An Evidence-Based Care Protocol Decreases Length of Stay and Cost in Pediatric Appendicitis

Vei Shaun Siow, University of Pittsburgh Medical Center; Gabriella Butler, Children's Hospital of Pittsburgh of UPMC; Anthony Lewis, University of Pittsburgh Medical Center; Srinivasan Suresh, Children's Hospital of Pittsburgh of UPMC; Andrew Buchert, Children's Hospital of Pittsburgh of UPMC; Marissa Narr, Children's Hospital of Pittsburgh of UPMC; Michael Morowitz, Children's Hospital of Pittsburgh of UPMC; Kevin Mollen, Children's Hospital of Pittsburgh of UPMC

Appendicitis remains one of the most frequently encountered pediatric surgical diagnoses. In an effort to improve patient care, we implemented an evidence-based treatment protocol that prioritized limited IV narcotic and fluid use, early postoperative enteral feeding and ambulation, decreased central lines and Foley catheter usage, as well as timely preoperative and reduced postoperative antibiotic administration.

We hypothesized that a standardized, evidence-based perioperative care protocol would result in decreased hospital length of stay and a lower overall cost of care without compromising patient outcomes.

Data from patients treated surgically for appendicitis after protocol initiation was prospectively collected from January 2015 to September 2016. We compared this cohort with historical control patients treated from November 2013 to December 2014, prior to the initiation of our protocol. We examined length of stay (LOS), surgical site infection (SSI), readmission, and cost data. Continuous variables were compared with a Wilcoxon rank-sum test. Categorical data was compared using Fisher’s Exact Test. All tests were two-sided with alpha=0.05. Statistical analysis was performed using Stata 14.2.

The protocol group containing 810 patients was compared to the historical control group of 506 patients. There were no significant differences in age or sex between the two groups. Median LOS decreased from 39.9 [IQR 29.0-87.0] hours to 35.5 [IQR 24.2-62.2] hours after protocol implementation (p<0.001). There were no significant differences in the rate of SSI (control 0.7% vs. protocol 0.2%; p=0.24) or readmissions between groups (control 4.8% vs. protocol 3.4%; p=0.33). Cost analysis showed a 10.4% decrease in average cost per patient treated after protocol initiation. Subgroup analysis of patients with complicated appendicitis (defined as patients found at the time of surgery to have a perforated appendix ± abscess formation) showed a significant reduction in LOS (147.4 [IQR 128.4-219.1] vs. 110.5 [IQR 77.1-159.1] hours; p<0.001) and average cost per patient (-19.7%) after initiation of the protocol.

Initiation of an evidence-based protocol to treat pediatric patients with appendicitis resulted in a significant decrease in LOS and cost per patient without negatively affecting SSI and readmission rates. Continued use and development of data-driven standardized treatment protocols may prove beneficial to patients and cost-effective for health-care systems.