Distilling the Key Elements of Pediatric Appendicitis Clinical Practice Guidelines

Abstract

Background: Use of clinical practice guidelines (CPGs) have been shown to reduce care delays, optimize resource utilization, and improve patient outcomes. We conducted a systematized review to identify key elements that should be included in an evidence-based CPG for pediatric appendicitis.

Methods: We characterized key decision points and content areas from CPGs developed from 2000 to 2019 that were identified using publicly available platforms and manual search/personal communications.

Results: Twenty-seven CPGs were reviewed with content saturation achieved after reviewing eight. We found 16 key elements spanning from triage to postoperative care. Elements with high accord among CPGs included use of laparoscopy and delay of postoperative imaging for abscess screening until postoperative day seven. For simple appendicitis, all CPGs endorsed antibiotic cessation, diet advancement, and early activity, and 11 CPGs included same-day discharge. Elements with heterogeneity in decision-making included antibiotic selection/duration for perforated appendicitis, criteria defining perforation, and utility of postoperative laboratory evaluations.

Conclusions: Development of an evidence-based CPGs for pediatric appendicitis requires attention to a finite number of key decision points and content areas. Existing literature demonstrates improved patient outcomes with CPG implementation.

Keywords: Clinical practice guideline; Pediatric appendicitis; Perforated appendicitis; Practice guideline; Quality improvement; Simple appendicitis.

Fig. 1 –

Decision points for pediatric appendicitis clinical practice guidelines (CPGs) (simple and perforated). Twenty-seven CPGs for pediatric appendicitis were reviewed and deconstructed at their decision points, revealing 16 key elements necessary for development of a clinical practice guideline. Relative heterogeneity among CPG elements are reflected by the color scheme as follows. CBC = complete blood count; IR = interventional radiology; NGT = nasogastric tube; PICC = peripherally inserted central venous catheter.

Fig. 2 –

Key elements for CPG development. CPG = clinical practice guideline. (Color version of figure is available online.)