explaining the project and its background, along with the current iteration of the guideline, was sent to rotating residents a few days before the start of each rotation. Surgeons, rotating residents, and nurse practitioners were primarily responsible for ensuring that the guideline was followed.
The first iteration of the guideline was implemented November 1, 2016, and was periodically updated following the Plan-Do-Study-Act model.6 Data for all pediatric patients undergoing appendectomy were collected retrospectively from the electronic health record. Data points of interest included the following:
- Patient demographics
- Transfer status
- Diagnostic modality
- Length of stay
- Procedure performed (open versus laparoscopic)
- Operating surgeon
- Intraoperative findings (simple versus complicated appendicitis)
- Pathology results
- Intraoperative culture results (if applicable)
- Peripherally inserted central catheter placement
- Total parenteral nutrition use
- Complete blood count results before discharge (if applicable)
- Antibiotics prescribed at discharge
- Duration of antibiotics (intravenous, oral, and total)
- Compliance with the guideline
- Infectious complications
- Emergency room (ER) visits
- 30-day follow-up
Children who underwent interval and incidental appendectomies were excluded from further analysis.
The lead research fellow analyzed patient data every three months to assess key outcomes, specifically length of stay and complication rates. Results were presented at the weekly pediatric surgery department meeting and potential changes proposed. Changes were approved by consensus and a new iteration of the guideline released every four months, allowing a month between study periods to assess outcomes and discuss changes (see Figure 2).
Figure 2. Sequential guideline revision using Plan-Do-Study-Act Model
Resources used and skills needed
The UC Davis pediatric surgery department is composed of nine pediatric surgeons, including a mix of academic and private practitioners, three to four rotating general surgery residents, and one to two dedicated nurse practitioners. The pediatric infectious disease department was also involved in clinical practice guidelines development. One general surgery research fellow oversaw the development, implementation, data collection, and periodic analysis of the project.
Costs were minimal, limited to printing and laminating for distribution of each iteration of the guideline. Funding was provided through a grant from the UC Davis office of graduate medical education.
Over the 12 months following implementation, the length of stay for all children undergoing appendectomy for acute appendicitis decreased from an average of 3.6 days to 2.6 days. For children with complicated appendicitis, the average length of stay decreased from 6.5 days to 5.4 days. Compliance with the guideline was high and observed in more than 93 percent of patients despite introduction of a new iteration every four months (see Table 1).
Table 1. Compliance with the clinical practice guideline after implementation
Importantly, rates of postoperative complications, including infectious complications, ER visits, and readmissions, did not increase after implementation.
No major setbacks were encountered, which is likely attributable to buy-in from each pediatric surgeon during development of the guideline.
As mentioned previously, direct cost related to implementation of this project was minimal. Cost data for the index hospitalization was obtained and the median direct and total per patient costs were calculated. Direct costs per patient decreased from $6,159 to $5,917, while total costs per patient decreased from $10,109 to $9,748. When these average per patient savings were extrapolated out to the total number of patients treated for the year following implementation, there were estimated savings of $47,432 in direct costs and $70,756 in total costs. These estimates represent net savings, given the minimal monetary investment required to develop and implement the guidelines.
To implement this QI project, it was important to identify a dedicated project lead to ensure timely guideline distribution and periodic analysis, as well as a surgeon champion to provide project support. Presentation of performance metrics, particularly areas of poor performance and national statistics, led to increased motivation. Inclusion of all involved parties during guideline development was likely a crucial component for postimplementation compliance, as practice patterns prior to implementation were highly variable.
A high rate of compliance was maintained through monthly reminders for new rotating residents, as well as updates to the surgeons every three months regarding outcomes and potential changes.
Distributed copies of the guideline should be numbered or dated to ensure easy identification of the newest iteration when changes are made. Alternatively, older versions could be collected and destroyed with each new release.
The author would like to acknowledge the mentorship of Payam Saadai, MD, and Shinjiro Hirose, MD, FACS, during development and implementation of this project.
- U.S. Department of Health & Human Services. Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project (HCUPnet). Available at: https://hcupnet.ahrq.gov/. Accessed September 28, 2018.
- Coran AG, Caldamone A, Adzick NS, Krummel TM, Laberge JM, Shamberger R. Chapter 100–Appendicitis A2. In: Pediatric Surgery, 7th Edition. Philadelphia, PA: Mosby; 2012:1255-1263.
- Gross TS, McCracken C, Heiss KF, Wulkan ML, Raval MV. The contribution of practice variation to length of stay for children with perforated appendicitis. J Pediatr Surg. 2016;51(8):1292-1297.
- Rice-Townsend S, Barnes JN, Hall M, Baxter JL, Rangel SJ. Variation in practice and resource utilization associated with the diagnosis and management of appendicitis at freestanding children’s hospitals: Implications for value-based comparative analysis. Ann Surg. 2014;259(6):1228-1234.
- Lee SL, Islam S, Cassidy LD, Abdullah F, Arca MJ, 2010 American Pediatric Surgical Association Outcomes and Clinical Trials Committee. Antibiotics and appendicitis in the pediatric population: An American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. J Pediatr Surg. 2010;45(11):2181-2185.
- Institute for Healthcare Improvement. The breakthrough series: IHI’s collaborative model for achieving breakthrough improvement. 2003. Available at: https://qrisnetwork.org/sites/all/files/session/resources/BreakthroughSeries.pdf. Accessed September 28, 2018.