Implementing Pediatric Appendicitis Pathways Across Multiple Hospitals: A Quality Improvement Project

INTRODUCTION: Standardized care pathways for appendicitis are safe and effective ways to minimize practice variation and optimize resource allocation. This project aims to improve appendectomy outcomes through the implementation of an enterprise-wide pathway for appendicitis across a multi-hospital children's healthcare system (Nemours Children's Hospital- Delaware (NCH-DE) and Nemours Children's Hospital-Florida (NCH-FL).

METHODS: A multidisciplinary team was convened to create a standard approach to care for patients with appendicitis across the Nemours enterprise. The pathway included standardized antibiotic selection of ceftriaxone and metronidazole, discharge criteria, and a multimodal opioid-sparing analgesic regimen. We evaluated post-operative length of stay (LOS), narcotic prescription at or after discharge, return to emergency department (ED) visits and readmissions 1 year pre- and post-pathway implementation. Special cause variation (SCV) was defined as having eight points above or below center line according to standard criteria.

RESULTS: A total of 560 patients pre-implementation and 781 post-implementation were analyzed. LOS at NCH-FL decreased for both uncomplicated (mean 0.19 to 0.12 days) and complicated appendicitis (mean 3.87 days to 3.28 days), both meeting criteria for SCV. NCH-DE LOS remained stable for both uncomplicated and complicated appendicitis. Narcotic prescriptions at NCH-FL decreased from 35.0% to 0% after pathway implementation. NCH-DE baseline narcotic prescription rate was 0.2% and it remained stable at 0% post-implementation. There were no increases in returns to system.

CONCLUSION: An appendicitis pathway can successfully be scaled and implemented across a children's hospital system, decreasing LOS and narcotic prescriptions at discharge without increasing returns to the system.