Fleischman Ross J, Devine Miranda K, Yagapen Marie-Annick N, Steichen Angela J, Hansen Matthew L, Zigman Andrew F, Spiro David M
From the *Department of Emergency Medicine, Oregon Health and Science University; and †Division of Pediatric Surgery, Kaiser Permanente Northwest, Portland, OR.
Pediatr Emerg Care. 2013 Oct;29(10):1060-5. doi: 10.1097/PEC.0b013e3182a5c9b6.
This study aimed to determine the test characteristics of a pathway for pediatric appendicitis and its effects on emergency department (ED) length of stay, imaging, and admissions.
Children age 3 to 18 years with suspicion for appendicitis at 1 tertiary care ED were prospectively enrolled, using validated low- and high-risk scoring systems incorporating history, physical examination, and white blood cell count. Low-risk patients were discharged or observed in the ED. High-risk patients were admitted. Those meeting neither low-risk nor high-risk criteria were evaluated by surgery, with imaging at their discretion. Chart review or telephone follow-up was conducted 2 weeks after the visit. A retrospective study before and after was also performed. Charts of a random sample of patients evaluated for appendicitis in the 8 months before and after the pathway implementation were reviewed.
Appendicitis was diagnosed in 65 of 178 patients. Of those with appendicitis, 63 were not low-risk (sensitivity, 96.9%; specificity, 40.7%). The high-risk criteria had a sensitivity of 75.3% and specificity of 75.2%. We reviewed 292 visits before and 290 after the pathway implementation. Emergency department length of stay was similar (253 minutes before vs 257 minutes after, P = 0.77). Computed tomography was used in 12.7% of visits before and 6.9% of visits after (P = 0.02). Use of ultrasound was not significantly different (47.3% vs 53.7%). Admission rates were not significantly different (45.5% vs 42.7%).
The low-risk criteria had good sensitivity in ruling out appendicitis. The high-risk criteria could be used to guide referral or admission. Neither outperformed the a priori judgment of experienced providers.
本研究旨在确定小儿阑尾炎诊疗路径的检测特征及其对急诊科（ED）住院时间、影像学检查和住院率的影响。
前瞻性纳入一家三级医疗急诊科中3至18岁疑似阑尾炎的儿童，采用经过验证的低风险和高风险评分系统，该系统纳入了病史、体格检查和白细胞计数。低风险患者在急诊科出院或留观。高风险患者收住院。既不符合低风险也不符合高风险标准的患者由外科进行评估，并酌情进行影像学检查。就诊2周后进行病历审查或电话随访。还进行了一项前后对照的回顾性研究。对路径实施前后8个月内评估阑尾炎的随机抽样患者病历进行审查。
178例患者中有65例被诊断为阑尾炎。在这些阑尾炎患者中，63例不属于低风险（敏感性为96.9%；特异性为40.7%）。高风险标准的敏感性为75.3%，特异性为75.2%。我们审查了路径实施前的292次就诊和实施后的290次就诊。急诊科住院时间相似（实施前为253分钟，实施后为257分钟，P = 0.77）。实施前12.7%的就诊使用了计算机断层扫描，实施后为6.9%（P = 0.02）。超声的使用无显著差异（47.3%对53.7%）。住院率无显著差异（45.5%对42.7%）。
低风险标准在排除阑尾炎方面具有良好的敏感性。高风险标准可用于指导转诊或住院。两者均未超过经验丰富的医疗人员的先验判断。
