JMIR Publications

ABSTRACT

Background:

Pediatric appendicitis accounts for an estimated 7-10% of abdominal pain cases in the emergency department (ED). The diagnosis is time consuming, and the investigative process is dependent on physician assessment, resulting in delays in diagnosis and therapeutic management. The utility of an advanced nursing directive to expedite this process is unclear and needs further exploration.

Objective:

Our study aims to describe key components of ED flow in suspected appendicitis patients seen at a pediatric ED and pilot a directive that allows ED nurses to perform an order-set that includes blood work, urine tests, analgesics, fluids, and order an abdominal-pelvis ultrasound prior to physician assessment.

Methods:

This study involves conducting a retrospective chart review alongside a quality improvement initiative to compare key ED flow metrics before and after advanced nursing directive implementation. Primary outcome measures include median time from ED triage assessment to ultrasound completion, analgesia administration, bloodwork results, time to disposition (consult or discharge), alongside other key ED flow metrics for suspected appendicitis. Secondary outcomes will involve patient and caretaker satisfaction surveys. Descriptive statistics will be used to summarize the data. For differences in proportions, a χ2 test will be used. Student’s t-test will be used for continuous variables. A variable-controlled run chart will be performed to assess impact on ED flow metrics. Patient and family satisfaction surveys are administered immediately after the directive encounter and seven days afterwards.

Results:

There are currently 3900 patients who have been screened, 344 patients enrolled, and 90 patients who have received the medical directive since implementation in June 2020. Interim results on reduction of time to diagnostic and therapeutic ED flow parameters and satisfaction surveys are expected to be published in February 2022. The final study endpoint will be in June 2022.

Conclusions:

This study proposes a novel protocol for improving the diagnosis and treatment of suspected pediatric appendicitis through implementation of an evidence-based advanced nursing directive. This model may provide a standardized, international pathway for management of common pediatric and adult emergencies.