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Original Investigation |

Effect of a Clinical Practice Guideline for Pediatric Complicated Appendicitis Online Only

Zachary I. Willis, MD1; Eileen M. Duggan, MD, MPH2; Brian T. Bucher, MD2,3; John B. Pietsch, MD2; Monica Milovancev, MSN, CPNP2; Whitney Wharton, MSN, CPNP2; Jessica Gillon, PharmD, BCPS4; Harold N. Lovvorn III, MD2; James A. O’Neill Jr, MD2; M. Cecilia Di Pentima, MD, MPH2; Martin L. Blakely, MD, MS2
[+] Author Affiliations
1Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
2Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
3Division of Pediatric Surgery, University of Utah, Salt Lake City
4Monroe Carell, Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
JAMA Surg. 2016;151(5):e160194. doi:10.1001/jamasurg.2016.0194.
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Importance  Complicated appendicitis is a common condition in children that causes substantial morbidity. Significant variation in practice exists within and between centers. We observed highly variable practices within our hospital and hypothesized that a clinical practice guideline (CPG) would standardize care and be associated with improved patient outcomes.

Objective  To determine whether a CPG for complicated appendicitis could be associated with improved clinical outcomes.

Design, Setting, and Participants  A comprehensive CPG was developed for all children with complicated appendicitis at Monroe Carell Jr Children’s Hospital at Vanderbilt, a freestanding children’s hospital in Nashville, Tennessee, and was implemented in July 2013. All patients with complicated appendicitis who were treated with early appendectomy during the study period were included in the study. Patients were divided into 2 cohorts, based on whether they were treated before or after CPG implementation. Clinical characteristics and outcomes were recorded for 30 months prior to and 16 months following CPG implementation.

Exposure  Clinical practice guideline developed for all children with complicated appendicitis at Monroe Carell Jr Children’s Hospital at Vanderbilt.

Main Outcomes and Measures  The primary outcome measure was the occurrence of any adverse event such as readmission or surgical site infection. In addition, resource use, practice variation, and CPG adherence were assessed.

Results  Of the 313 patients included in the study, 183 were boys (58.5%) and 234 were white (74.8%). Complete CPG adherence occurred in 78.7% of cases (n = 96). The pre-CPG group included 191 patients with a mean (SD) age of 8.8 (4.0) years, and the post-CPG group included 122 patients with a mean (SD) age of 8.7 (4.1) years. Compared with the pre-CPG group, patients in the post-CPG group were less likely to receive a peripherally inserted central catheter (2.5%, n = 3 vs 30.4%, n = 58; P < .001) or require a postoperative computed tomographic scan (13.1%, n = 16 vs 29.3%, n = 56; P = .001), and length of hospital stay was significantly reduced (4.6 days post-CPG vs 5.1 days pre-CPG, P < .05). Patients in the post-CPG group were less likely to have a surgical site infection (relative risk [RR], 0.41; 95% CI, 0.27-0.74) or require a second operation (RR, 0.35; 95% CI, 0.12-1.00). In the pre-CPG group, 30.9% of patients (n = 59) experienced any adverse event, while 22.1% of post-CPG patients (n = 27) experienced any adverse event (RR, 0.72; 95% CI, 0.48-1.06).

Conclusions and Relevance  Significant practice variation exists among surgeons in the management of pediatric complicated appendicitis. In our institution, a CPG that standardized practice patterns was associated with reduced resource use and improved patient outcomes. Most surgeons had very high compliance with the CPG.

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Clinical Practice Guideline (CPG) Used for Suspected and Confirmed Complicated Appendicitis

POD7 indicates postoperative day 7. To convert white blood cell count to ×109/L, multiply by 0.001.

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