CT Scan Utilization Decreases With Implementation of a Clinical Pathway for Children With Suspected Acute Appendicitis

OBJECTIVES: The National Surgical Quality Improvement Program-Pediatric (NSQIP-P) recommends reducing computed tomography (CT) scan use to <25% in children with suspected appendicitis. Our multidisciplinary team developed a pediatric appendicitis clinical pathway that emphasizes the use of ultrasound as first-line imaging and reserves CT for patients with both non-diagnostic ultrasounds and agreement from pediatric emergency medicine and surgery teams. METHODS: For this local study, all cases of patients aged younger than 19 years who were diagnosed with appendicitis from 2021 to 2023 were reviewed, with emergency department (ED) length of Stay (LOS) as a balancing measure. A series of Plan-Do-Study-Act cycles was used to implement the clinical pathway and to involve multiple teams. A Statistical Process Control chart was generated and possible special cause variations were analyzed using Six Sigma rules. RESULTS: Ultrasound was the first-line imaging in over 90% of total cases. However, CT utilization steadily decreased from 39% to 22% by the end of our initiative. This was paralleled by a sharp increase in surgical consults before CT scan order from 21% to 41%, and a decrease in non-diagnostic ultrasounds from 35% to 20% across the 3 years of the study. ED LOS decreased from 538 to 435 minutes on average. In addition, 2 patients underwent an MRI in quarter 4 of 2023, demonstrating its potential in the workflow. CONCLUSIONS: Overall, by implementing a clinical pathway this team was able to significantly reduce CT scan utilization in the diagnosis of pediatric appendicitis. STUDY TYPE AND EVIDENCE LEVEL: Cohort study, level III.