Standardizing Appendicitis Care

Dr. Adam Goldin with patient Elias Metallo
Dr. Adam Goldin with patient Elias Metallo

This story was originally featured in Seattle Children’s Hospital 2014 Academic Annual Report. The report provides a look into the top clinical and research accomplishments that took place at Seattle Children’s in 2014.

Appendicitis is one of the most common reasons children need surgery, yet diagnosis and treatment approaches vary greatly among hospitals and caregivers and are not always based on best practices.

The Washington State Hospital Association (WSHA) chose Drs. Adam Goldin and Daniel Ledbetter as part of a statewide team to draft standardized diagnostic and clinical care guidelines for appendicitis in 2014. The goals for the new guidelines are to reduce radiation exposure, provide clear guidance for giving antibiotics and outline other evidence-based practices to improve care for hundreds of children throughout Washington state each year.

Ledbetter and Goldin got the nod after they spearheaded a clinical standard work pathway for appendicitis at Seattle Children’s in 2013.

“WSHA chose to focus on appendicitis because it is the most common surgical condition in children,” Goldin says. About 1,000 children in Washington state are treated for appendicitis every year – including more than 300 a year at Seattle Children’s.

Washington will become one of the first states with standard diagnostic and clinical care guidelines for appendicitis when the WSHA’s draft guidelines are finalized in 2015.

Use ultrasound, not CT

Around the country CT scans have been the primary imaging choice for diagnosing appendicitis for many years. But CT exposes children to radiation when their bodies are growing and increases the risk of developing cancer later in life.

Using radiation-free ultrasound as the first imaging choice for diagnosing appendicitis in children is a key component of the new WSHA guidelines. This action aligns with the American Board of Radiology Foundation’s national 100K Children’s Campaign to minimize radiation exposure in all medical imaging of children to reduce the risk of malignancies.

Ultrasound became the go-to imaging choice for appendicitis some time ago at Seattle Children’s as part of hospital-wide efforts to minimize radiation exposure for all patients. However, CT is still used nearly half the time elsewhere in the state because it’s an easier way to image appendicitis.

“Ultrasound requires more hands-on skill and experience by the ultrasound technician than CT,” Ledbetter says. “You have to know what to look for, how to position the sensors and how to adjust the settings to get a high-quality image. Hospitals that see relatively few appendicitis patients a year can struggle to be proficient.”

Goldin has been supporting the work of his research residents Drs. Meera Kotagal and Morgan Richards, who started a statewide public health campaign called Safe and Sound to promote using ultrasound as the first imaging choice for appendicitis before CT.

Safe and Sound, piloted by Seattle Children’s and eight other hospitals in 2014, trains practitioners to become more skilled and confident using ultrasound while also building community support for ultrasound as the first imaging choice for appendicitis.

Shortening stays

The number of days a child needs IV antibiotics after an appendectomy is a major factor in their length of stay in the hospital. The appendicitis pathway at Seattle Children’s and the new WSHA clinical care guideline include steps to help decide the appropriate course of antibiotics based on the severity of a patient’s condition and their response to surgery.

Following the steps enables practitioners to safely switch some patients from IV antibiotics to oral antibiotics sooner and send them home faster. Antibiotics after surgery can be avoided entirely when the appendix is not ruptured. Seattle Children’s has reduced IV antibiotic use for nonruptured appendicitis by more than 50% and IV antibiotic use for ruptured appendicitis by more than 20% overall since establishing an appendicitis pathway in 2013.

“There used to be a lot of disagreement about the duration of antibiotics and some kids may have been hospitalized longer than necessary,” Ledbetter says. “After standardizing care around best practices, we’ve been able to shorten average hospital stays.”