Reducing Computed Tomography Use for Appendicitis Evaluation in a Pediatric Emergency Department: A Multidisciplinary Quality Improvement Initiative.

Introduction: Appendicitis is the most common pediatric surgical emergency, and computed tomography (CT) remains an overused diagnostic test for appendicitis. Our institutional rate of CT utilization for suspected appendicitis was higher than in peer children's hospitals, so we aimed to reduce CT utilization during the evaluation of pediatric appendicitis from 31.3% to 15% within 12 months.

Methods: From September 2021 to October 2022, we conducted a multidisciplinary quality improvement initiative among patients evaluated for appendicitis in the pediatric emergency department (PED). Interventions included standardizing evaluation with a clinical practice guideline, an order set in the electronic medical record for clinical decision support, and radiologist use of an ultrasound report template. The primary measure was the percentage of patients undergoing evaluation for appendicitis who received an abdominal CT scan. Process measures were the timing of surgical consultation and ultrasound report template use. Balancing measures included negative pathology appendectomies and PED return visits within 72 hours with subsequent appendicitis diagnosis. We analyzed data using statistical process control charts and Nelson rules to detect special cause variation.

Results: We evaluated a total of 2,010 patients for acute appendicitis, with 624 representing baseline encounters with a CT rate of 31.3%. Quality improvement interventions reduced the CT rate to 12.1% sustained for 10 months without impacting the rate of negative pathology appendectomy or PED return visits within 72 hours.

Conclusions: Quality improvement methodology led to a sustained reduction in CT utilization for patients undergoing evaluation for appendicitis in a PED.