Improving ultrasound for appendicitis through standardized reporting of secondary signs

Abstract

Objective: Our aim was to implement a standardized US report that included secondary signs of appendicitis (SS) to facilitate accurate diagnosis of appendicitis and decrease the use of computed tomography (CT) and admissions for observation.

Methods: A multidisciplinary team implemented a quality improvement (QI) intervention in the form of a standardized US report and provided stakeholders with monthly feedback. Outcomes including report compliance, CT use, and observation admissions were compared pretemplate and posttemplate.

Results: We identified 387 patients in the pretemplate period and 483 patients in the posttemplate period. In the posttemplate period, the reporting of SS increased from 5.4% to 79.5% (p<0.001). Despite lower rates of appendix visualization (43.9% to 32.7%, p<0.001) with US, overall CT use (8.5% vs 7.0%, p=0.41) and the negative appendectomy rate remained stable (1.0% vs 1.0%, p=1.0). CT utilization for patients with an equivocal ultrasound and SS present decreased (36.4% vs 8.9%, p=0.002) and admissions for observations decreased (21.5% vs 15.3%, p=0.02). Test characteristics of RLQ US for appendicitis also improved in the posttemplate period.

Conclusion: A focused QI initiative led to high compliance rates of utilizing the standardized US report and resulted in lower CT use and fewer admissions for observation. Study of a Diagnostic Test Level of Evidence: 1.

Keywords: Appendicitis; Quality improvement; Secondary signs; Ultrasound.

Copyright © 2017 Elsevier Inc. All rights reserved.

Figures

Figure 1

Diagram of the specific aim and description of the key drivers of change for instituting a surgical quality improvement project to decrease the number of computer tomography scans (CTs) and admissions after an equivocal right lower quadrant (RLQ) ultrasound (US) for appendicitis.

Figure 2

Control Chart (p-chart) of monthly computer tomography scans (CTs) utilization rate and admission rate with standardized ultrasound report compliance rate.