How Long Does it Take to Diagnose Appendicitis? Time Point Process Mapping in the Emergency Department.

OBJECTIVES: Appendicitis is the most common surgical emergency encountered in the pediatric emergency department (ED). We analyzed the time course of children evaluated for suspected appendicitis in relation to implementation of a risk-stratified ultrasound scoring system and structured reporting template (Appy-Score). METHODS: In July 2013, a 6-level ultrasound (US)-based appendicitis scoring system was developed and implemented. The records of children (age ≤18 years) who underwent limited abdominal US exams for suspected appendicitis at a large academic pediatric ED were reviewed retrospectively. Time periods evaluated were from January 1 to April 1, 2013 (before implementation of the US scoring system, "PRE") and July 1 to October 1, 2013 (after implementation of the US scoring system, "POST"). Times are presented as medians with interquartile range. RESULTS: A total of 926 children were included (median age, 9.5 years [range, 0.1-18 years]; 49% female). Four hundred eighty-one patients were evaluated PRE and 445 POST. When comparing the 2 groups, there were no differences in the PRE and POST periods with regard to time from US ordered to first read (102 vs 112 minutes, P = 0.30), US ordered to disposition (215 vs 208 minutes, P = 0.40) and operating room posting (121 vs 122 minutes, P = 0.59), and overall ED stay (329 vs 333 minutes, P = 0.39). CONCLUSIONS: The development of a radiographic appendicitis score, although allowing for a standardized reporting method, did not significantly alter the ED process flow for evaluation of appendicitis. This reflects the complexities in ED throughput and reveals the need for additional factors to change to improve patient flow.

Impact of the surgeon of the week system in an academic pediatric surgery practice.

BACKGROUND: A pilot rounding surgeon of the week (SOW) program was implemented in our institution on July 2013 to improve patient care through focused attending rounds. The purpose of this study was to assess the impact of the SOW. METHODS: We performed a descriptive retrospective study from a single, large-volume academic center. Data were collected from July to December 2013 (post-SOW) and compared to July to December 2012 (pre-SOW). Outcomes included patient safety (safety reports) and team productivity (billing data). We also evaluated nursing satisfaction through a 10-point Likert scale survey. RESULTS: The total number of patient safety complaints decreased after the SOW (37 pre-SOW versus 27 post-SOW). Work relative value units (wRVUs) increased by 8% while nonoperative billing increased by 15%. Twenty of the daytime nursing staff completed the survey and overall satisfaction with the SOW was 8.3. Twelve were employed prior to the SOW and, when analyzed independently, the proportion of employees satisfied with nursing to physician communication was higher after the SOW (55% pre-SOW vs. 83% post-SOW, p=0.13) as was perception of parental satisfaction (33% vs. 75%, p=0.04). CONCLUSIONS: The SOW program appears to improve patient safety as evidenced by a decrease in patient safety events. Additionally, the SOW program led to higher ancillary staffing satisfaction and perceived parental satisfaction without decreasing revenue. This study suggests that the SOW may be a beneficial program that could be considered at other large-volume institutions.

Ovarian lesion volumes as a screening tool for malignancy in adolescent ovarian tumors.

BACKGROUND: Preoperative evaluation of ovarian tumors for malignancy is essential to determine appropriate treatment. Our study assessed the utility of ovarian lesion volumes to screen for malignancy in adolescent ovarian lesions. METHODS: A retrospective chart review of adolescent patients (8-18years) who underwent an ovarian operation from January 2008 to December 2012. Data included demographics, ultrasonographic volume measurements, and tumor markers. Volumes were calculated using the prolate ellipsoid formula. Data are presented as medians. RESULTS: One hundred twenty-three females were included at a median age of 13.7years (IQR 12.5-16). Eight patients had malignancies. The median benign lesion volume was significantly smaller than malignant [152cm3 (IQR 57-592)vs. 1548cm(3) (IQR 627-2105), p=0.001]. A receiver operating characteristic (ROC) curve analysis (AUC 0.84, p=0.001) revealed a threshold ovarian lesion volume of <184cm(3) (100% sensitivity, 54% specificity, NPV 100%, PPV 13%) to accurately screen for malignancy. This held true when applied to our dataset as none of the 62 girls with volumes <184cm(3) had malignant pathology. CONCLUSIONS: This is the first documented use of ovarian lesion volumes as a screening tool in adolescent ovarian lesions. This should be used in conjunction with tumor markers and other imaging features to better screen for malignancy.

Development and validation of an ultrasound scoring system for children with suspected acute appendicitis.

BACKGROUND: To facilitate consistent, reliable communication among providers, we developed a scoring system (Appy-Score) for reporting limited right lower quadrant ultrasound (US) exams performed for suspected pediatric appendicitis. OBJECTIVE: The purpose of this study was to evaluate implementation of this scoring system and its ability to risk-stratify children with suspected appendicitis. MATERIALS AND METHODS: In this HIPAA compliant, Institutional Review Board-approved study, the Appy-Score was applied retrospectively to all limited abdominal US exams ordered for suspected pediatric appendicitis through our emergency department during a 5-month pre-implementation period (Jan 1, 2013, to May 31, 2013), and Appy-Score use was tracked prospectively post-implementation (July 1, 2013, to Sept. 30,2013). Appy-Score strata were: 1 = normal completely visualized appendix; 2 = normal partially visualized appendix; 3 = non-visualized appendix, 4 = equivocal, 5a = non-perforated appendicitis and 5b = perforated appendicitis. Appy-Score use, frequency of appendicitis by Appy-Score stratum, and diagnostic performance measures of US exams were computed using operative and clinical finding as reference standards. Secondary outcome measures included rates of CT imaging following US exams and negative appendectomy rates. RESULTS: We identified 1,235 patients in the pre-implementation and 686 patients in the post-implementation groups. Appy-Score use increased from 24% (37/155) in July to 89% (226/254) in September (P < 0.001). Appendicitis frequency by Appy-Score stratum post-implementation was: 1 = 0.5%, 2 = 0%, 3 = 9.5%, 4 = 44%, 5a = 92.3%, and 5b = 100%. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 96.3% (287/298), 93.9% (880/937), 83.4% (287/344), and 98.8% (880/891) pre-implementation and 93.0% (200/215), 92.6% (436/471), 85.1% (200/235), and 96.7% (436/451) post-implementation - only NPV was statistically different (P = 0.012). CT imaging after US decreased by 31% between pre- and post-implementation, 8.6% (106/1235) vs. 6.0% (41/686); P = 0.048). Negative appendectomy rates did not change (4.4% vs. 4.1%, P = 0.8). CONCLUSION: A scoring system and structured template for reporting US exam results for suspected pediatric appendicitis was successfully adopted by a pediatric radiology department at a large tertiary children's hospital and stratifies risk for children based on their likelihood of appendicitis.