An evidenced-based clinical pathway for acute appendicitis decreases hospital duration and cost

Warner, Brad W.; Kulick, Roy M.; Stoops, Marilyn; Mehta, Sanjeev; Stephan, Maria; Kotagal, Uma R.

doi:10.1016/s0022-3468(98)90010-0

Cited by 127 publications

(83 citation statements)

References 11 publications

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“…5,10 The quality of care in this study, using as indicators the rates of appendiceal perforation (7; 3.2%) and the rates of true negative appendectomy (5; 3.2%), was satisfactory when compared with other studies (including those that had medical imaging as their routine work-up). 1,5,16,18,19 Five of 10 negative appendicectomies were found to have other major pathology, which would still need surgery. Tw o of seven appendiceal perforations occurred during surgery.…”

Section: Discussionmentioning

confidence: 99%

“…In addition, both medical imaging modalities were found useful in demonstrating peritoneal fluid which might explain a patient's symptoms and signs. 1,8,16,18,19,26 Subsequently, the finding might lead to diagnostic laparoscopy with clinical correlation. In addition, medical imaging has prevented 'missed appendicitis' in two equivocal presentations in this series.…”

Section: Discussionmentioning

confidence: 99%

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‘To have … or not to have’. Should Computed Tomography and Ultrasonography be Implemented as a Routine Work-Up for Patients with Suspected Acute Appendicitis in a Regional Hospital?

Chiang

Tan²,

Birks

2008

annals

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This study was a retrospective audit of patients over 15 years of age who presented to the emergency department of Appendicitis is a common diagnosis, but is by no means a simple one to establish. This retrospective study investigated the value of medical imaging (ultrasonography and/or computed tomography [CT]) for patients with suspected appendicitis. Negative appendicectomy rate and appendiceal perforation with or without medical imaging were used as end points for this investigation.PATIENTS AND METHODS This study retrospectively reviewed all patients admitted in one district general hospital with suspected acute appendicitis. The patient cohort was identified from the Unit Registry and an International Classification of Diseasesbased Review of medical records. The medical records were analysed, and the outcome of patients were followed up. RESULTS Between 12 January 2004 to 27 May 2005, 168 patients' medical records were audited. The negative appendicitis rate was 6.7% and appendiceal perforation rate was 3.2%. Among them, only 20 in-patients (12%) had medical imaging (ultrasonography and/or CT scan) after clinical assessment for suspected acute appendicitis. Medical imaging had a 70% prediction rate for acute appendicitis, 20% false-negative rate, and 10% false-positive rate. Overall, the prediction rate for appendicitis by clinical assessment supplemented by laboratory tests and medical imaging at clinician's discretion was 93.2%.CONCLUSIONS Despite studies advocating routine use of medical imaging for patients with suspected acute appendicitis, this study showed that the clinical evaluation is still paramount to the management of patients with suspected acute appendicitis before considering medical imaging.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

‘To have … or not to have’. Should Computed Tomography and Ultrasonography be Implemented as a Routine Work-Up for Patients with Suspected Acute Appendicitis in a Regional Hospital?

Chiang

Tan²,

Birks

2008

annals

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“…The sensitivity of sonography for the diagnosis of appendicitis increases with the number of studies performed, but the learning curve in children is long and requires teaching the entire team, including residents, how to use it for this diagnosis [7]. In agreement with these data, each team, and in particular, pediatric surgery teams, should set up a formal diagnostic approach because the literature shows that an evidence-based clinical pathway improves patient management and decreases costs [12], or, at the very least, a sonography should be performed for every patient with clinically suspected appendicitis. One recent study from the French Ministry of Social Affairs has shown a substantial reduction in the annual number of appendectomies performed, dropping from 268,300 in 1986 to 83,400 in 2012, attesting to better management by decreasing the number of unnecessary appendectomies [13].…”

Section: Discussionmentioning

confidence: 99%

An easy-to-follow algorithm to improve pre-operative diagnosis for appendicitis in children

Podevin

Vries

Lardy

et al. 2017

Journal of Visceral Surgery

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Summary Goal:To evaluate physician compliance with use of a diagnostic algorithm for appendicitis in children. Our secondary objective was to determine the impact of the algorithm on diagnostic accuracy and morbidity. Methods: We conducted a clustered randomized trial in eight centers. A total of 866 patients were included and, depending on the period of randomization at particular centers, 543 patients were managed before the formal institution of the diagnostic algorithm; their diagnostic management was compared to that of the subsequent 323 patients. Results: There was a 29.1% mean increase in the use of imaging studies included in the algorithm after algorithm set-up, rising from 50.8 to 79.9% (P < 0.02). When we used a composite endpoint of ''poor results'' (grouping patients with incorrect diagnoses and/or post-operative complications), no statistically significant difference was found between the two periods (85/543 (15.6%) before vs. 45/323 (13.9%) after set-up, P = 0.5). But when the number of incorrect diagnoses of appendicitis made without the use of the algorithm was compared to that of patients who took advantage of the algorithm, the difference was highly significant (67/332 [20.2%] vs. 63/534 [11.8%], P < 0.001), and the rate of unnecessary appendectomy decreased from 11.9 to 5.3% (P < 0.01). Conclusions: Our diagnostic algorithm improved the adherence to good practice for the diagnosis of appendicitis in children, reducing the rates of unnecessary appendectomy and morbidity. This strategy, combining laboratory tests and imaging, should permit pediatric surgeons to adapt their therapeutic approaches to specific cases.

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“…The plain film findings in appendicitis are otherwise disappointingly insensitive and nonspecific (1,(6)(7)(8)(9). At least one suggested pathway for the evaluation of appendicitis in children proposes that plain films be performed only if perforation, peritonitis or bowel obstruction is suspected, or a palpable mass is appreciated (10).…”

Section: Plain Filmsmentioning

confidence: 99%

Contemporary imaging of the child with abdominal pain or distress

Manson

2004

Paediatrics &Amp; Child Health

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As technological advances in the field of diagnostic imaging progress rapidly, there is increasing confusion as to how to utilize these resources efficiently in the evaluation of the child with acute abdominal pain. The history and physical examination become extremely important to help guide the subsequent imaging protocol. Plain films have limited value. Sonographic technology is particularly well suited to the child for the initial imaging investigation because the sonographic examination can demonstrate excellent sensitivity and specificity for some disease entities. Computed tomography is a useful adjunctive imaging modality, while magnetic resonance imaging for abdominal pain is still in its infancy. Nuclear medicine isotope studies will not be addressed in this review.

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An evidenced-based clinical pathway for acute appendicitis decreases hospital duration and cost

Cited by 127 publications

References 11 publications

‘To have … or not to have’. Should Computed Tomography and Ultrasonography be Implemented as a Routine Work-Up for Patients with Suspected Acute Appendicitis in a Regional Hospital?

‘To have … or not to have’. Should Computed Tomography and Ultrasonography be Implemented as a Routine Work-Up for Patients with Suspected Acute Appendicitis in a Regional Hospital?

An easy-to-follow algorithm to improve pre-operative diagnosis for appendicitis in children

Contemporary imaging of the child with abdominal pain or distress

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