Journal of Pediatric Surgery 49 (2014) 10201025

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Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Standardization and improvement of care for pediatric patients with

perforated appendicitis
Joyce Slusher, Christina A. Bates, Catherine Johnson, Christina Williams,
Roshni Dasgupta, Daniel von Allmen
Cincinnati Childrens Hospital Medical Center, Cincinnati, OH, USA

a r t i c l e i n f o a b s t r a c t

Article history: Background/purpose: Reduction of treatment variation and application of evidenced based care are
Received 26 January 2014 increasingly important in the current care environment. Utilizing formal quality improvement methods, an
Accepted 27 January 2014 evidenced based guideline was implemented at our institution.
Methods: A guideline was established regarding timing of surgery (immediate vs interval appendectomy) and
Key words:
duration of antibiotics. Twelve months of baseline data were collected prior to implementation. The guideline
Perforated appendicitis
dictates immediate appendectomy (IA) and postoperative antibiotic therapy until discharge (regular diet,
Evidence based practice
Interval appendectomy
clinically improved, normal complete blood count (CBC)). Data was collected prospectively during
hospitalization and at 30 days postdischarge. Control charts document adherence to the overall guideline,
IA, antibiotic guideline, and readmission for complications.
Results: Guideline implementation resulted in an increase in IA (79% vs 94%), decrease in the use of IV
antibiotics post discharge (25% to 4%), no change in overall LOS, no change in postoperative abscess formation,
and slight decrease in 30 day readmission. Charges were decreased.
Conclusion: Implementation of an evidenced based guideline resulted in signicant practice change for
managing perforated appendicitis. The changes suggest more efcient care without compromising patient
outcome. Utilization of quality improvement methods allows for implementing and tracking the change as
well as creating a platform for future improvement.
2014 Elsevier Inc. All rights reserved.

Reduced variation, evidenced based care and improved outcomes
are basic tenets of quality improvement work in medicine. Application
of formal quality improvement techniques to common pediatric
surgical conditions like perforated appendicitis offers the opportunity
to standardize care and create a platform for further improvements in
treatment algorithms.
1. Background/purpose
Appendicitis is the most common surgical abdominal emergency
in children, and comprises a signicant percentage of the operations
performed on children, accounting for more than 320,000 operations
per year within the United States [1]. Approximately 2040% of
patients present with perforated appendicitis.
Currently, there remain no formal evidence based practice
guidelines for the treatment of perforated appendicitis regarding
the timing of surgery (early vs. interval appendectomy) or the length
of the antibiotic course within the pediatric population.
Corresponding author at: Cincinnati Childrens Hospital Medical Center, 3333
Burnet Avenue, MLC 2023, Cincinnati, OH 45229-3026, USA. Tel.: + 1 513 636 4371;
fax: + 1 513 636 7657.
E-mail address: daniel.vonallmen@cchmc.org (D. von Allmen).
Our institution is a 540 bed, free standing childrens hospital where
ve to six hundred children between the ages of 2 and 19 years are
treated for appendicitis every year. Of those, approximately 25 percent
are perforated. In this study, the treatment of perforated appendicitis
was standardized among the seventeen attending surgeons in the
pediatric surgery practice at our institution. By standardizing care, we
hoped to reduce variation in practice and in turn reduce consumption
of health care resources while maintaining excellent patient outcomes.
In recent years quality improvement techniques developed in industry
by Edward Deming [2] and others have been applied in medicine.
Unlike traditional prospective randomized controlled studies that
have a dened study period, these changes were made within a formal
quality improvement infrastructure that is designed to provide
ongoing documentation of compliance, outcomes, and the opportunity
for further improvement interventions.
2. Methods
In an effort to standardize the care for children admitted to the
surgical service for perforated appendicitis at our institution, we
utilized resources at the James M. Anderson Center for Health Systems
Excellence and a process referred to as Rapid Cycle Improvement
Collaborative (RCIC). RCIC is designed in such a way as to allow a small

http://dx.doi.org/10.1016/j.jpedsurg.2014.01.045
0022-3468/ 2014 Elsevier Inc. All rights reserved.
 J. Slusher et al. / Journal of Pediatric Surgery 49 (2014) 10201025 1021

quality improvement (QI) team to achieve a measurable improve-
ment in a focused, narrow-scoped project in a short period of time
(180 days). The RCIC process utilizes the model for improvement and
basic QI tools in which plan, do, study, act (PDSA) cycles are used to
implement changes in clinical care design to reduce variation and
improve outcomes.
A review of current pediatric and adult literature, with regard to
timing of surgery (immediate vs interval appendectomy) and length
of course for antibiotics, was performed for the purpose of developing
an evidence based care guideline for the treatment of perforated
appendicitis at our institution. A retrospective review of the medical
records of all patients (19 years of age) treated for perforated
appendicitis from February 1, 2011 through June 30, 2012 was
performed. This data provided the baseline documentation of
treatment variation, length of stay (LOS), charge data and complica-
tion rates prior to initiation of the guideline. Data collected included
patient age, duration of symptoms, WBC results, imaging studies
obtained, timing of surgery, antibiotic regimen, length of stay, and
readmission for abscess within 30 days of discharge. Charge data
included hospital fees, professional fees and home care charges. For

Fig. 1. Perforated appendicitis care algorithm.

1022 J. Slusher et al. / Journal of Pediatric Surgery 49 (2014) 10201025
Fig. 2. % of patients with perforated appendicitis treated with immediate operative management (within 24 hours).
purposes of comparison, only data from July 1, 2011 through June 30,
2012 were used for the preguideline baseline group.
The baseline data and a proposed care algorithm for the
standardized treatment of perforated appendicitis were presented
to faculty members of the surgery department at the end of June of
2012 and adopted for use (Fig. 1).
The algorithm calls for immediate appendectomy to be
performed on all patients with suspected perforated appendicitis
unless they present with a chronic well-formed abscess amenable to
drainage. Intentionally, no specic duration of symptoms was
included in the guideline as a cutoff for pursuing immediate
appendectomy. A three port laparoscopic technique was used for
virtually all appendectomies and there was no change in technique
over the course of the study. Patients receive either Piperacillin-
tazobactam or ertapenem IV beginning prior to surgery and
postoperatively, in the absence of a contraindication. Intravenous
antibiotics are continued until the patient is afebrile and tolerating a
regular diet. A complete blood count (CBC) with differential was
obtained when these milestones were achieved and if the WBC and
neutrophil count were within normal limits, the patient was
discharged without additional antibiotic therapy. If the neutrophil
count demonstrated a left shift at the time of discharge, the patient
was discharged on either oral amoxicillin-clavulanate or ciprooxin
and metronidazole to complete a 7 day total course of antibiotics.
Patients who presented with a chronic well formed, rim enhancing
uid collection received care per the interval appendectomy
pathway. This included Interventional Radiology (IR) consult for
possible drain placement and either Piperacillin-tazobactam or
ertapenem IV until afebrile for N 24 hours, drain output was
minimal, tolerating regular diet and clinically improved. The patient
was discharged on amoxicillin-clavulanate or ciprooxacin plus
metronidazole for total of 2 weeks. The patient would then return
in 810 weeks for an interval appendectomy.
The algorithm was implemented using a series of tests of change
incorporating the surgical fellows, residents and nurse practitioners
caring for patients on the surgical service to assure the new guideline
was followed. Data was collected from 7/1/2012 through 6/30/2013.
Timing of surgery, antibiotic use, adherence to the guideline, total
charges (12 month data), readmission within 30 days, and length of
stay were compared for both groups. Shewhart control charts are
maintained on an ongoing basis to document compliance and
complications. All data is maintained in a password protected le. The
study was approved by the institutional review board (IRB) (IRB no.
2013-1743) at our institution.
3. Results
In the preguideline group, a retrospective chart review (7/1/2011
6/30/2012) identied 119 total patients (219 years) with perforated
appendicitis. Immediate appendectomy was performed in 95 patients
and initial antibiotic therapy followed by interval appendectomy in 24
patients. All patients who were treated with interval appendectomy
received a PICC line and IV antibiotic postdischarge from original
hospitalization to complete a 2 week course of antibiotic therapy.
Readmission rate because of abscess within 30 days of original
discharge date for the preguideline group was 9%. Mean LOS for this
group was 6 days. Preguideline charges ranged from $26,000 to
$208,000 with median total charges of $49,900.
Following implementation of the guideline (7/1/20126/30/2013),
134 (217 years) consecutive patients were followed. Immediate
appendectomy was performed in 126 patients and interval appen-
dectomy in 8. (5 treated with oral antibiotic, 3 with IV antibiotic)
postdischarge from original hospitalization. Two of the three patients
who received a PICC line and IV antibiotic postdischarge went home
with a drain in place. Readmission rate for abscess within 30 days of
original discharge was 7% for patients following the guideline. Mean
LOS was 6 days for patients in this group. One child in this group
sustained a trocar injury and hematoma that prolonged his hospital
stay but other complications were comparable between groups. Total
charges ranged from $26,500 to $188,000, with the median charges
falling at $46,900. Compliance for following all aspects of the
guideline in regard to timing of surgery and antibiotic use, including
a CBC prior to discharge, was 89%.
Implementation of the guideline drove a signicant change in
clinical practice. The operative management shifted strongly toward
immediate appendectomy and away from antibiotics and drain
followed by interval appendectomy (Fig. 2). Similarly, virtually all
patients were discharged home on antibiotics prior to the guideline
and that practice has changed dramatically (Fig. 3). Importantly, there
has been no signicant increase in the rate of readmissions for abscess
formation despite the change in practice (Fig. 4).
The determination of perforated appendicitis was based on the
clinical impression of the surgeon at the time of surgery for all
operated cases and on imaging characteristics of those managed
 J. Slusher et al. / Journal of Pediatric Surgery 49 (2014) 10201025 1023

Fig. 3. % of patients with perforated appendicitis discharged without antibiotic.

nonoperatively. The guideline was implemented once the diagno-
sis of perforated appendicitis was determined and no effort was
made to alter the pre diagnosis work up. However, there was a
shift toward the use of ultrasound and away from CT scanning over
the course of the study. The use of CT ordered by the surgery
service for diagnosis decreased from 28% to 15% while the use of
ultrasound increased from 39% to 57%. Overall the number of CT
scans performed on patients decreased from 46% to 39% when all
imaging ordered by the Emergency Department physicians or
those who underwent CT imaging prior to reaching our institution
were included.
4. Discussion and conclusions
It is well accepted that there are two approaches to the treatment
of perforated appendicitis immediate appendectomy and interval
appendectomy. Simillis et al found no difference in the length of stay
(LOS) or duration of IV antibiotic treatment for adult and pediatric
patients who underwent immediate vs. interval appendectomy. There
was noted an increase incidence of complications in the immediate
appendectomy group especially for the pediatric population [3].
However, Blakelys randomized control trial regarding timing of
surgery favored immediate appendectomy reporting decreased LOS,
fewer complications and earlier return to normal activity [4]. It has
also been noted that fewer complications and decreased LOS result in
decreased cost associated with immediate appendectomy [5].
Similar controversy is also found in the discussion of the antibiotic
course for perforated appendicitis. The number of pediatric patients in
studies or the number of studies focused on the pediatric population is
limited. One randomized controlled trial found no difference in
postoperative abscess rate between pediatric patient treated with IV
plus oral antibiotic or those treated with a minimum 5 day course of
IV antibiotics [6]. Nadler and Gaines and Lee et al conducted reviews
of the literature regarding the use of antibiotics for the treatment of
appendicitis in children. Both recommended that the duration of IV

Fig. 4. % of patients treated according to perforated appendicitis guideline readmitted with abscess following original discharge.
1024 J. Slusher et al. / Journal of Pediatric Surgery 49 (2014) 10201025
antibiotics for perforated appendicitis be guided by clinical criteria
consisting of the presence or absence of fever, white blood cell count,
and resolution of symptoms [7,8]. In addition, Nadler and Gaines also
concluded that oral antibiotic treatment was not necessary after an
appropriate course of IV therapy was completed [7].
Based on the literature cited above, the current treatment guideline
was implemented after vetting by the surgical staff. Run charts were
then created and are followed on an ongoing basis to track adherence to
the various aspects of the guideline and outcome variables of length of
stay and readmission for intraabdominal abscess formation. The results
demonstrate several signicant ndings. First, treatment variation has
been dramatically reduced as evidenced by very high adherence to the
guideline by the surgical staff for both the operative and antibiotic
components of the algorithm (Figs. 2 and 3). Reducing variation is a
critical rst step in quality improvements efforts. Low level common
variation indicates a system that is in control. Variation that falls outside
the calculated control limits signies special cause variation indicating a
departure from the standard process. In this study, occurrences of
postoperative abscess are tracked as a balancing measure for reduced
antibiotic therapy. At no point following implementation of the
guideline does the rate of readmission for intraabdominal abscess
formation exceed the upper control limit thus conrming no change
from the preguideline abscess rate (Fig. 4).
The advantage of the quality improvement approach is that these
data continue to be collected and plotted in an ongoing fashion. In a
typical randomized controlled study once the study period is over,
there is no documentation of adherence to the study guideline and no
way to identify changing outcomes. Conversely, Shewhart control
charts provide not only ongoing documentation of patient treatments
and outcomes; they also provide a platform for testing additional
improvement initiatives such as a change in antibiotic coverage or
further reduction in antibiotic therapy.
The ndings of this study are signicant for a number of reasons.
First, the data conrm previous work indicating that immediate
surgery in perforated appendicitis is associated with equivalent
outcomes and reduced costs. The data also supports the practice of
limiting the duration of postoperative antibiotic therapy to in-patient
care with dened clinical endpoints. More importantly, the ability to
implement a standard treatment protocol for a common pediatric
surgical condition in a large academic surgical group is conrmed.
While this is not unique, utilizing the QI approach assures that each of
the changes implemented lasts beyond the study period and provide
the opportunity for ongoing adaptation of the treatment algorithm.
Understanding and applying formal quality improvement tech-
niques to pediatric surgical conditions is an efcient, cost effective
mechanism for improving care on an ongoing basis.
Acknowledgments
Assistance was utilized from the James M. Anderson Center for
Health Systems Excellence, Betsy Gerrein, DNP, CPNP, Alicia Vincent,
BBA and Jessica Burkhard, RN, BSN.
References
[1] Muehlstedt S, Pham T, Schmeling D. The management of pediatric appendicitis: a
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[2] Deming WE. The new economics for industry, government, education. Cambridge,
MA: Massachusetts Institute of Technology, Center for Advanced Engineering
Study; 1993 .
[3] Simillis C, Symeonides P, Shorthouse AJ, et al. A meta-analysis comparing
conservative treatment versus acute appendectomy for complicated appendicitis
(abscess or phlegmon). Surgery 2010;147(6):81829.
[4] Blakely ML, Williams R, Dassinger MS, et al. Early vs interval appendectomy for
children with perforated appendicitis. Arch Surg 2011;146(6):6605.
[5] Myers A, Williams R, Giles K, et al. Hospital cost analysis of a prospective,
randomized trial of early vs interval appendectomy for perforated appendicitis in
children. J Am Coll Surg 2012;214(4):42734.
[6] Fraser J, Aguayo P, Leys C, et al. A complete course of intravenous antibiotics
vs. a combination of intravenous and oral antibiotics for perforated appendi-
citis in children: a prospective, randomized trial. J Pediatr Surg 2010;45(6):
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[7] Nadler EP, Gaines BA. The surgical infection society guidelines on antimicrobial
therapy for children with appendicitis. Surg Infect (Larchmt) 2008;9(1):7583.
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Discussion
Discussant: Dr. Harold Lovvorn, Nashville, TN: I think the important
thing about quality improvement and standardizing care, the
nuances of protocol can be argued but getting one out and then
adjusting it over time until you get the effect that you want is
where it goes. I think the hardest part about these projects is
getting the buy in to change behavior. As a broader question,
how do you deal with this within your group and how do you nd
success with that?
Response: Dr. Von Allmen: It was interesting, that was one of our major
concerns was would we be able to get buy in for the guideline in
the rst place. I have to credit our faculty and we did the due
diligence to do the evidence-based research. If you present an
evidence-based guideline and you present it in a way and I think
one of the important things was we are not just going to start this
guideline and do it. We're going to do it and track what happens
with regard to complications and such so that as you said, using
these kind of methods you can track what happens and it allows
you to change the nuances of what you do. In fact, we've already
changed the antibiotic regimen we use and we can put a point on
that graph and track it. If we end up with points above the upper
control limit of the control chart then we know that that was either
a good or a bad thing to do.
Discussant: Dr. Mark Wulkan, Atlanta, GA: One of the challenges with
any of these projects is once you get it started you've got buy in
and everyone is going to participate and then when we try to do
this there is an experience drift. Whether it is rotating residents
coming in when the fellow is not around or if it is the attending
surgeons who just seem to forget what the algorithm is, how do
you maintain the enthusiasm and how do you keep people on
track?
Response: Dr. Von Allmen: That's a great question and something that
we have been concerned about especially since we have a number
of quality improvement projects all going on at the same time. You
worry about overload and drift as you say. We actually have these
charts very prominently posted in our ofce so that you have to
walk by them every day. They are updated on a monthly basis so
that we can continue to track things. Again, we're fortunate that
we have two fellows who are really the ones responsible so instead
of having to do it once a month with new residents we can do it
once a year with new fellows.
Dr. Wulkan: Just as a follow-up do you give individual surgeons
feedback as to where they stand and on what frequency do you do
that?
Response: Dr. Von Allmen: Thus far as some of those data showed we've
had very little variance from the guideline, that hasn't been
necessary but, if there is variance and variance can be a good
thing or a bad thing. If somebody does something different it
actually might end up in an improvement and we can track that
fact. We are very careful to explore variance because it's either bad
and you can say to the surgeon here is the data, your outcomes are
 J. Slusher et al. / Journal of Pediatric Surgery 49 (2014) 10201025
going to be worse based on our results. Or what did you do that
was different because whatever happened it made an improve-
ment as opposed to something worse.
Discussant: Dr. Elizabeth Beierle, Birmingham, AL: Excellent presenta-
tion on a wide variance of practice with complicated appendicitis.
I'm curious what you thought of the nationwide study that was
presented here where they really showed with complicated
appendicitis a higher SSI rate. If you, when you changed your
antibiotics in decision with white blood cells to increase antibiotics
and they go home on the seven days did you see a change in the
surgical incision sites?
1025
Response: Dr. Von Allmen:Thank you for the question. Again, the
advantage of this is we can change these things. I think Mary
Brandt presented some data on Friday from Texas suggesting that a
left shift or a band count is not important and does not make a
difference in the antibiotic regimen. We implemented that based
on what is admittedly sort of a knee jerk reaction to a couple of
early complications. My hope is that we are going to use this to
continue to ramp down our antibiotic therapy. She also presented
data to suggest that they saw their complication rate go up when
they were using one antibiotic and ended up switching to another
because of increased resistance. I think that those are ongoing
opportunities to perfect the guideline.