Conference Coverage

Pediatric appendectomy fast track reduced LoS, narcotic use



– A fast-track protocol for pediatric patients with noncomplicated appendicitis significantly reduced length of stay and improved other measures of quality care, according to results from a recent single-center quality improvement project.

After implementation of the multidisciplinary clinical pathway, postoperative narcotic use decreased, while use of a standard antibiotic regimen increased, said Angela M. Kao, MD, a surgical resident with Carolinas Medical Center, Charlotte, N.C.

Of the patients treated according to the fast-track pathway, 90% were discharged within 8 hours of surgery or immediately after morning rounds with no increase in complications or readmissions, said Dr. Kao, who was named the Trainee Abstract Competition Winner based on this research presented at the American College of Surgeons Quality and Safety Conference.

While same-day discharge after laparoscopic appendectomy is safe for most children with nonperforated acute appendicitis, there is wide variability in its perioperative management, Dr. Kao said in an oral abstract presentation.

“At our institution, we noted that no standardized protocol existed for patients with noncomplicated appendicitis, leading to wide variations in postoperative length of stay,” she said.

In addition, preoperative antibiotics and postoperative pain regimens were largely based on provider preference, she added.

Accordingly, a multidisciplinary team used information from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) to identify areas for improvement, including multimodal analgesia, standardization of antibiotics, early mobilization, and discharge initiated by nursing.

They also created a designated pre- and postoperative unit staffed by nurses trained in ERAS (Enhanced Recovery After Surgery), which greatly facilitated the goals of the project, Dr. Kao and her coauthors said.

The study results included 61 patients with noncomplicated acute appendicitis who underwent laparoscopic appendectomy after implementation of the fast-track pathway initiative. They were compared with a historical cohort of 58 patients treated in the year leading up to implementation of the pathway.

Dr. Kao and her colleagues found that 87% of fast-track patients received the standard recommended dosing of a third-generation cephalosporin and metronidazole, compared with just 13.8% among those in the period before the fast track’s implementation. In addition, duplicate antibiotic dosing was seen in 6.6% of cases, down from 49%.

Postoperative nausea was minimal, with 9% of fast-tracked patients requiring antiemetic, down from 18.9% in the previous period.

Postoperative IV narcotic use decreased from 86% to 54% because of the use of multimodal analgesia, Dr. Kao added.

Total hospital length of stay decreased 43% to a mean of 16 hours, and the postoperative length of stay decreased by 60% to a mean of 8 hours with no differences in complications or readmission, compared with the period before the fast track’s implementation, according to Dr. Kao.

Almost all of the fast-track patients (90.2%) were discharged within 8 hours or, in the case of procedures performed between midnight and 7 a.m., discharged immediately after morning rounds, according to data presented by the investigators.

“At our institution, a transition from patients discharged by the surgical team to nursing-initiated recovery and discharge was a key component,” Dr. Kao said at the meeting. “Earlier discharge was largely facilitated by nursing-initiated discharge, which allowed for more frequent evaluation of discharge readiness, compared to surgeon providers.”

Dr. Kao had no disclosures relevant to her presentation.

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