Evaluation of a novel pediatric appendicitis pathway using high- and low-risk scoring systems

Ross J. Fleischman, Miranda K. Devine, Marie Annick N. Yagapen, Angela J. Steichen, Matthew L. Hansen, Andrew F. Zigman, David M. Spiro

Research output: Contribution to journalArticlepeer-review

21 Scopus citations


OBJECTIVES: This study aimed to determine the test characteristics of a pathway for pediatric appendicitis and its effects on emergency department (ED) length of stay, imaging, and admissions. METHODS: Children age 3 to 18 years with suspicion for appendicitis at 1 tertiary care ED were prospectively enrolled, using validated low- and high-risk scoring systems incorporating history, physical examination, and white blood cell count. Low-risk patients were discharged or observed in the ED. High-risk patients were admitted. Those meeting neither low-risk nor high-risk criteria were evaluated by surgery, with imaging at their discretion. Chart review or telephone follow-up was conducted 2 weeks after the visit. A retrospective study before and after was also performed. Charts of a random sample of patients evaluated for appendicitis in the 8 months before and after the pathway implementation were reviewed. RESULTS: Appendicitis was diagnosed in 65 of 178 patients. Of those with appendicitis, 63 were not low-risk (sensitivity, 96.9%; specificity, 40.7%). The high-risk criteria had a sensitivity of 75.3% and specificity of 75.2%. We reviewed 292 visits before and 290 after the pathway implementation. Emergency department length of stay was similar (253 minutes before vs 257 minutes after, P = 0.77). Computed tomography was used in 12.7% of visits before and 6.9% of visits after (P = 0.02). Use of ultrasound was not significantly different (47.3% vs 53.7%). Admission rates were not significantly different (45.5% vs 42.7%). CONCLUSIONS: The low-risk criteria had good sensitivity in ruling out appendicitis. The high-risk criteria could be used to guide referral or admission. Neither outperformed the a priori judgment of experienced providers.

Original languageEnglish (US)
Pages (from-to)1060-1065
Number of pages6
JournalPediatric emergency care
Issue number10
StatePublished - Oct 1 2013


  • Abdominal pain
  • Appendicitis
  • Clinical pathways

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Emergency Medicine


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