32 Transfer patterns for suspected appendicitis from community hospitals to a paediatric tertiary emergency department and associated outcomes

Abstract Background Children with suspected appendicitis are often transferred from community emergency departments (EDs) across the Greater Toronto Area to a Toronto paediatric tertiary ED (see Figure 1). While the majority of children in the GTA with suspected appendicitis initially present to one of these regional community EDs, variable access and proficiency of local community paediatric ultrasound, surgery expertise and anesthesia comfort with a paediatric patient as well as ability to admit a paediatric patient post-operatively necessitates that some patients be transferred to the paediatric tertiary ED for ongoing care. Objectives To investigate transfer patterns and outcomes in children with suspected appendicitis transferred from community hospital EDs to a paediatric tertiary care ED within a 12-month period. Design/Methods A retrospective chart review of children with suspected appendicitis transferred from 19 community hospital EDs to a paediatric tertiary hospital ED from October 1, 2021, to September 30, 2022. Outcomes included proportions of patients with documentation of 1) abdominal ultrasound (US) at the community ED, 2) repeated abdominal ultrasound at the tertiary ED, 3) surgical consultation in the tertiary ED. Results Of the 282 transferred children (mean age 7 years, 60% male), 164 (58%) were diagnosed with appendicitis, while 118 (42%) were discharged home without this diagnosis. For the 118 patients not diagnosed with appendicitis, the most common discharge diagnosis was unspecified abdominal pain (111/118, 94%); other diagnoses included a viral illness (2/118, 1.7%), constipation (3/118, 2.5%), adnexal torsion (1/118, 0.8%) and an eating disorder (1/118, 0.8%). For the non-appendicitis patients, 100/118 (85%) had an abdominal ultrasound prior to transfer, and 77/100 (77%) imaged children had ultrasound findings consistent with appendicitis. On arrival to the paediatric tertiary ED, 90/118 (76%) of the non-appendicitis patients had repeat ultrasounds (see Figure 2), and 26/118 (22%) had a surgical consultation. Comparatively, all 164 patients with appendicitis had surgical consultation and 78/144 (54%) had repeat ultrasound at the tertiary ED. Conclusion Almost half of the children transferred to a paediatric tertiary ED for suspected appendicitis were discharged home with no appendicitis. The data sheds light on potential avenues of exploration into optimizing transfers such exploring challenges related to obtaining and interpreting ultrasound imaging in community EDs, optimized use of virtual tertiary-care paediatric surgical consultation services prior to transfer from community ED sites, standardizing transfer algorithms in children with suspected appendicitis, and developing standardized appendicitis-specific documentation records.