O3303: Continuous Quality Improvement: Implementation of a Standardized Treatment Pathway for Children with Uncomplicated Appendicitis

Background: Nearly 130,000 children are treated for appendicitis annually with significant heterogeneity in the quality of care and management strategies across providers and institutions. The ongoing adoption of non-operative treatment strategies for appendicitis has further increased this variability. Prior research has demonstrated that treatment algorithms can improve quality and reduce healthcare costs. Thus, we implemented an institutional treatment algorithm for children with appendicitis which included standardized criteria for non-operative outpatient management. This study evaluates the association of this algorithm with changes in clinical outcomes and balancing measures.

Methods: We conducted an institutional retrospective cohort study of patients aged 17 years and younger treated for appendicitis from 06/2018-09/2024. We assessed three distinct time periods including pre-algorithm implementation from 06/2018-12/2018, early-algorithm implementation from 01/2019-09/2021, and late-algorithm implementation from 10/2021-09/2024. The early-algorithm standardized eligibility for non-operative management, antibiotic therapy, and post-operative analgesia. The late-algorithm included specific clinical criteria for non-operative outpatient management. We evaluated the outcomes of length of stay, postoperative opioid administration, and opioid prescription at discharge. We evaluated the balancing measures of patient-reported pain scores, time to surgery, and readmission. Differences were evaluated with chi-squared tests and Wilcoxon rank-sum tests. Trends over time were assessed with run charts and linear regression.

Results: Of 291 children with uncomplicated appendicitis, 31 (11%) were treated pre-implementation, 160 (55%) during early-implementation, and 100 (34%) during late-implementation. Overall, 25% (n=73) underwent non-operative management including 23% (n=7) during pre-implementation, 18% (n=29) during early-implementation, and 37% (n=37) during late-implementation (p=0.003). For patients undergoing non-operative management, one of seven (14%) patients treated during pre-implementation was discharged from the emergency department versus 20 of 37 (54%) patients treated during late-implementation (p=0.009).
Median hospital length of stay decreased from 29 hours (IQR=23-40) during pre-implementation to 24 hours (IQR=15-35) during late implementation (p < 0.001). The proportion of patients receiving any postoperative opioids decreased from 32% (n=10) during pre-implementation to 6% (n=6) during late-implementation (p < 0.001; Figure). Overall, 7% (n=20) received discharge opioids with no change during the study period (p=0.40). There was no significant change in any balancing measure including length of stay prior to operation (p=0.52); patient-reported pain scores on postoperative day 0 (p=0.67) or postoperative day 1 (p=0.33); or frequency of readmission (p=0.32; Table).

Conclusion: Implementation of a treatment algorithm for pediatric appendicitis was associated with decreased hospital length of stay and opioid exposures. These efforts did not adversely affect patient-reported pain scores, time to operation, nor readmission frequency. Notably, we identified marked improvements in hospital length of stay during late-implementation, perhaps reflecting a shift toward non-operative outpatient management of appendicitis. Out future work will seek to identify factors that may further enhance implementation of this algorithm as well as determine the generalizability of these findings in diverse clinical settings.