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It is not what you do, it is the way that you do it: impact of a care pathway for appendicitis
Journal of Pediatric Surgery (2008) 43, 315–319
www.elsevier.com/locate/jpedsurg
It is not what you do, it is the way that you do it: impact of a care pathway for appendicitis Sarah L. Almond a,⁎, Megan Roberts a , Victoria Joesbury a , Sue Mon a , Jeff Smith a , Nevila Ledwidge a , Sailaja Pisipati a , Amir Khan a , Basem A. Khalil a , Elvina White a , Colin T. Baillie a , Simon E. Kenny b a
Department of Paediatric Surgery, Royal Liverpool Children's NHS Trust, L12 2AP Liverpool, UK Institute of Child Health, University of Liverpool, L12 2AP Liverpool, UK
b
Received 27 September 2007; accepted 9 October 2007
Index words: Appendicitis; Appendicectomy; Children; Care pathway
Abstract Background/Purpose: Appendicitis is the most common surgical emergency in children. However, management varies widely. The aim of this study was to assess the impact of introducing a care pathway on the management of childhood appendicitis. Methods: Data were collected prospectively for 3 successive cohorts: Group A, before introduction of pathway; Group B, after introduction of pathway; Group C, after modification of pathway. All patients operated for suspected appendicitis were included. The pathway was modified after interim analysis of group B data. P b .05 was significant. Results: Six hundred patients were included. When compared with group A, group C patients were more likely to receive preoperative antibiotics (P b .0001), undergo formal pain assessment (P b .0001), and be operated before midnight (P = .025). There was a significant decrease in readmission rates from 10.0% to 4.2% (P = .023) despite an increase in cases of gangrenous and perforated appendicitis (P = .010). Conclusions: The introduction of a care pathway resulted in improved compliance with antibiotic regimens, more frequent pain assessment, and fewer post-midnight operations. Postappendicectomy readmission rates were reduced despite an increase in disease severity. This was achieved by critical reevaluation of outcomes and pathway redesign where appropriate. © 2008 Elsevier Inc. All rights reserved.
Integrated care pathways detail steps in the care of patients with a specific clinical problem, within a set time scale and reflecting current management guidelines [1,2]. A defining characteristic of an integrated care pathway (ICP) Presented at the British Association of Paediatric Surgeons meeting, Edinburgh, Scotland, July 17-20, 2007. ⁎ Corresponding author. Tel.: +44 0 151 2284811. E-mail address: [email protected] (S.L. Almond). 0022-3468/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2007.10.019
is the opportunity to record variations from standard practice (variances). Recording the reasons for variances enables more meaningful audit and ICP reevaluation and update [1,3]. Integrated care pathways are ideally suited to the management of common surgical conditions with welldefined outcomes, such as appendicitis [1,4]. Furthermore, management of appendicitis varies widely even within individual institutions [5]. We aimed to develop guidelines
316 Table 1
S.L. Almond et al. diagnosis, histologic results, analgesic requirements, preand postoperative antibiotic regimens, requirement for and duration of parenteral nutrition, and postoperative course including complication and readmission rates.
Exclusion criteria for study
Appendicitis not suspected preoperatively (even if found at operation) Elective appendicectomy Incidental appendicectomy (eg, during surgery for malrotation) Interval appendicectomy after nonoperative management of appendix mass
1.3. Group B: pathway development and implementation
for the management of appendicitis in our hospital and implement these within an ICP as a means of improving patient care.
1. Materials and methods 1.1. Data collection Data were collected prospectively by junior medical staff. All patients undergoing surgery for suspected appendicitis were included in the study, even if an alternative diagnosis was discovered at operation. Exclusion criteria are summarised in Table 1. Data collection began from the time a decision to operate was made, and data were stored on an Access database (Microsoft Corporation, Redmond, WA). To ensure complete ascertainment, a list of all appendix specimens received by the hospital histopathology department was cross-checked with the prospectively collected data, and missing cases were added to the database. Data were collected for 3 cohorts:
After the analysis of group A data, key areas for improvement were identified and incorporated into an integrated care pathway. A multidisciplinary team led by a surgical trainee, a senior nurse and the hospital's Pathway Coordinator designed the pathway. The ICP was implemented after a series of multidisciplinary meetings explaining its relevance in terms of the results of the group A data. Data collection resumed after a 1-month pilot period. All patients undergoing surgery for presumed appendicitis were entered into the study and commenced on the pathway, in an attempt to standardise management and thus improve outcomes. The pathway was divided into 4 sections: • Decision to operate checklist (medical): recommended intravenous antibiotic (cefotaxime and metronidazole) and fluid regimens (0.45% saline/5% dextrose, 10 mmol KCl in 500 mL); prompts to discuss patient with anaesthetist and theatre staff; preprinted consent form with current complication rates. • Preoperative care (nursing): space to record observations; pain scoring scales and guidelines on analgesia use. • Operation record (medical): surgery commenced before/ after midnight; details of operative technique and findings; hospital guidelines for postoperative antibiotic administration (cefotaxime and metronidazole) single dose (normal appendix), 3 doses (inflamed), 5 days (gangrenous), and 5 days with gentamicin (perforated); • Postoperative care (nursing): detailing management of observations, analgesia, oral intake, and mobility.
• Group A (control group): before introduction of ICP, September 2002 to September 2003 (1 year) • Group B: after introduction of ICP, March 2004 to September 2004 (6 months) • Group C: after modification of ICP, October 2004 to October 2005 (1 year)
1.2. Group A: measuring current practice The first step was to audit established practice to set standards. Patient management was determined by the preferences of the surgical on-call team, without any defined guidelines being used. Variables included demographics, preoperative investigations, operative technique (laparoscopic or open), operative details including surgical Table 2
1.4. Group C: pathway reevaluation and modification Interim analysis of group B data was undertaken after 6 months and the ICP modified according to these results and to suggestions arising from a further series of multidisciplinary meetings (see Results). Subsequently, patients
Surgical outcomes
Laparoscopic Gangrenous/perforated Inflamed Normal Other diagnosis
A (n = 211)
B (n = 172)
P (A vs B)
C (n = 217)
P (A vs C)
61/211 68/210 102/210 32/210 8/210
39/172 65/172 76/172 29/172 2/172
.198 .282 .411 .676 .196
95/216 96/214 73/214 41/214 4/214
.001 .010 .003 .305 .256
(28.9%) (32.4%) (48.6%) (15.2%) (3.8%)
(22.7%) (37.8%) (44.2%) (16.9%) (1.2%)
(44.0%) (44.9%) (34.1%) (19.2%) (1.9%)
Impact of a care pathway for appendicitis Table 3
317
Outcomes
Outcome variable
A (n = 211)
B (n = 172)
P (A vs B)
C (n = 217)
P (A vs C)
Preoperative antibiotics Formal pain assessment Operation after midnight Intraabdominal collection or wound infection Readmission within 6 months
66/211 (31.3%) 66/211 (31.3%) 38/211 (18.0%) 19/211 (9.0%)
80/172 (46.5%) 136/168 (81.0%) 30/172 (17.4%) 14/172 (8.1%)
.003 b.0001 .894 .856
136/217 152/209 22/217 10/216
b.0001 b.0001 .025 .084
21/211 (10.0%)
14/172 (8.1%)
.596
were managed according to the modified ICP protocols and data were collected for a further year.
1.5. Primary outcome variables Improved outcomes were considered to be a reduction in pathway variances, length of postoperative stay, complications (wound infection, abscess formation), and readmission within 6 months of surgery.
1.6. Data analysis Data were analysed using SPSS (v12, SPSS Inc, Chicago, IL) and GraphPad Prism (v5, Graphpad Software Inc, San Diego, Calif) software. Fisher's Exact test or 1-way analysis of variance was used as appropriate. P b .05 was significant.
2. Results 2.1. Demographics Six hundred patients were included in the study. There were no significant differences between the groups in age (in mean [SD]: group A, 10.8 [3.4] years; group B, 10.8 [3.6] years; group C, 11.5 [3.1] years; P = .064) or sex (males: group A, 50.7%; group B, 55.2%; group C, 57.1%; P = .207). Surgical outcomes are summarised in Table 2. There was a strong correlation between surgical diagnosis and histologic findings (data not included). Group C contained significantly more cases of gangrenous/perforated appendicitis and significantly fewer cases of inflamed appendicitis. More laparoscopic appendicectomies were performed in group C.
(62.7%) (72.7% (10.1%) (4.6%)
9/216 (4.2%)
.023
formal pain assessment tools (Table 3). However, postmidnight operating, complication, and readmission rates were unaffected. One hundred percent of eligible patients were commenced on the ICP.
2.4. Group C After the analysis of group B data, the pathway was modified in an attempt to further improve outcomes. A preoperative checklist including antibiotic prescribing, with space to document variances, was included, and operating after midnight was included as a separate category requiring variances to be recorded and justified. Other changes related to document layout for ease of use and data collection. Subsequent to the pathway modifications, preoperative antibiotic administration improved to 62.7% (P b .0001) and post-midnight operating was reduced to 10.1% (P = .025). These improvements were accompanied by a halving in readmission rates (P = .023) and a nonsignificant trend toward a reduction in intraabdominal collection and hospitaltreated wound infection rate, despite significantly more cases of gangrenous/perforated appendicitis (Tables 2 and 3). No differences in postoperative length of stay were seen between the groups (data not shown). The increased number of laparoscopic appendicectomies performed in group C could have represented a confounding factor in the reduction in post-midnight operations, complication rates, and readmission rates. However, subgroup analysis demonstrated no significant differences for these variables when laparoscopic and open procedures were compared independently (Table 4).
3. Discussion 2.2. Group A After the analysis of group A data (Table 3), target areas for improvement were identified as preoperative antibiotic administration, formal pain assessment, and the numbers of cases being performed after midnight.
2.3. Group B Introduction of the ICP resulted in significant improvements in preoperative antibiotic administration and the use of
This article describes the successful implementation of an ICP for the management of childhood appendicitis in a tertiary paediatric centre. This was achieved by a stepwise sequence of events beginning with an audit of current practice. At this stage, 3 target areas for improvement were identified, namely, pain management, antibiotic administration, and post-midnight operating. It is well recognised that the use of age-appropriate pain scoring systems improves pain management [6], yet only 31% of children were undergoing formal pain assessment. Similarly, only a third of
318
Table 4
Subanalysis of laparoscopic and open appendicectomy groups Operated after midnight
Group A Group C P (A vs C)
Intraabdominal collection or wound infection
Readmission within 6 mo
OA
LA
OA + LA
OA
LA
OA + LA
OA
LA
OA + LA
31/150 (20.7%) 18/121 (14.9%) .267
7/61 (11.5%) 4/95 (4.2%) .111
38/211 (18.0%) 22/217 (10.1%) .025
13/150 (8.7%) 7/121 (5.8%) .485
6/61 (9.8%) 3/95 (3.2%) .155
19/211 (9.0%) 10/216 (4.6%) .084
15/150 (10.0%) 6/121 (5.0%) .170
6/61 (9.8%) 3/95 (3.2%) .155
21/211 (10.0%) 9/216 (4.2%) .023
OA indicates open appendicectomy; LA, laparoscopic appendicectomy.
S.L. Almond et al.
Impact of a care pathway for appendicitis children received preoperative antibiotics, despite hospital policy. Several studies conclude that the use of antibiotics in patients undergoing appendicectomy results in reduction in the rate of postoperative wound infections and intraabdominal abscess collections [7]. Finally, post-midnight operations are difficult to justify in patients who do not have peritonitis [8,9]. We were concerned that the high number of appendicectomies being performed after midnight was a reflection of time pressure in theatre rather than clinical necessity. The high numbers of patients re-presenting with wound infections and intraabdominal collections or requiring readmission to hospital (9% and 10%, respectively) made these obvious outcomes by which to measure improvements in practice. Introduction of the ICP resulted in immediate improvement in antibiotic administration and pain monitoring. However, other outcomes were unchanged. This was recognised by interim audit and pathway changes were made, as previously described. Subsequently, improvements were seen in all parameters despite an increase in numbers of gangrenous and perforated appendicitis. The increase in cases of complicated appendicitis could be attributed to fewer postmidnight operations, but this is countered by a concomitant increase in preoperative antibiotics and reduction in readmission rates. The normal appendix rate remained unchanged at 19%; this is to be expected as patients were only commenced on the pathway after a decision to operate had been made. Of note is the increase in numbers of laparoscopic appendicectomies in group C, which was being introduced at our institution during the period of this study. Again, it could be suggested that this would account for changes in complication/readmission rates and timing of surgery. However, subanalysis showed that this was not the case. The use of integrated care pathways is now commonplace, particularly in the management of surgical conditions [1]. They have variously been shown to improve patient care and outcomes, reduce costs, guide decision-making by junior clinicians, and improve professional relationships, as well as provide a powerful audit tool [1,3-5,10-12]. However, most studies are retrospective or descriptive [1]. Attitudes to pathways are variable with many health care workers feeling that they stifle innovation and limit clinical judgement. Pathways are also instituted at a local level, meaning that they are reliant on a high degree of enthusiasm from several individuals to ensure they are well designed and remain in use [1,3-5]. We found that the keys to successful pathway implementation were selection of an appropriate condition and targets for improvement, a multidisciplinary approach to pathway
319 design, communication and discussion of results with all staff and, above all, frequent reevaluation of outcomes. To our knowledge, only one previous group has reevaluated an appendicectomy care pathway after initial implementation [5]. This group found that not all favourable outcomes of their pathway were sustained and suggested further monitoring and education may remedy this. Our pathway continues to evolve to reflect changing practice.
Acknowledgment The authors acknowledge the involvement and cooperation of all surgeons at Royal Liverpool Children's NHS Trust with this study. They would also like to recognize the work of Sister Tracey Irvine in the design and development of the pathway.
References [1] Campbell H, Hotchkiss R, Bradshaw N, et al. Integrated care pathways. BMJ 1998;316(7125):133-7. [2] Kitchiner D, Bundred P. Integrated care pathways. Arch Dis Child 1996;75(2):166-8. [3] Kitchiner D, Davidson C, Bundred P. Integrated care pathways: effective tools for continuous evaluation of clinical practice. J Eval Clin Pract 1996;2(1):65-9. [4] Barker SG, Sachs R, Louden C, et al. Integrated care pathways for vascular surgery. Eur J Vasc Endovasc Surg 1999;18(3): 207-15. [5] Warner BW, Rich KA, Atherton H, et al. The sustained impact of an evidenced-based clinical pathway for acute appendicitis. Semin Pediatr Surg 2002;11(1):29-35. [6] Howard RF. Current status of pain management in children. JAMA 2003;290(18):2464-9. [7] Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for prevention of postoperative infection after appendicectomy. Cochrane Database Syst Rev 2005;3:CD001439. [8] Yardeni D, Hirschl RB, Drongowski RA, et al. Delayed versus immediate surgery in acute appendicitis: do we need to operate during the night? J Pediatr Surg 2004;39(3):464-9. [9] Taylor M, Emil S, Nguyen N, et al. Emergent vs urgent appendectomy in children: a study of outcomes. J Pediatr Surg 2005;40(12):1912-5. [10] Warner BW, Kulick RM, Stoops MM, et al. An evidenced-based clinical pathway for acute appendicitis decreases hospital duration and cost. J Pediatr Surg 1998;33(9):1371-5. [11] Gholve PA, Kosygan KP, Sturdee SW, et al. Multidisciplinary integrated care pathway for fractured neck of femur. A prospective trial with improved outcome. Injury 2005;36(1):93-8. [12] Emil S, Taylor M, Ndiforchu F, et al. What are the true advantages of a pediatric appendicitis clinical pathway? Am Surg 2006;72(10):885-9.
www.elsevier.com/locate/jpedsurg
It is not what you do, it is the way that you do it: impact of a care pathway for appendicitis Sarah L. Almond a,⁎, Megan Roberts a , Victoria Joesbury a , Sue Mon a , Jeff Smith a , Nevila Ledwidge a , Sailaja Pisipati a , Amir Khan a , Basem A. Khalil a , Elvina White a , Colin T. Baillie a , Simon E. Kenny b a
Department of Paediatric Surgery, Royal Liverpool Children's NHS Trust, L12 2AP Liverpool, UK Institute of Child Health, University of Liverpool, L12 2AP Liverpool, UK
b
Received 27 September 2007; accepted 9 October 2007
Index words: Appendicitis; Appendicectomy; Children; Care pathway
Abstract Background/Purpose: Appendicitis is the most common surgical emergency in children. However, management varies widely. The aim of this study was to assess the impact of introducing a care pathway on the management of childhood appendicitis. Methods: Data were collected prospectively for 3 successive cohorts: Group A, before introduction of pathway; Group B, after introduction of pathway; Group C, after modification of pathway. All patients operated for suspected appendicitis were included. The pathway was modified after interim analysis of group B data. P b .05 was significant. Results: Six hundred patients were included. When compared with group A, group C patients were more likely to receive preoperative antibiotics (P b .0001), undergo formal pain assessment (P b .0001), and be operated before midnight (P = .025). There was a significant decrease in readmission rates from 10.0% to 4.2% (P = .023) despite an increase in cases of gangrenous and perforated appendicitis (P = .010). Conclusions: The introduction of a care pathway resulted in improved compliance with antibiotic regimens, more frequent pain assessment, and fewer post-midnight operations. Postappendicectomy readmission rates were reduced despite an increase in disease severity. This was achieved by critical reevaluation of outcomes and pathway redesign where appropriate. © 2008 Elsevier Inc. All rights reserved.
Integrated care pathways detail steps in the care of patients with a specific clinical problem, within a set time scale and reflecting current management guidelines [1,2]. A defining characteristic of an integrated care pathway (ICP) Presented at the British Association of Paediatric Surgeons meeting, Edinburgh, Scotland, July 17-20, 2007. ⁎ Corresponding author. Tel.: +44 0 151 2284811. E-mail address: [email protected] (S.L. Almond). 0022-3468/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2007.10.019
is the opportunity to record variations from standard practice (variances). Recording the reasons for variances enables more meaningful audit and ICP reevaluation and update [1,3]. Integrated care pathways are ideally suited to the management of common surgical conditions with welldefined outcomes, such as appendicitis [1,4]. Furthermore, management of appendicitis varies widely even within individual institutions [5]. We aimed to develop guidelines
316 Table 1
S.L. Almond et al. diagnosis, histologic results, analgesic requirements, preand postoperative antibiotic regimens, requirement for and duration of parenteral nutrition, and postoperative course including complication and readmission rates.
Exclusion criteria for study
Appendicitis not suspected preoperatively (even if found at operation) Elective appendicectomy Incidental appendicectomy (eg, during surgery for malrotation) Interval appendicectomy after nonoperative management of appendix mass
1.3. Group B: pathway development and implementation
for the management of appendicitis in our hospital and implement these within an ICP as a means of improving patient care.
1. Materials and methods 1.1. Data collection Data were collected prospectively by junior medical staff. All patients undergoing surgery for suspected appendicitis were included in the study, even if an alternative diagnosis was discovered at operation. Exclusion criteria are summarised in Table 1. Data collection began from the time a decision to operate was made, and data were stored on an Access database (Microsoft Corporation, Redmond, WA). To ensure complete ascertainment, a list of all appendix specimens received by the hospital histopathology department was cross-checked with the prospectively collected data, and missing cases were added to the database. Data were collected for 3 cohorts:
After the analysis of group A data, key areas for improvement were identified and incorporated into an integrated care pathway. A multidisciplinary team led by a surgical trainee, a senior nurse and the hospital's Pathway Coordinator designed the pathway. The ICP was implemented after a series of multidisciplinary meetings explaining its relevance in terms of the results of the group A data. Data collection resumed after a 1-month pilot period. All patients undergoing surgery for presumed appendicitis were entered into the study and commenced on the pathway, in an attempt to standardise management and thus improve outcomes. The pathway was divided into 4 sections: • Decision to operate checklist (medical): recommended intravenous antibiotic (cefotaxime and metronidazole) and fluid regimens (0.45% saline/5% dextrose, 10 mmol KCl in 500 mL); prompts to discuss patient with anaesthetist and theatre staff; preprinted consent form with current complication rates. • Preoperative care (nursing): space to record observations; pain scoring scales and guidelines on analgesia use. • Operation record (medical): surgery commenced before/ after midnight; details of operative technique and findings; hospital guidelines for postoperative antibiotic administration (cefotaxime and metronidazole) single dose (normal appendix), 3 doses (inflamed), 5 days (gangrenous), and 5 days with gentamicin (perforated); • Postoperative care (nursing): detailing management of observations, analgesia, oral intake, and mobility.
• Group A (control group): before introduction of ICP, September 2002 to September 2003 (1 year) • Group B: after introduction of ICP, March 2004 to September 2004 (6 months) • Group C: after modification of ICP, October 2004 to October 2005 (1 year)
1.2. Group A: measuring current practice The first step was to audit established practice to set standards. Patient management was determined by the preferences of the surgical on-call team, without any defined guidelines being used. Variables included demographics, preoperative investigations, operative technique (laparoscopic or open), operative details including surgical Table 2
1.4. Group C: pathway reevaluation and modification Interim analysis of group B data was undertaken after 6 months and the ICP modified according to these results and to suggestions arising from a further series of multidisciplinary meetings (see Results). Subsequently, patients
Surgical outcomes
Laparoscopic Gangrenous/perforated Inflamed Normal Other diagnosis
A (n = 211)
B (n = 172)
P (A vs B)
C (n = 217)
P (A vs C)
61/211 68/210 102/210 32/210 8/210
39/172 65/172 76/172 29/172 2/172
.198 .282 .411 .676 .196
95/216 96/214 73/214 41/214 4/214
.001 .010 .003 .305 .256
(28.9%) (32.4%) (48.6%) (15.2%) (3.8%)
(22.7%) (37.8%) (44.2%) (16.9%) (1.2%)
(44.0%) (44.9%) (34.1%) (19.2%) (1.9%)
Impact of a care pathway for appendicitis Table 3
317
Outcomes
Outcome variable
A (n = 211)
B (n = 172)
P (A vs B)
C (n = 217)
P (A vs C)
Preoperative antibiotics Formal pain assessment Operation after midnight Intraabdominal collection or wound infection Readmission within 6 months
66/211 (31.3%) 66/211 (31.3%) 38/211 (18.0%) 19/211 (9.0%)
80/172 (46.5%) 136/168 (81.0%) 30/172 (17.4%) 14/172 (8.1%)
.003 b.0001 .894 .856
136/217 152/209 22/217 10/216
b.0001 b.0001 .025 .084
21/211 (10.0%)
14/172 (8.1%)
.596
were managed according to the modified ICP protocols and data were collected for a further year.
1.5. Primary outcome variables Improved outcomes were considered to be a reduction in pathway variances, length of postoperative stay, complications (wound infection, abscess formation), and readmission within 6 months of surgery.
1.6. Data analysis Data were analysed using SPSS (v12, SPSS Inc, Chicago, IL) and GraphPad Prism (v5, Graphpad Software Inc, San Diego, Calif) software. Fisher's Exact test or 1-way analysis of variance was used as appropriate. P b .05 was significant.
2. Results 2.1. Demographics Six hundred patients were included in the study. There were no significant differences between the groups in age (in mean [SD]: group A, 10.8 [3.4] years; group B, 10.8 [3.6] years; group C, 11.5 [3.1] years; P = .064) or sex (males: group A, 50.7%; group B, 55.2%; group C, 57.1%; P = .207). Surgical outcomes are summarised in Table 2. There was a strong correlation between surgical diagnosis and histologic findings (data not included). Group C contained significantly more cases of gangrenous/perforated appendicitis and significantly fewer cases of inflamed appendicitis. More laparoscopic appendicectomies were performed in group C.
(62.7%) (72.7% (10.1%) (4.6%)
9/216 (4.2%)
.023
formal pain assessment tools (Table 3). However, postmidnight operating, complication, and readmission rates were unaffected. One hundred percent of eligible patients were commenced on the ICP.
2.4. Group C After the analysis of group B data, the pathway was modified in an attempt to further improve outcomes. A preoperative checklist including antibiotic prescribing, with space to document variances, was included, and operating after midnight was included as a separate category requiring variances to be recorded and justified. Other changes related to document layout for ease of use and data collection. Subsequent to the pathway modifications, preoperative antibiotic administration improved to 62.7% (P b .0001) and post-midnight operating was reduced to 10.1% (P = .025). These improvements were accompanied by a halving in readmission rates (P = .023) and a nonsignificant trend toward a reduction in intraabdominal collection and hospitaltreated wound infection rate, despite significantly more cases of gangrenous/perforated appendicitis (Tables 2 and 3). No differences in postoperative length of stay were seen between the groups (data not shown). The increased number of laparoscopic appendicectomies performed in group C could have represented a confounding factor in the reduction in post-midnight operations, complication rates, and readmission rates. However, subgroup analysis demonstrated no significant differences for these variables when laparoscopic and open procedures were compared independently (Table 4).
3. Discussion 2.2. Group A After the analysis of group A data (Table 3), target areas for improvement were identified as preoperative antibiotic administration, formal pain assessment, and the numbers of cases being performed after midnight.
2.3. Group B Introduction of the ICP resulted in significant improvements in preoperative antibiotic administration and the use of
This article describes the successful implementation of an ICP for the management of childhood appendicitis in a tertiary paediatric centre. This was achieved by a stepwise sequence of events beginning with an audit of current practice. At this stage, 3 target areas for improvement were identified, namely, pain management, antibiotic administration, and post-midnight operating. It is well recognised that the use of age-appropriate pain scoring systems improves pain management [6], yet only 31% of children were undergoing formal pain assessment. Similarly, only a third of
318
Table 4
Subanalysis of laparoscopic and open appendicectomy groups Operated after midnight
Group A Group C P (A vs C)
Intraabdominal collection or wound infection
Readmission within 6 mo
OA
LA
OA + LA
OA
LA
OA + LA
OA
LA
OA + LA
31/150 (20.7%) 18/121 (14.9%) .267
7/61 (11.5%) 4/95 (4.2%) .111
38/211 (18.0%) 22/217 (10.1%) .025
13/150 (8.7%) 7/121 (5.8%) .485
6/61 (9.8%) 3/95 (3.2%) .155
19/211 (9.0%) 10/216 (4.6%) .084
15/150 (10.0%) 6/121 (5.0%) .170
6/61 (9.8%) 3/95 (3.2%) .155
21/211 (10.0%) 9/216 (4.2%) .023
OA indicates open appendicectomy; LA, laparoscopic appendicectomy.
S.L. Almond et al.
Impact of a care pathway for appendicitis children received preoperative antibiotics, despite hospital policy. Several studies conclude that the use of antibiotics in patients undergoing appendicectomy results in reduction in the rate of postoperative wound infections and intraabdominal abscess collections [7]. Finally, post-midnight operations are difficult to justify in patients who do not have peritonitis [8,9]. We were concerned that the high number of appendicectomies being performed after midnight was a reflection of time pressure in theatre rather than clinical necessity. The high numbers of patients re-presenting with wound infections and intraabdominal collections or requiring readmission to hospital (9% and 10%, respectively) made these obvious outcomes by which to measure improvements in practice. Introduction of the ICP resulted in immediate improvement in antibiotic administration and pain monitoring. However, other outcomes were unchanged. This was recognised by interim audit and pathway changes were made, as previously described. Subsequently, improvements were seen in all parameters despite an increase in numbers of gangrenous and perforated appendicitis. The increase in cases of complicated appendicitis could be attributed to fewer postmidnight operations, but this is countered by a concomitant increase in preoperative antibiotics and reduction in readmission rates. The normal appendix rate remained unchanged at 19%; this is to be expected as patients were only commenced on the pathway after a decision to operate had been made. Of note is the increase in numbers of laparoscopic appendicectomies in group C, which was being introduced at our institution during the period of this study. Again, it could be suggested that this would account for changes in complication/readmission rates and timing of surgery. However, subanalysis showed that this was not the case. The use of integrated care pathways is now commonplace, particularly in the management of surgical conditions [1]. They have variously been shown to improve patient care and outcomes, reduce costs, guide decision-making by junior clinicians, and improve professional relationships, as well as provide a powerful audit tool [1,3-5,10-12]. However, most studies are retrospective or descriptive [1]. Attitudes to pathways are variable with many health care workers feeling that they stifle innovation and limit clinical judgement. Pathways are also instituted at a local level, meaning that they are reliant on a high degree of enthusiasm from several individuals to ensure they are well designed and remain in use [1,3-5]. We found that the keys to successful pathway implementation were selection of an appropriate condition and targets for improvement, a multidisciplinary approach to pathway
319 design, communication and discussion of results with all staff and, above all, frequent reevaluation of outcomes. To our knowledge, only one previous group has reevaluated an appendicectomy care pathway after initial implementation [5]. This group found that not all favourable outcomes of their pathway were sustained and suggested further monitoring and education may remedy this. Our pathway continues to evolve to reflect changing practice.
Acknowledgment The authors acknowledge the involvement and cooperation of all surgeons at Royal Liverpool Children's NHS Trust with this study. They would also like to recognize the work of Sister Tracey Irvine in the design and development of the pathway.
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