Reducing Postoperative CT Imaging for Children With Complicated Appendicitis: A Pediatric Surgical Quality Collaborative Quality Improvement Project

Peter Juviler; Alicia C Greene; Terry Fisher; Afif N Kulaylat; John Chandler; Fabienne Gray; Cindy Gingalewski; Catherine Ehster; Mary Bolhuis; Elisa Garcia; Maryam Broussard; Kevin P Lally; Tamar Levene; Derek Wakeman

doi:10.1016/j.jpedsurg.2024.03.040

Reducing Postoperative CT Imaging for Children With Complicated Appendicitis: A Pediatric Surgical Quality Collaborative Quality Improvement Project

J Pediatr Surg. 2024 Mar 20:S0022-3468(24)00194-5. doi: 10.1016/j.jpedsurg.2024.03.040. Online ahead of print.

Authors

Affiliations

¹ Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, United States. Electronic address: peter_juviler@urmc.rochester.edu.
² Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, PA, United States.
³ Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States.
⁴ University of South Carolina School of Medicine - Greenville, Greenville, SC, United States.
⁵ Children's Hospital New Orleans, Louisiana State University, New Orleans, LA, United States.
⁶ Pediatric Surgery, Randall Children's Hospital, Portland, OR, United States.
⁷ Children's Wisconsin, Medical College of Wisconsin, Milwaukee, WI, United States.
⁸ Division of Pediatric General and Thoracic Surgery, Joe DiMaggio Children's Hospital, Hollywood, FL, United States.
⁹ Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, United States.

PMID: 38609761
DOI: 10.1016/j.jpedsurg.2024.03.040

Abstract

Background: Despite widespread initiatives to reduce ionizing radiation for appendicitis diagnosis, computed tomography (CT) scanning postoperatively remains common. The Pediatric Surgery Quality Collaborative (PSQC) aimed to identify differences between children's hospitals with high and low postoperative CT usage for complicated appendicitis.

Methods: Using National Surgery Quality Improvement Program Pediatric data from PSQC children's hospitals, we compared postoperative CT imaging for complicated appendicitis (April 2020-March 2021). Key stakeholders from 11 hospitals (5 low CT utilization, 6 high CT utilization) participated in semi-structured interviews regarding postoperative imaging. Qualitative analysis of transcripts was performed deductively and inductively based on the Theoretical Domains Framework (TDF).

Results: Five of twelve TDF domains were most prominent in influencing CT use: skills, beliefs about capabilities, intentions/goals, memory and decision processes, and environment. Children's hospitals with lower rates of postoperative CT use tended to: trust and educate the ultrasound technicians; believe US strengths outweigh weaknesses; image no sooner than 7 days postoperatively; have access to sufficient quality improvement resources; maintain trusting relationships between specialties; and prioritize radiation stewardship.

Conclusion: Hospitals at extremes of postoperative CT use for complicated appendicitis reveal strategies for improvement, which include imaging protocol development and adherence, quality improvement resource availability, interdisciplinary collaboration, and promoting radiation stewardship.

Level of evidence: Level V.

Keywords: Complicated appendicitis; Computed tomography (CT); National Surgery Quality Improvement Program (NSQIP); Pediatric surgery; Quality improvement; Radiation stewardship.