Expedited Surgical Care of Appendicitis is Associated With Improved Resource Utilization.

INTRODUCTION: Appendectomy for acute appendicitis is the most common pediatric intra-abdominal operation. Current literature supports the notion that modest in-hospital, preoperative delays are not associated with greater patient morbidity. However, there is less certainty regarding the role that hour-of-presentation plays in determining the timing of surgery. Thus, we aimed to evaluate how after-hours presentation may relate to the timing of surgery and to assess the outcomes and resource utilization associated with expedited appendectomy compared to nonexpedited. METHODS: Patient records for children who underwent an appendectomy at a freestanding pediatric hospital from 2015 to 2019 were reviewed. Business hour presentations were defined as arrival at the emergency department from 7 AM to 6 PM. Primary outcomes were hospital length of stay (LOS), cost derived from the Pediatric Health Information System database, perforation, surgical complications, and 30-day readmissions. RESULTS: Nine hundred forty-two patients underwent appendectomy over the study period. The median time to OR was 2.0 h in the expedited cohort and 9.8 h in the nonexpedited group. Presentation during business hours was associated with 4.4 higher odds (P < 0.001) of expedited workflow. Expedited appendectomies were associated with shorter hospital LOS (11.5 h, P < 0.001), less costly admissions ($1,155, P < 0.001); LOS measured in midnights, perforation and readmission rates were similar between groups. CONCLUSIONS: We found reduced resource utilization associated with expedited appendectomy. Additionally, the demonstrated association between the time of presentation to the emergency department (ED) and the timing of surgery may be utilized to inform staffing and resource deployment decisions. Further research regarding the generalizability and sustainability of an expedited presurgical workflow in pediatric appendectomy is certainly indicated.

Management of Children With Uncomplicated Cellulitis in Emergency and Hospital Settings.

OBJECTIVE: The aim of the study is to establish consensus recommendations on features used to determine the route of antibiotic administration and disposition for children with uncomplicated cellulitis. METHODS: Modified Delphi methodology was performed with 2 rounds of confidential surveys of Emergency medicine and hospital medicine (HM) providers at Lurie Children's Hospital to assess cellulitis management in children (ages 6 months-18 years) without signs of sepsis or abscess formation. Using a 9-point Likert scale, emergency medicine providers ranked features by perceived level of importance when deciding initial antibiotic route and HM providers ranked features on importance when transitioning to oral antibiotics. Responses were grouped as not important (1-3), neutral (4-6), and important (7-9) and re-evaluated in the second round to reach consensus, defined as ≥70% agreement. RESULTS: Emergency medicine providers (n = 17) reached consensus on 15 of 16 features (93.8%), 10 deemed important. Participants reached greatest consensus (100%) on fevers/chills, lymphangitis, and functional impairment as considerations for initiating intravenous antibiotics. HM providers (n = 15) reached consensus on 9 of 11 factors (81.8%), with 7 considered important when deciding on readiness for oral antibiotics. Providers indicated that stability, rather than reduction, of erythematous margins is sufficient to consider transition and de-escalation of therapy at less than 24 hours if all other clinical improvement criteria are met. CONCLUSIONS: This study achieved consensus on important features for treatment and disposition of children with uncomplicated cellulitis in both emergency and inpatient contexts. These features have the potential to aid in decision making and improve standardization of clinical practice.

Novel Quality Improvement Targets to Address Healthcare Encounters After Pediatric Appendectomy.

INTRODUCTION: Pediatric appendicitis clinical practice guidelines (CPGs) do not typically address postdischarge healthcare encounters. This study aims to examine common indications for returns to the health system to identify novel quality improvement targets. METHODS: This retrospective cohort study analyzed patients aged 3 to 18 y undergoing appendectomy at a single institution from July 1, 2019, to July 31, 2020. The primary outcome was physical postdischarge encounters comprising emergency department (ED) visits and hospital readmissions. Indications for each encounter were categorized and stratified by appendicitis type (i.e., simple, gangrenous, or perforated). Multivariable logistic regression models were used to estimate association between appendicitis category and postdischarge encounters. RESULTS: Of 434 patients, 240 (55.3%) had simple appendicitis, 77 (17.7%) gangrenous, and 117 (29.9%) perforated appendicitis. Overall, 48 patients had at least one instance of an unplanned postdischarge encounter with a total of 56 unplanned ED presentations and 24 readmissions. Perforated patients were significantly more likely to experience postdischarge ED (odds ratio 2.55; 95% confidence interval 1.29-5.02) and readmission encounters (odds ratio 6.63; 95% confidence interval 2.28-19.28). Common indications for ED encounters included abdominal pain (n = 20) with 25.0% readmitted, abdominal pain and gastrointestinal symptoms (e.g., diarrhea, vomiting, distention) (n = 16) with 87.5% readmitted, and incision concerns (n = 6) with 16.7% readmitted. Common indications for readmissions included intraabdominal abscesses (n = 8) and small bowel obstruction (n = 4). CONCLUSIONS: Assessing indications for postdischarge healthcare encounters enables identification of novel quality improvement targets, including proactively addressing incision concerns and abdominal pain.

Antibiotic resistance is common in the cultures of intraabdominal abscess drainage after appendectomy.

INTRODUCTION: Intraabdominal abscesses (IAA) are a common complication following appendectomy. Empiric antibiotic regimens may fail to prevent IAA due to changes in bacterial resistance. We aim to describe the bacteriology of pediatric patients requiring drainage of an IAA after an appendectomy for appendicitis. METHODS: We performed a retrospective study of patients ≤18 years who underwent percutaneous drainage of an IAA following appendectomy a single U.S. children's hospital between 2015 and 2018. Patient demographics, appendicitis characteristics, antibiotic regimens, and culture data were collected. RESULTS: In total, 71 patients required drainage of an IAA of which 48 (67%) were male, the average age was 9.81 (SD 3.31) years and 68 (95.7%) having complicated appendicitis. Ceftriaxone/metronidazole was the most common empiric regimen prior to IAA drainage occurring in 64 (90.1%) patients. IAA cultures isolated organisms in 34 (47.9%) patients. Of those with positive cultures, 17 (50%) cases demonstrated an antimicrobial resistant organism. Most notably, 20% of Escherichia coli was resistant to the empiric regimen. Empiric antimicrobial regimens did not appropriately cover 92.3% of Pseudomonas aeruginosa cultures or 100% of Enterococcus species cultures. Antimicrobial regimens were changed following IAA drainage in 30 (42.2%) instances with 23 (32.4%) instances due to resistance in culture results or lack of appropriate empiric antimicrobial coverage. CONCLUSIONS: IAA culture data following appendectomy for appendicitis frequently demonstrates resistance to or lack of appropriate coverage by empiric antimicrobial regimens. These data support close review of IAA culture results to identify prevalent resistant pathogens along with local changes in resistance. LEVEL OF EVIDENCE: Level III.

The costs and benefits of emergent surgical workflow for acute appendicitis in children.

BACKGROUND: Controversy exists regarding how operative timing affects patient safety and resource utilization for acute appendicitis. Over 3 years, our institution trialed efforts to optimize appendectomy workflow. Our aim is to describe the ramifications of expediting appendectomy and implementing standardized protocols relative to historic controls. METHODS: Patient records at a freestanding children's hospital were reviewed from synchronized 6-month periods from 2019 to 2021. During Year 1 (historic), no standardized workflows existed. In Year 2 (expedited), appendicitis management was protocoled using a clinical quality improvement bundle, which included performing appendectomies within two hours of diagnosis. In Year 3 (QI), operative timing was relaxed to the same calendar day while all prior QI initiatives continued. Descriptive statistics were performed, using hospital length of stay (LOS) as the primary outcome. RESULTS: 298 patients underwent appendectomy for acute appendicitis. The median expedited workflow LOS was 15.3 hours shorter (p = 0.003) than historic controls; however, this was sustained despite relaxation of surgical urgency in the QI workflow. No differences in perforation rates were observed. During the expedited workflow, OR overtime staffing expense increased by $90,000 with no significant change in hospital costs. In multivariate regression, perforation was the only variable associated with LOS. CONCLUSION: Hospital LOS can be shortened by expediting appendectomy. However, in our institution this did not decrease hospital costs and was furthermore balanced by higher personnel expenses. A sustained decrease in LOS after relaxing operative urgency standards implies that concurrent QI initiatives represent a more effective and cost-efficient strategy to decrease hospital resource utilization. LEVEL OF EVIDENCE: Level III.

Timeliness of pediatric surgical appendicitis care is associated with time of hospital admission.

BACKGROUND: Despite the frequency of acute appendicitis in children, there is no evidence-based consensus surrounding the urgency of the operation if a diagnosis is made after regular business hours. Although a modest delay in time to operation does not increase disease severity, postponing cases to the next calendar day may be associated with higher resource utilization. We aimed to evaluate the trend of delaying appendectomies to the next calendar day and its associated outcomes. METHODS: We queried the Pediatric Health Information System to analyze appendectomy patients younger than 18 y of age from 2010 to 2018. Same-day appendectomy and next-day appendectomy cohorts were created using admission hour and operative day. Healthcare cost, length of stay, surgical complications, and 30-day readmission rates were collected. Bivariate analyses and multivariable regressions were used to evaluate groups stratified by time of presentation. RESULTS: During the study period, 113,662 appendectomies were performed, comprising 88,715 (78.1%) same-day appendectomies and 24,947 (21.9%) next-day appendectomies. A higher proportion of same-day appendectomies (80.5%) were performed during hours 12:00am to 5:00pm and 19.5% were performed during hours 6:00pm to 11:00pm. The trend of next-day appendectomies increased during the study period from 13.9% to 20.2%. This was primarily evident in the 6:00pm to 11:00pm period. The 5:00pm cutoff was most predictive of a next-day appendectomy. Next-day appendectomies had similar rates of surgical complications; however, they were associated with higher costs, longer lengths of stay, and higher readmission rates. CONCLUSION: As the understanding of appendicitis urgency has changed, a more tempered approach of delivering surgical care has trended. Although short delays appear safe, postponement to the next calendar day is associated with higher resource utilization.