Standardization of care for pediatric perforated appendicitis improves outcomes

Background The treatment of perforated appendicitis in children is characterized by significant variability in care, morbidity, resource utilization, and outcomes. We prospectively studied how minimization of care variability affects outcomes. Methods A clinical pathway for perforated appendicitis, in use for three decades, was further standardized in May 2015 by initiation of a disease severity classification, refinement of discharge criteria, standardization of the operation, and establishment of criteria for use of postoperative total parenteral nutrition, imaging, and invasive procedures. Prospective evaluation of all children treated for 20 months on the new fully standardized protocol was conducted and compared to a retrospective cohort treated over 58 months prior to standardization. Differences between outcomes before and after standardization were analyzed using regression analysis techniques to adjust for disease severity. Results Median follow-up time post discharge was 25 and 14 days in the post- and prestandardization groups, respectively. Standardization significantly reduced postoperative abscess (9.8% vs. 17.4%, p = 0.001) and hospital stay (p = 0.002). Standardization reduced the odds of developing a postoperative abscess by four fold. Conclusion Minimizing variability of care at all points in the treatment of perforated appendicitis significantly improves outcomes. Type of study Prospective Cohort Study. Level of evidence Level II.