Children's Dr. Robert Russell Creates Appendicitis Algorithm

Robert Russell, MD consults with a young patient.

When a parent brings a child into the ER with a fever and stomachache, one possible diagnosis is appendicitis. Given the possible need for emergency surgery, it is important to quickly get an accurate diagnosis.

With this in mind, Robert Russell, MD, a pediatric general surgeon for Children's Hospital of Alabama, has created an algorithm with a Pediatric Appendicitis Score to either confirm or eliminate the appendix as the source of the problem.

Both UAB and Children's are taking part in the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP), which aims to improve the quality of surgical care.

"We're collecting data around pediatric surgical patients in all specialties, but the pilot focuses on appendicitis which is something we see commonly," Russell said.

Children's is one of only 53 pediatric hospitals nationwide to join NSQIP, which tracks data on surgical patients to analyze more than 100 clinical variables that relate to outcomes. Using that analysis, the participating hospital is able to determine where improvements are needed and develop processes to implement those improvements.

One of the pilot program's queries asks about the types of radiologic imaging hospitals are using, particularly in diagnostics for appendicitis.

"The trend has been to use ultrasound more for diagnosis of appendicitis, along with lab results and physical exams," Russell said. "The ultrasounds involve non-ionizing radiation. CT scans contain some radiation."

In examining data at Children's, Russell noted that CT scans were used more frequently than ultrasounds.

"That was not in line with other pediatric facilities around the country," Russell said. "We decided to emphasize use of an algorithm to try to utilize physical exams and labs in conjunction with ultrasound to cut down on the rate of using CT scans to diagnose appendicitis."

The Pediatric Appendicitis Score (PAS) algorithm sets up a formula and flow chart to follow depending on each outcome stemming from the time of admission with suspected appendicitis. Nausea and vomiting receive a score of 1, while migration of the pain to the right lower quadrant of the abdomen also receives a 1. Tenderness in that area of the anatomy earns a 2. Other factors include anorexia, fever, effects of coughing on the pain, leukocytosis and neutrophilia.

A score of 1-3 on the PAS scale is determined to be a "low suspicion" of appendicitis with no imaging needed. A Score of 4-7 indicates that appendicitis is "equivocal" and calls for ultrasound in facilities where available or a surgery consult when it is not. Scoring 8-10 falls under the heading of "high suspicion" and leads to immediate surgery consult with the decision on imaging determined by a surgical consultant - an ultrasound or a CT with IV contrast.

It's an easy-to-follow, color-coded algorithm that gives each diagnostician a straightforward approach to determine the source of the patient's complaint.

"When we see a patient, we score what type of symptom values and laboratory values they have," Russell said. "Then we ask how likely it is that this child will have appendicitis. If the score is low, they won't fall into the algorithm. If it's high, they will."

If a child falls in the spectrum of possible appendicitis, the next step on the algorithm is getting the ultrasound first. If the test is non-diagnostic, then a CT scan may be required. Factors that prohibit an effective ultrasound can vary from the experience of the radiologists - with children or with utilizing ultrasound specifically for appendicitis - as well as the patient's body habitus. Reading an ultrasound through excessive tissues makes it more difficult to detect an inflamed appendix.

"We cut out the CT scan as a first line of imaging," Russell said. "In the literature, as high as 30 percent of ultrasounds can be non-diagnostic, but if the radiologist looks at the ultrasound and says the appendix is not visualized, that affects the outcome. We also have a standardized ultrasound report. If there is dilated intestine around where the area might be, or if there is an infection, we take that into account."

"We created this in February, did a pilot introduction in March and started in April," Russell said. "We will look at data for the eight months before instituting the program and eight months after. The last data we look at will be in November this year, and we will ask if we made improvements."

While the results are not yet in, the costs associated with diagnosis are expected to be less due to fewer CT scans. That, combined with the more limited exposure to ionizing radiation, is the impetus.

"We've also standardized ultrasound," Russell said. "A radiologist can identify the appendix, but also can look at secondary factors. We ask how likely a child is to have appendicitis looking at everything: exam, labs, ultrasound. Then we can make an informed decision."


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