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The costs and benefits of emergent surgical workflow for acute appendicitis in children

  • Katherine C. Ott
    Correspondence
    Corresponding author.
    Affiliations
    Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
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  • Maxwell A. McMahon
    Affiliations
    Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
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  • Jonathan C. Vacek
    Affiliations
    Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
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  • Suhail Zeineddin
    Affiliations
    Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
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  • Yue-Yung Hu
    Affiliations
    Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
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  • Mehul V. Raval
    Affiliations
    Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
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  • Seth D. Goldstein
    Affiliations
    Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
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      Highlights

      • A modest delay in time to operation does not increase disease severity in acute appendicitis.
      • QI initiatives are likely more effective than expediting urgency at decreasing hospital resource utilization.
      • Institutions are recommended to focus on standardization of workflow and same day discharge for nonperforated appendicitis.

      Abstract

      Background

      Controversy exists regarding how operative timing affects patient safety and resource utilization for acute appendicitis. Over 3 years, our institution trialed efforts to optimize appendectomy workflow. Our aim is to describe the ramifications of expediting appendectomy and implementing standardized protocols relative to historic controls.

      Methods

      Patient records at a freestanding children's hospital were reviewed from synchronized 6-month periods from 2019 to 2021. During Year 1 (historic), no standardized workflows existed. In Year 2 (expedited), appendicitis management was protocoled using a clinical quality improvement bundle, which included performing appendectomies within two hours of diagnosis. In Year 3 (QI), operative timing was relaxed to the same calendar day while all prior QI initiatives continued. Descriptive statistics were performed, using hospital length of stay (LOS) as the primary outcome.

      Results

      298 patients underwent appendectomy for acute appendicitis. The median expedited workflow LOS was 15.3 hours shorter (p = 0.003) than historic controls; however, this was sustained despite relaxation of surgical urgency in the QI workflow. No differences in perforation rates were observed. During the expedited workflow, OR overtime staffing expense increased by $90,000 with no significant change in hospital costs. In multivariate regression, perforation was the only variable associated with LOS.

      Conclusion

      Hospital LOS can be shortened by expediting appendectomy. However, in our institution this did not decrease hospital costs and was furthermore balanced by higher personnel expenses. A sustained decrease in LOS after relaxing operative urgency standards implies that concurrent QI initiatives represent a more effective and cost-efficient strategy to decrease hospital resource utilization.

      Level of evidence

      Level III

      Keywords

      Abbreviations:

      CT (computed tomography), ED (emergency department), MRI (magnetic resonance imaging), OR (operating room), QI (quality improvement), IV (intravenous), LOS (length of stay)
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