Implementing a surgeon-reported categorization of pediatric appendicitis severity
The purpose of this study was to implement a novel surgeon-reported categorization (SRC) for pediatric appendicitis severity and determine if SRC was associated with outcomes.
We conducted a retrospective review of appendectomies by 15 surgeons within a single center from January to December 2016. The SRC was defined as: simple (category 1), gangrenous or adherent (category 2A), perforation with localized abscess (category 2B), and perforation with gross contamination (category 2C). Logistic regression modeled the surgical site infections (SSI) and returns to the system. Cox proportional hazards analyses modeled the length of stay (LOS).
The cohort included 697 patients (mean age 10.7 years). Compliance with SRC documentation increased from 33.5 to 85.9%. Review of operative findings revealed 100% concordance with SRC. The combined morbidity (SSI and revisits) rate was 9.8%. Category 2C patients had the highest odds of SSI (odds ratio 3.37 95% confidence interval 1.07–10.59). Median LOS increased with each category (category 1 = 1d, category 2A = 2d, category 2B = 4d, category 2C = 6d). When modeling intra-abdominal abscess, SRC displayed an improved model calibration and discrimination compared to wound class.
SRC implementation is feasible and provides a granular assessment of appendicitis severity and outcomes. SRC may guide future quality improvement through development of grade-specific care pathways.
KeywordsPediatric Appendicitis Severity Grading Outcomes
The authors would like to thank the multidisciplinary QI team at Children’s Hospital of Atlanta for their assistance on this project and to the surgeons in the Division of Pediatric Surgery for participating in the QI process.
KJB: study design, data collection, drafting manuscript, critical revision of manuscript. HLS: study design, data collection, critical revision of manuscript. CDT: study design, data analysis, creating tables, critical revision of manuscript. KFH: concept development, study design, critical revision of manuscript. MVR: concept development, study design, data analysis, critical revision of manuscript.
This study was funded in part using internal Children’s Healthcare of Atlanta Quality Improvement Award.
Compliance with ethical standards
Conflict of interest
Katherine J. Baxter, MD, MS reports no conflicts of interest. Heather L. Short, MD reports no conflicts of interest. Curtis D. Travers, MPH reports no conflicts of interest. Kurt F. Heiss, MD reports no conflicts of interest. Mehul V. Raval, MD, MS reports no conflicts of interest.
Research involving human participants and/or animals
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Approval was obtained from the Emory University Internal Review Board (#00077519) before the retrospective data review.
Not applicable based on the retrospective nature of the study.