BACKGROUND
Appendicitis is the most common abdominal emergency in adults and surgical emergency in children aged 5 years or older worldwide. The diagnosis of acute appendicitis is primarily clinical but the use of imaging and laboratory studies can greatly aid practitioners in making a more expeditious clinical diagnosis, preventing complications and limiting the rate of negative appendectomies [5]. The gold standard of treatment for acute appendicitis remains to be appendectomy, either open or laparoscopic procedure, with the latter becoming more common in the recent years[3]. Open pediatric appendectomy is one of the top surgical procedures performed in our institution [6].The practice of laparoscopic appendectomy in pediatric patients is still under development in our institution.
The diagnosis and management in children involve a unique set of challenges for clinicians. In order to efficiently diagnose and manage acute appendicitis (AP) in children, algorithms and clinical pathways are formulated and implemented to serve as a guide to healthcare providers.
Several algorithms have been developed to stratify patients into low, intermediate, and high-risk categories for acute appendicitis [5]. Some studies that have examined the efficiency of clinical pathways reveal that the use of laboratory tests, diagnostic delays, and even health insurance all play a part in the outcome of appendicitis management [4].
Systematic process of care is designed collaboratively based on scientific evidence and clinical standards in the form of clinical practice guidelines (CPG). The Philippine Health Insurance Corporation (PHIC) advocates the use of CPGs in the standard of patient care [7]. The development of CPGs entails extensive work which is costly and labor intensive.
Another approach in integrated health-care delivery is the use of a clinical pathway (CP). CP allows all members of the health-care team to recognize and understand the various clinical aspects of diseases or procedures throughout the patient’s stay in the hospital. CP incorporates CPGs agreed on by experts in the field of the disease. A CP integrates the local clinical practices which are patient-centered (including cultural values and patient preferences) and evidence-based. It also provides an optimal order of assessment that could be pre-determined based on the patient’s prioritized needs, reducing unnecessary costs.
In our institution, a CP was established for suspected cases of uncomplicated appendicitis. A multidisciplinary team composed of different clinical departments (Surgery, Pediatrics, Anesthesiology, Radiology), nursing service (Operating Room, Ward, Emergency Room), and ancillary staff (Pharmacy, Laboratory) convened and developed the CP for pediatric AP. The CP uses pediatric appendicitis score (PAS) for the initial clinical impression. Management will depend on the corresponding scores, with 8-10 being diagnostic of AP. A score of 5-7 will require a transabdominal ultrasound to aid in diagnosis, and a score of <4 is considered to have an alternate diagnosis. Admitted patients should be operated within six hours of diagnosis and antibiotics should be given within an hour of cutting time. Patients are discharged on the third postoperative day. All patients were scheduled for outpatient follow-up on the 7th and 30th postoperative day. The proposed clinical pathway has been approved for implementation by the Quality Assurance office of the institution. (Please see appendix A)
The WVSUMC is a tertiary government hospital with a 300-bed capacity. We cater to a wide geographic area in region VI. Our aim is to implement CPs for common diseases such as acute AP to improve quality healthcare delivery as well as standardization of the step-wise management of acute appendicitis. Our results will show the potential benefits of CP implementation by comparing its outcomes against a prepathway set of patients
STATEMENT OF THE PROBLEM
Among pediatric patients admitted at WVSUMC for uncomplicated acute appendicitis, does clinical pathway improve average length of stay, hospital cost, surgical site infection, readmission, negative appendectomy rate, antibiotic timing and time to appendectomy?
OBJECTIVES OF THE STUDY
General Objective:
To determine the difference between the outcome of management in pediatric patients with uncomplicated acute appendicitis admitted at WVSUMC before and after CP implementation.
Specific Objectives:
To compare the outcome of management in pediatric patients
diagnosed with uncomplicated acute appendicitis before and after CP implementation in terms of the following:
- Average length of hospital stay
- Hospital Cost
- Surgical site infection rate
- Readmission rate
- Negative appendectomy rate
- Antibiotic timing
- <60 minutes prior to surgery
- >60 minutes prior to surgery
- Time to appendectomy
- < 6 hours
- >6 hours
SIGNIFICANCE OF THE STUDY
This research will provide insights into the benefit of a clinical pathway in managing pediatric patients with acute appendicitis. Through this research, health care providers, especially physicians, will have improved efficiency in managing pediatric AP cases. Moreover, CPs have been used as a tool for quality improvement by hospitals. Institutions can improve policy making and provide recommendations regarding quality improvement in standards of care for patients with pediatric acute appendicitis. Lastly, other institutions, including the primary healthcare setting may apply the CP in managing pediatric AP cases.
Operational definition of terms
- Average length of hospital stay – is the number of days from admission until discharge. For patients enrolled in the pediatric uncomplicated acute appendicitis clinical pathway, the recommended length of hospital stay is up to 3rd postoperative day.
- Clinical Pathway – refers to the tool used in the management of patients with pediatric uncomplicated acute appendicitis.
- Hospital cost – equivalent to the hospital expenses paid by the patient as reflected by the hospital bill, which includes cost of procedures, laboratories, and medications during the duration of the hospitalization
- Morbidity – a complication or undesirable side effect following surgery, specifically the occurrence of surgical site infection.
- Negative appendectomy rate – stated as the absence of neutrophilic infiltration on the walls of the appendix on final histopathology report
- Pediatric patients with acute appendicitis – all patients 5-18-year-old presenting with abdominal pain with a classic history, peri-umbilical/ epigastric abdominal pain with migration to right lower quadrant and with physical examination showing localized direct tenderness or guarding at the RLQ/ hypogastrium, and/or accompanied by hopping tenderness or pain upon coughing or percussion.
- Readmission rate – readmission with an overnight stay within 30 days upon initial discharge
- Rebound tenderness - a sign of acute appendicitis wherein the patient feels pain on right lower quadrant of the abdomen when pressure of deep palpation on that area is released
- Surgical site infection - Infection occurs within 30 days after the operation and infection involves only skin and subcutaneous tissue of the incision and at least one of the following: 13
- Purulent drainage with or without laboratory confirmation, from the superficial incision
- At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat
- Time to appendectomy – the time interval from patient admission to commencement of the surgery. CP target is within six hours of admission.
- Timely administration of antibiotic to surgery- time (in minutes) interval from administration of prophylactic antibiotic to the time of surgical inicision. CP target is within an hour of surgery
- Uncomplicated appendicitis- patients with history and physical exam consistent with appendicitis, localized pain at the right lower quadrant and intraoperative finding of an inflamed or suppurative appendix.
- Variances – any event that deviates from the prescribed steps in the clinical pathway.