*Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX †Division of Emergency Medicine and Urgent Care, Children's Mercy Hospital, Kansas City, MO ‡Department of Radiology, Children's Mercy Hospital, Kansas City, MO §Division of General and Thoracic Surgery, Children's Mercy Hospital, Kansas City, MO.
Ann Surg. 2016 Sep;264(3):474-81. doi: 10.1097/SLA.0000000000001867.
The primary objective of this project was to decrease computed tomography (CT) utilization for the diagnosis of appendicitis in an academic children's hospital emergency department (ED) through a multidisciplinary quality improvement initiative.
Appendicitis is the most common abdominal diagnosis leading to the hospitalization of children in the United States. However, the diagnosis of appendicitis in children can be difficult and many centers rely heavily upon CT scans. Recent recommendations emphasize decreasing CT use among pediatric patients because of an increased lifetime risk of radiation-induced malignancies.
A retrospective review was conducted of patients diagnosed with appendicitis in the ED at Children's Mercy Hospital from January 1, 2011 to February 28, 2014 to establish a baseline cohort. From August 1, 2014 to July 31, 2015, a newly designed diagnostic algorithm was used in the ED and patients were prospectively followed. Any patient discharged from the ED received a follow-up phone call. Patients treated for appendicitis before and after pathway implementation were compared. In addition, any patient evaluated for appendicitis after implementation of the algorithm was analyzed for adherence to the clinical pathway. Differences between the 2 groups were analyzed using ANOVA, Wilcoxon Rank Sum, χ, and Fisher Exact tests.
Of 840 patients seen after implementation of the diagnostic algorithm, 267 were diagnosed with appendicitis. After implementation of the algorithm, CT utilization decreased from 75.4% to 24.2% (P < 0.0001) in patients with appendicitis. CT utilization was 27.3% after implementation, regardless of the ultimate diagnosis or algorithm adherence. The diagnostic pathway had a sensitivity of 98.6% and specificity of 94.4%.
Implementation of a diagnostic algorithm for appendicitis in children significantly decreases CT utilization, whereas maintaining a high sensitivity and specificity.
本项目的主要目标是通过多学科质量改进措施，减少学术儿童医院急诊科（ED）中用于诊断阑尾炎的计算机断层扫描（CT）的使用。
阑尾炎是导致美国儿童住院的最常见腹部诊断，但儿童阑尾炎的诊断可能很困难，许多中心严重依赖 CT 扫描。最近的建议强调减少儿科患者的 CT 使用，因为辐射诱发恶性肿瘤的终生风险增加。
对 2011 年 1 月 1 日至 2014 年 2 月 28 日期间在儿童医院 ED 诊断为阑尾炎的患者进行了回顾性研究，以建立基线队列。从 2014 年 8 月 1 日至 2015 年 7 月 31 日，ED 中使用了新设计的诊断算法，并对患者进行了前瞻性随访。任何从 ED 出院的患者都接受了随访电话。比较了路径实施前后治疗阑尾炎的患者。此外，对算法实施后评估阑尾炎的任何患者进行了临床路径的依从性分析。使用方差分析、Wilcoxon 秩和检验、χ2 和 Fisher 精确检验比较两组间的差异。
在实施诊断算法后，共 840 例患者中，267 例被诊断为阑尾炎。实施算法后，阑尾炎患者的 CT 使用率从 75.4%降至 24.2%（P<0.0001）。无论最终诊断或算法依从性如何，实施后 CT 使用率均为 27.3%。诊断途径的敏感性为 98.6%，特异性为 94.4%。
在儿童中实施阑尾炎诊断算法可显著降低 CT 的使用，同时保持高敏感性和特异性。
