As compared to the previously critiqued publication, I am rather pleased with the protocol described by these authors.
This is a clinical pathway for appendicitis from Children’s in Memphis prospectively evaluated for diagnostic accuracy. They’ve taken the idealist route – risk-stratification, followed by discharge, ultrasound, or pediatric surgery evaluation. These authors use the Pediatric Appendicitis Score, dropping patients into buckets based on scores 1-3, 4-7, and 8-10. Most interestingly, there is no role for CT scanning in this pathway unless specifically requested by the consulting surgeon.
In this study, 196 children completed the full clinical pathway – 44 were in the low-risk group, 119 in the moderate-risk, and 33 in the high-risk group. Almost all the low-risk patients were discharged from the Emergency Department with a telephone call follow-up, and only one patient had a callback – for what was eventually diagnosed as an omental infarct. In the high-risk group, all 33 patients were admitted, and all 28 patients who were taken to the OR by surgery had appendicitis. The 119 patients in the moderate-risk group are much more interesting. 33 of 119 ultimately had ultrasounds supporting a diagnosis of appendicitis, and all were confirmed in the OR. However, the remainder of these patients either were discharged without ultrasound, or had negative ultrasounds. There were, ultimately, 5 cases of appendicitis in the moderate-risk group, despite a negative ultrasound.
This is the main flaw in external validity of their protocol – what to do with a moderate-risk patient with a negative ultrasound? Per the authors, the more concerning cases were admitted – either to surgery or pediatrics, depending on level of suspicion for an alternative diagnosis – or discharged with telephone follow-up. I think many folks, when faced with this level of uncertainty, proceed to CT scan – but, amazingly, only 13 kids in this cohort were subjected to diagnostic or therapeutic radiation. This statistic alone validates the protocol – and the cultural and operations changes necessary to make it work. By having a safety net of follow-up calls in place for patients discharged from this clinical pathway, the pressure for an immediate diagnosis is eliminated.
It is a small sample size, and it requires providers to increase their comfort level with diagnostic uncertainty – but it certainly seems rational and promising.
“Prospective Evaluation of a Clinical Pathway for Suspected Appendicitis”
http://www.ncbi.nlm.nih.gov/pubmed/24379237