Improving quality and efficiency of care for advanced appendicitis in children

• Published in: ANZ journal of surgery Vol. 91; no. 7-8; pp. 1497 - 1503
• Main Authors: Do‐Wyeld, Montgommery, Cundy, Thomas P., Court‐Kowalski, Stefan, Dandie, Lynda, Cooper, Celia, Burgoyne, Laura, Cooksey, Rebecca, Khurana, Sanjeev
• Format: Journal Article
• Language: English
• Published: Melbourne John Wiley & Sons Australia, Ltd 01-07-2021; Blackwell Publishing Ltd
• Subjects: Analgesia; Antibiotics; Antiemetics; appendectomy; Appendicitis; Children; clinical protocol; Criteria; Enterprise resource planning; Heterogeneity; Intravenous administration; Length of stay; Morphine; paediatrics; Pain perception; perioperative period; Recovery; Recovery (Medical); Variation; paediatrics; appendicitis; perioperative period; appendectomy; clinical protocol
• ISSN: 1445-1433; 1445-2197
• DOI: 10.1111/ans.16929

Background
Complicated appendicitis encompasses a spectrum of severity with heterogeneity in definition and substantial variation in care. Enhanced recovery after surgery or ‘fast‐track’ protocols aim to reduce practice variation by standardizing care. These initiatives may improve quality and efficiency of care, preserve resources and expedite discharge. This study aims to evaluate the impact of a standardized Enhanced Recovery Pathway (ERP) on the post‐operative recovery of children with a subset of complicated appendicitis termed ‘advanced’ appendicitis.
Methods
We defined advanced appendicitis as gangrenous or suppurative appendicitis without perforation, contained iatrogenic perforation, or localized purulent fluid. Children with operative findings reflecting these criteria were enrolled in the ERP protocol. Key protocol components include early upgrade of diet, avoidance of intravenous analgesia, abridged intravenous antibiotics, early ambulation and standardized discharge criteria. The study period was May 2018 to June 2019. A historical cohort was used as the comparator group.
Results
Outcomes for 44 children treated under the ERP were compared to 44 historical controls. There was a 20% reduction in median post‐operative length of stay (1.80 vs. 2.24 days, p = 0.02). Intravenous analgesia was received by fewer patients (6.8% vs. 36.4%, p = 0.01) with significant reduction in antiemetic requirement (p = 0.03). No significant difference in 30‐day complication rates was observed.
Conclusion
Reduced post‐operative length of stay and reduction in practice variation were achieved after implementation of a ‘fast‐track’ protocol for children with advanced appendicitis. Additional benefits of this protocol include reduced provision of intravenous morphine analgesia, decreased resource use and cost savings.
Outcomes for 44 children receiving protocolized post‐operative care for advanced appendicitis were compared to 44 controls. An enhanced recovery protocol (ERP) led to 20% reduction in median post‐operative length of stay, reduced intravenous analgesia and antiemetic requirement with reduced cost‐of‐care and no increase in complications. Reduction in the variation of care was also observed under the ERP.