DOI: 10.1542/peds.2013-2208; originally published online December 30, 2013;Pediatrics

Ashley Saucier, Eunice Y. Huang, Chetachi A. Emeremni and Jay PershadProspective Evaluation of a Clinical Pathway for Suspected Appendicitis

  

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located on the World Wide Web at: The online version of this article, along with updated information and services, is

 

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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Prospective Evaluation of a Clinical Pathway forSuspected Appendicitis

WHAT’S KNOWN ON THIS SUBJECT: Although appendicitis is themost common surgical cause of abdominal pain in pediatrics, itsdiagnosis remains elusive. When evaluated independently, clinicalscoring systems and ultrasonography have been shown to havelow to moderate sensitivity in the diagnosis of appendicitis.

WHAT THIS STUDY ADDS: Our study evaluated the accuracy ofa clinical practice guideline combining the Samuel’s pediatricappendicitis score and selective ultrasonography as the primaryimaging modality for children with suspected appendicitis. Ourclinical pathway demonstrated high sensitivity and specificity.

abstractOBJECTIVE: To evaluate the diagnostic accuracy of a clinical pathwayfor suspected appendicitis combining the Samuel’s pediatric appen-dicitis score (PAS) and selective use of ultrasonography (US) as theprimary imaging modality.

METHODS: Prospective, observational cohort study conducted at anurban, academic pediatric emergency department. After initial evalu-ation, patients were determined to be at low (PAS 1–3), intermediate(PAS 4–7), or high (PAS 8–10) risk for appendicitis. Low-risk patientswere discharged with telephone follow-up. High-risk patients receivedimmediate surgical consultation. Patients at intermediate risk forappendicitis underwent US.

RESULTS: Of the 196 patients enrolled, 65 (33.2%) had appendicitis. Aninitial PAS of 1–3 was noted in 44 (22.4%), 4–7 in 119 (60.7%), and 8–10 in 33 (16.9%) patients. Ultrasonography was performed in 128(65.3%) patients, and 48 (37.5%) were positive. An abdominal com-puted tomography scan was requested by the surgical consultants in13 (6.6%) patients. The negative appendectomy rate was 3 of 68(4.4%). Follow-up was established on 190 of 196 (96.9%) patients.Overall diagnostic accuracy of the pathway was 94% (95%confidence interval [CI] 91%–97%) with a sensitivity of 92.3% (95%CI 83.0%–97.5%), specificity of 94.7% (95% CI 89.3%–97.8%), likelihoodratio (+) 17.3 (95% CI 8.4–35.6) and likelihood ratio (2) 0.08 (95% CI0.04–0.19).

CONCLUSIONS: Our protocol demonstrates high sensitivity and spec-ificity for diagnosis of appendicitis in children. Institutions should con-sider investing in resources that increase the availability of expertisein pediatric US. Standardization of care may decrease radiation expo-sure associated with use of computed tomography scans. Pediatrics2014;133:e88–e95

AUTHORS: Ashley Saucier, MD,a,b,d Eunice Y. Huang, MD,b,c,d

Chetachi A. Emeremni, PhD,b,d and Jay Pershad, MDa,b,d

aDivision of Emergency Services, Departments of bPediatrics, andcSurgery, University of Tennessee Health Science Center,Memphis, Tennessee; and dChildren’s Foundation ResearchInstitute at Le Bonheur Children’s Hospital, Memphis, Tennessee

KEY WORDSappendicitis, clinical pathway, Pediatric Appendicitis Score,ultrasonography

ABBREVIATIONSCI—confidence intervalCT—computed tomographyED—emergency departmentIQR—interquartile rangePAS—pediatric appendicitis scoreUS—ultrasonography

Dr Pershad conceptualized and designed the study and draftedthe initial manuscript; Dr Saucier collected all data and helpeddraft the manuscript; Dr Emeremni provided statistical advice,analyzed the data, and critically reviewed the manuscript; DrHuang contributed to research design, data analysis, andmanuscript revisions; all authors approved the final manuscriptas submitted.

www.pediatrics.org/cgi/doi/10.1542/peds.2013-2208

doi:10.1542/peds.2013-2208

Accepted for publication Oct 24, 2013

Address correspondence to Jay Pershad, MD, Division ofEmergency Medicine, Department of Pediatrics, Le BonheurChildren’s Hospital, Memphis, TN 38103. E-mail: jay.pershad@mlh.org

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2014 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicatedthey have no potential conflicts of interest to disclose.

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Appendicitis is the most common sur-gical cause of atraumatic abdominalpain among children presenting to theemergency department (ED).1,2 Diag-nosis of appendicitis by clinical exam-ination alone remains elusive, andrates of perforated appendicitis in thepediatric population are high becauseits presentation overlaps with manyother childhood illnesses that causeabdominal pain.3,4

Early diagnosis of appendicitis is im-portant because of the increasedmorbidity, mortality, and costs associ-ated with perforated appendicitis.5,6

Although there is no diagnostic goldstandard for appendicitis, 2 gradingscores, the Alvarado and Samuel’s pe-diatric appendicitis score (PAS), havebeen developed to aid accurate di-agnosis of appendicitis.1,7–9

The PAS is a score that was firstreported by Samuel in Journal of Pe-diatric Surgery in 2002.7 Samuel’sscore and PAS are used interchange-ably (Table 1). A score of 1 to 3 isconsidered negative for appendicitis,whereas scores from 8 to 10 are con-sidered positive. In his derivation study,Samuel did not precisely define per-centage of neutrophilia or degree ofelevation of temperature as a compo-nent of the PAS. We elected to usea differential count of 75% neutrophilsor higher and a temperature of$38°Cas an objective cutoff point. This issimilar to other studies that validatedthe PAS.1,8,10,11 Both of these scoring

systems are composed of 8 compo-nents, with a total score of 10.

The Alvarado score was initially de-veloped in 1986 for use in the adultpopulation. It has been validated ina subsequent study that included pe-diatric patients14 (Table 2). Alvaradoscores of 1 to 4 are negative for ap-pendicitis, whereas scores from 9 to 10are considered diagnostic of appendi-citis. Similar to the PAS, it also has 8components with differences in defini-tion of fever and descriptors for peri-toneal signs on clinical examination.

The PAS was first published and ori-ented exclusively to the pediatric pop-ulation. It has since been used in otherstudies that also demonstrated thelimitations of exclusively using the PASto identify patients with acute appen-dicitis.8,10,11

We are not aware of any previousprospective studies that have useda clinical score and ultrasonography(US) for risk stratification of patientswith abdominal pain with suspicion forappendicitis presenting to the ED.

The goal of the current study is toevaluate the diagnostic accuracy ofa clinical pathway for suspected ap-pendicitis using Samuel’s PAS and USas the primary imaging modality. Ourhypothesis is that the sensitivity andspecificity of the PAS with selective useof US would be superior to PAS alone.

METHODS

This was a prospective, observationalstudy conducted at our urban, tertiary

level, free-standing, pediatricEDwithanannual census of 84 000 patient visits.Appropriate institutional review boardapproval with waiver of informed con-sent for completion of data forms andmedical record review was obtainedbefore the study initiation. We enrolleda convenience sample of patients be-tween the ages of 3 and 17 years, pre-senting with abdominal pain andsuspicion of appendicitis based oninitial evaluation by the ED physician.We excluded patients with known in-flammatory bowel disease, sickle celldisease, chronic steroids, or chronicimmunosuppression. We also excludedpatients who had a computed tomog-raphy (CT) scan of the abdomen beforearrival at our institution and those whoreceived antibiotics before arrival.

Our department’s usual practice forchildren presenting with suspectedappendicitis is to administer a bolus of20 mL/kg of isotonic intravenous fluidsin conjunction with basic laboratorytesting and period of observation in theED. This includes a complete bloodcount, urinalysis, and metabolic panel.Also, based on the treating physician’sclinical judgment, they may receivea chest radiograph and/or a plain ab-dominal radiograph to exclude alter-native diagnoses. Although our clinicalpathway did not require a specific du-ration of observation, typically thisperiod entailed time until completionof initial bolus and receipt of results oflaboratory tests (Fig 1).

The PAS was assigned by the treatingphysician in the ED when results ofcomplete blood count were available.

Our clinical pathway involved riskstratification based on the PAS. Patientswith PAS of 1 to 3 (low probability ofappendicitis) were either dischargedfrom the hospital and received a follow-up phone call within 24 hours or, ifwarranted, admitted to the generalpediatrics service with an alternate

TABLE 1 Pediatric Appendicitis Score

Sign/Symptom Points

Cough/percussion/heel tappingtenderness at RLQ

2

Anorexia 1Low-grade fever $38.0°C 1Nausea/emesis 1RLQ tenderness on light palpation 2Leucocytosis (. 10 000/mm3) 1Left shift (.75% neutrophilia) 1Migration of pain to RLQ 1

RLQ, right lower quadrant.

TABLE 2 Alvarado Score

Sign/Symptom Points

Migration of pain 1Anorexia 1Nausea/vomiting 1Right lower quadrant tenderness 2Rebound pain 1Increase in temperature (.37.3°C) 1Leucocytosis (.10 000/mL) 2Polymorphonuclear neutrophilia (.75%) 1

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diagnosis and without surgical con-sultation.

Participants with a PAS of 4 to 7 (in-termediate probability of appendicitis)had a focused right lower quadrant USperformedafteraperiodof observationand parenteral hydration in the ED. Theduration of observation and decision toobtain the US was left to the discretionof the treating clinician.

If the US was negative and there re-mained no continued suspicion forappendicitis, the patient was dischargefrom the ED with a phone follow-up oradmitted to the general pediatric ser-vice with an alternate diagnosis andwithout surgical consultation. If US waspositive or there remained continuedsuspicion of appendicitis, surgical con-sultation was sought. If warranted, a CTscanwas performed only after pediatricsurgical consultation.

The written US report from the radiol-ogist on call was used to aid medicaldecision-making. For thepurposeofourstudy, US results were dichotomized aseither positive or negative. If the ap-pendix was visualized and reported asabnormal or if the report was sug-gestive of appendicitis on the basis ofsecondary signs of inflammation in theright lower quadrant, the result wasdeemed positive. The US was consid-ered negative if the appendix was vi-sualized and normal or if the appendixwas not visualized and there were nosecondary findings to suggest appen-dicitis.

The criteria fora positive or negative USwere set a priori. Sonographic resultswere classified in a binary manner onthe basis of evidence from the recentpediatric radiology literature examin-ing methods to improve diagnosticperformance of this modality in clinical

practice.13 Specific radiologic criteriasuch as evidence of secondary signs ofappendicitis, size of appendix, andpresence of appendicolith were left tothe discretion of the radiologist per-forming the US in real time. We alsodeliberately included preliminary, notfinal, radiology reports into our studydatabase, to reflect information avail-able at the time of clinical decision-making.

For participantswith a PAS score of 8 to10 (high probability of appendicitis),pediatric surgery was consulted forfurther management.

UseofCTscans toassist in thediagnosisof appendicitis was not a specific com-ponent of our clinical pathway guideline.Therefore, they were obtained only ifrequested by the consulting pediatricsurgeon. The most common indicationsfora CTwere either toprovideadditionalinformation when the diagnosis was un-clear or to assess for an intra-abdominalabscess, which may alter managementapproach.

Before enrollment of participants, theclinical pathway was presented at ourphysician staff meeting and monthlythereafter for the duration of the study.A copy of the algorithm was postedin the work area, and an electroniccopy was shared with all ED physi-cians. The PAS and its componentswere built into our electronic medicalrecord. The physicians could selectthe subcomponents, and a cumulativescore would auto-populate in the pa-tient’s record.

All the participating clinicians wereadvised to notify the principle inves-tigator (AS) via e-mail or text within24 hours of enrolling a patient in thepathway. In addition, the informationsystems analyst assigned to the EDprovided the investigator (AS) witha weekly list of all patients who hada PAS recorded in their charts. Afterdeidentification, subject data were

FIGURE 1Flow diagram of clinical pathway for management of suspected appendicitis. BMP, basic metabolicprofile; CBC, complete blood count; CxR, chest radiograph; IVF, intravenous fluids; KUB, Kidney UreterBladder; USG, ultrasonography.

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entered into a secure electronic spread-sheet for analysis.

Final follow-up was obtained through 3mechanisms: operative and pathologicfinding of appendicitis after surgicalprocedure, medical record review ofhospital stay of patients admitted to thehospital for observation, and telephonefollow-up at 24 hours after discharge ofpatients discharged from the ED. Thegold standard used to confirm thepresence of appendicitis was a pathol-ogy report consistent with appendicealinflammation. Perforation was basedon gross operative finding of a hole inthe appendix as determined by theoperating surgeon.

We used the following definitions toassess the diagnostic accuracy of ourclinical pathway: patients were consid-ered “test-positive,” that is, high suspi-cion of appendicitis, if they had a PAS.7 or a PAS of 4 to 7 and a US that waspositive for appendicitis. Patients wereconsidered “test-negative” if they hada PAS ,4 or a PAS of 4 to 7 and a neg-ative US. Patients with a score of 4 to 7who did not receive US because theyimproved after hydration or were notedto have an alternative diagnosis werealso considered test-negative.

Data Analysis

The diagnostic accuracy of the clinicalpathway was assessed by calculatingits sensitivity, specificity and positivelikelihood ratios along with 95% confi-dence intervals (CIs) using standardformulae. To compare the accuracy ofthe clinical pathway guideline, which isa dichotomous variable, to the PAS,which is a continuousvariable,wefittedthe receiver operator characteristiccurve using the PAS score alone to oursample to obtain an optimal cutoffpoint. Sensitivity and specificity alongwith95%CIswerecalculated for thePASscorebasedon thisoptimal cutoff point.We then compared the diagnostic ac-curacy of the clinical pathway with that

of the PAS score alone in our sample. Allanalyses were carried out using thesoftware packages SAS version 9.3 (SASInstitute Inc, Cary, NC).

RESULTS

Two hundred sixteen patients wererecruited over an 11-month period(October 2011–August 2012). We ex-cluded 20 patients from analysis, 2 forincorrect enrollment because theyhad previous antibiotic use and 18 forprotocol deviation (ie, imaging studieswere obtained with a score,4 or.7,or surgical consultation was soughtbefore advanced imaging for patientswith a score of 4–7).

An initial PAS of 1 to 3 was noted in 44(22.4%), 4 to 7 in 119 (60.7%), and 8 to 10in 33 (16.9%) subjects. Of the 65patientsdiagnosed with appendicitis, 0.0% hada low risk score, 37 (56.9%, 95% CI44.4%–69.2%) had an intermediatescore, and 28 (43.1%, 95% CI 30.9%–56.0%) had a high score. Of the patientswith a low risk score, 0 of 44 (0.0%) hadappendicitis. Of the patients with anintermediate score, 37 of 119 (31.1%)had appendicitis. Of the patients witha high-risk score, 28 of 33 (84.8%) hadappendicitis. Perforated appendicitiswas noted in 18 of 65 (15.4%) patients(Fig 2).

Ultrasonography was performed in 128(65.3%) patients, of which 48 (37.5%)were positive for appendicitis. An ab-dominal CT scan was requested by thesurgical consultants in 13 (6.6%)patients. Of the 68 patients who un-derwent an operation, 29 (42.6%) didnot receive imaging. Ninety-nine of 196patients were admitted for observationor surgery (50.5%, 95% CI 43.3%–57.7%). Telephone follow-up was es-tablished in 91 of 97 (93.8%) of thepatients whowere discharged from theED without diagnosis of appendicitis,resulting in a total follow-up rate of96.9% (190 of 196 patients who com-pleted the pathway).

Three of the 68 patientswho underwentappendectomy had a normal appendix(4.4% 95% CI 0.09%–12.4%). Two ofthese patients were admitted with anintermediate probability PAS and neg-ative US. The other patient had a low-probability PAS, was discharged, andcalled back for continued severe ab-dominal pain. She was eventually di-agnosed with omental infarction. Oneparticipant with an intermediate pro-bability PAS score and negative US wasdischarged from the ED after she wasdeemed to have clinically improved withintravenous hydration. At the follow-upphone call the next day, she was advisedto return to the ED for reevaluation andwas eventually diagnosed with a rup-tured appendix.

The optimal cutoff point for the PASalone inourstudywasascertainedtobe6. At this cutpoint, thePASscoreshowedmodest performance characteristics,with a sensitivity of 81.5% (95% CI70.0%–90.1%) and a specificity of 71.0%(95% CI 62.4%–78.6%). The receiveroperator characteristic curve with PASalone at an optimal cutoff score of 6 isshown in Fig 3. The area under thecurve is 0.8610 (0.8108–0.9111) Incontrast, our clinical pathway hada sensitivity of 92.3% (95% CI 83.0%–97.5%), specificity of 94.7% (95% CI89.3%–97.8%), likelihood ratio (+) 17.3(95% CI 8.4–35.6) and likelihood ratios(2) 0.08 (95% CI 0.04–0.19; Table 3).

Median time to surgical consultationwas 209.5 (interquartile range [IQR]163.5–310.5) minutes from arrival attriage and 127.5 (IQR 79.0–182.5)minutes from initial evaluation by anED physician. Median Ed length of staywas 374 minutes (IQR 290.0–475.5). TheCT use rate was 6.6% (13 of 196).

A summary of patient characteristics ofthe patients enrolled and those whowere excluded is shown in Table 4. Eightpatients who were noncompliant werediagnosed with appendicitis.

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DISCUSSION

We prospectively evaluated a collabo-rative clinical pathway guideline, com-bining the PAS with selective use of USas the primary diagnostic imagingmodality for patients with suspectedappendicitis. Our results demonstratethat the diagnostic accuracy of ourclinical pathway to risk-stratify patientswith suspected appendicitis was su-perior to using the PAS alone, withsignificantly improved sensitivity andspecificity. The likelihood ratio for a test

enables a clinician to update his or herestimate of the probability of disease.Using our clinical pathway guideline,the likelihood of a patient with appen-dicitis having a positive “test” is 17.3times greater than for a child withoutappendicitis. Conversely, the negativelikelihood ratio of 0.08 tells us howmuch less likely it is that a child withappendicitis will test negative comparedwith someone without appendicitis.

Several studies have prospectively eval-uated the Samuels and Alvarado scores

in pediatric patients.1,9,10,12,14,15 Neitherscore was sufficient as a stand-alone toestablish diagnosis of appendicitis. Thisdilemma has led to the recent trend ofrelying on diagnostic imaging in theevaluation of suspected pediatric ap-pendicitis.16–18 CT scans, the imagingmodality of choice, have improved di-agnosis of appendicitis.19,20 As a result,use of CT scans for diagnosis of pedi-atric appendicitis has increased.20,21–25

A 10-year review of the National Am-bulatory Medical Care Survey data inpatients aged ,19 years presentingto a pediatric ED noted a rise in CT usefrom 0.9% in 1998% to 15.4% in 2008.23

Furthermore, data from pediatricsurgical services at 2 centers suggestthat initial evaluation for suspectedappendicitis at a community hospitalis associated with a higher preop-erative use of CT scans compared witha children’s hospital (50%–75.2% vs26.3%).21,22,24

Recently, because of heightened con-cerns surrounding risks of radiationexposure in children, US has emergedas an increasingly popular first-linediagnostic imaging modality, particu-larly at tertiary-level pediatric facilitieswhere pediatric ultrasonographers arereadily available.19,26,27 However, visu-alization of the appendix by US can bevariable, potentially leading to manyinconclusive studies.19,27,28 Neverthe-less, despite judicious use of diag-nostic imaging and the development ofprotocols for diagnosis of appendicitis,negative appendectomy rates in chil-dren remain high, ranging from 4.4% to13%.4,21,29,30

Few studies have systematically exam-ined the performance characteristicsof using a clinical pathway combiningan objective appendicitis grading scorewith selective diagnostic imaging forchildrenwithsuspectedappendicitis.31,32

Our study has shown that use of a clini-cal pathway that combines a clinicalgrading score and selective use of US can

FIGURE 2Flow diagram of study subjects. Gray boxes represent test positive patients. ABP, abdominal pain; Appy,appendicitis; AGE, acute gastroenteritis; Dx, final diagnosis; FU, follow-up; MA, mesenteric adenitis; OR,operating room; OVC, ovarian cyst; PID, pelvic inflammatory disease; PS, Pediatric Service; SS, SurgeryService; UTI, Urinary tract infection.

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improve accuracy of risk stratificationof suspected appendicitis while in the ED.Furthermore, this was accomplishedwhile limiting CT scan use to 6.6% of ourpatients and maintaining a low rate of

missed appendicitis and negative ap-pendectomies.

In a recent study across Canadian pe-diatric EDs assessing site variations inflow metrics for children with sus-

pected appendicitis, the average EDlength of stay was 438 minutes, witha range of 321 to 638 minutes betweentheir lowest and highest sites.33 Wewere able to keep the ED length of stayfor patients in our study within thepublished length-of-stay metrics, de-spite having to bring in US technolo-gists from home for imaging requeststhat occurred after regular workinghours. Of note, 43% of the patients inour study population arrived in triageafter 5 PM.

There are several limitations to ourstudy. Without a comparative controlgroup, we cannot objectively assess theimpact of our clinical pathway on CTuseand length of stay in the ED for patientswith suspected appendicitis. Becausewe did not track patients with sus-pected appendicitis who were not en-rolled during this period, it is possiblethat some patients with suspected ap-pendicitis were evaluated in our ED andnot enrolled in our study. Recent datasuggest that the diagnostic value ofa clinical score or laboratory test suchas a complete blood count may vary atdifferent time points of right lowerquadrant pain. We did not specificallyevaluate thedurationof abdominalpainrelative to the timing of imaging orlaboratory tests.34–36

It could be argued that we were as-sessing the impact of a suggestedevaluation based simply on the PAS andclinical judgment rather than studyingthe impact of a pathway. Although clin-ical judgment was ineluctably linked to2 subcomponents of the PAS (namely,assessment of right lower quadranttenderness and presence or absence ofperitoneal signs) the role of clinicaljudgmentwasminimized by adopting anobjective score to risk-stratify patients,along with strict criteria for advancedimaging and surgical consultation. Thisdecreased practice variation in theworkupof patientswith suspectedacuteappendicitis.

FIGURE 3Receiver Operator Characteristic Curve of PAS

TABLE 3 “Two-by-Two” Diagram Showing Performance Characteristics of Clinical Pathway

Appendicitis (Disease +) n (%) Not Appendicitis (Disease –) n (%)

Test (+) 60 (92.3) 7 (5.3)PAS .7PAS 4–7/US (+)Test (–) 5 (7.7) 124 (94.7)PAS ,4PAS 4–7/US (–)PAS 4–7/No US

TABLE 4 Comparison of Patients Excluded From Analysis

Patient Characteristic Excluded Group (n =20) Study Group (n = 196)

Age, mean (SD) 11.3 y (3.73) 10.7 y (3.64)Male, n (%) 6 (30%) 102 (52.0%)African American 9 (45%) 73 (37.2%)Appendicitis, n (%) 8 (40%) 65 (33.2%)Admission rate, n (%) 13 (65%) 99 (50.5%)US performed, n (%) 12 (60%) 128 (65.3%)CT performed, n (%) 5 (25%) 13 (6.6%)Distribution of PAS, n (%)1–3 8 (40%) 44 (22.5)4–7 6 (30%) 119 (60.7%)8–10 6 (30%) 33 (16.8%)

Time from MD evaluation to surgicalconsultation, median (Q1–Q3)

124.0 min (67.0–204.0) 127.5 min (79.0–182.5)

ED length of stay, median (Q1–Q3) 439.0 min (316.0–527.5) 374 min (290.0–475.50)

Q, quartile.

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Our results cannot be generalized to anonacademic and/or general ED, whichmay lack the around-the-clock avail-ability of pediatric ultrasonographers andsurgeons. We were unable to contact 6patients at follow-up after being dis-charged from the ED.

The strength of our study was that weused a strict criterion standard andstaged imaging protocol for evaluationof patientswith suspectedappendicitis.By using an objective, validated clini-cal scoring system, we may decrease

variability in patient assessment amongdiffering clinicians.

CONCLUSIONS

Our study suggests that a clinicalpathway combining PAS and US for usein children with suspected appendicitispresenting to our pediatric ED demon-strateshighersensitivity andspecificitythan using the PAS alone. Institutionsshould consider investing in resourcesto improve availability and expertise inpediatric abdominal US, such that ac-

curacy of diagnosis of appendicitis andminimization of radiation exposure canboth be maintained in the pediatricpopulation.

ACKNOWLEDGMENTSWe thank Sandy Grimes, RN, for herassistance in working with our institu-tional reviewboardandall thephysiciansin the ED, Division of Surgery, and De-partment of Radiology at Le BonheurChildren’s Hospital for their support,without which the study would not havebeen feasible.

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PEDIATRICS Volume 133, Number 1, January 2014 e95 by guest on April 11, 2014pediatrics.aappublications.orgDownloaded from

DOI: 10.1542/peds.2013-2208; originally published online December 30, 2013;Pediatrics

Ashley Saucier, Eunice Y. Huang, Chetachi A. Emeremni and Jay PershadProspective Evaluation of a Clinical Pathway for Suspected Appendicitis

  

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