Standardization and Improvement of Care for Children With Perforated Appendicitis

Sunday, October 27, 2013: 10:48 AM
Windermere Ballroom W (Hyatt Regency Orlando, formerly the Peabody)
Joyce A. Slusher, MSN1, Kate Johnson, BBA1, Christina Bates, MSN1, Roshni Dasgupta, MD, MPH, FACS, FAAP2, Alicia M. Vincent, BBA1, Betsy Gerrein, MSN1, Jessica Burkhard, BSN3 and Daniel von Allmen, MD, FACS, FAAP1, (1)Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, (2)Pediatric Surgery, Cincinnati Childrens Hospital, Cincinnati, OH, (3)Cincinnati Children's Hospital Medical Center, Cincinnati, OH

Purpose: Reduced variation, evidenced based care and improved outcomes are basic tenets of quality improvement work in medicine.  In this study, the treatment of perforated appendicitis has been standardized in a large academic pediatric surgery practice with goals of reducing variation in practice, reducing consumption of health care resources and maintaining excellent outcomes.  These changes were made within a quality improvement infrastructure designed to provide ongoing documentation of compliance, outcomes, and the opportunity for further improvement interventions.

Methods:  Current pediatric and adult literature on the treatment of perforated appendicitis was evaluated with regard to the timing of surgery (immediate vs interval appendectomy) and duration and route of post-operative antibiotics.   A proposed algorithm was agreed upon by all members of the practice group and was implemented in July of 2012.  The guideline stipulated immediate appendectomy in the absence of a well-defined walled off abscess followed by intravenous antibiotics until discharge criteria were met (normal WBC, afebrile, tolerating a regular diet).  Patients were discharged home on no antibiotics (oral or IV) except in cases of a normal WBC with left shift in which patients were sent home on oral antibiotics to complete a 7 day course.  Data were tracked for 9 months following implementation of the guideline and compared to a baseline data from all cases of perforated appendicitis from the previous 12 months.  Timing of surgery, antibiotic use, adherence to the guideline, total charges (6 months' data), readmission within 30 days, and length of stay were compared for both groups.  Shewhart control charts are maintained on an ongoing basis to document compliance and complications.




Immediate appendectomy

Interval appendectomy



IV antibiotic post-D/C

Re-admit within 30 days

Median total charges

Compliance with Guideline






6.1 days











5.9 days







Conclusions: Adoption of an evidenced based guideline using quality improvement methods resulted in a change in practice and reduction in the variation of care provided in a large surgical group.  The changes resulted in a statistically significant difference in total charges without increasing the complication rate. Additional benefits to the quality of life for patients and families including earlier return to school/work and eliminating the burdens associated with administration of IV antibiotics in the home setting were not quantified. Ongoing tracking of guideline compliance and complication rates in real time provides a mechanism for sustained improvement and further optimization of health care resources as well as subsequent modification of the paradigm of care, providing a template for spread to other surgical conditions.  The methods utilized differ significantly from standard pre/post comparisons studies and provide a template for improvement work in other common surgical conditions.

Fig 1