Dr Mary McCaskill and her team at The Children’s Hospital at Westmead have developed a safe and effective model of care for children presenting to the emergency department (ED) with possible appendicitis.

Appendicitis in the children’s emergency department

Appendicitis is the most common reason for emergency surgery in children but is difficult to diagnose. Although abdominal pain is one of the most typical reasons for children presenting to an ED, almost 90% will not have acute appendicitis.

For doctors, making a correct and early diagnosis is important because delayed diagnosis of appendicitis can lead to complications and potentially major consequences. However, this means that children are often over-investigated, with more invasive and expensive investigations performed.

Tackling the problem

While various investigations and scoring systems have looked at ways to better diagnose appendicitis, little research has been done to work out which children have a risk level low enough to be sent home. Thanks to HCF Research Foundation funding, Dr McCaskill and her team at The Children’s Hospital at Westmead created a model of care using one of the best known and most studied decision rules for acute appendicitis (Paediatric Appendicitis Score, or PAS) to assess children presenting to the ED with possible appendicitis. The aim of the study was to understand if it is safe to discharge children aged between five and 16 who have signs indicating a ‘low risk’ of appendicitis, with early follow-up with their own GP to check their progress. They looked at the risk of those children having to come back to hospital within 24 hours. Each child was assessed and scored on the elements such as the location of the pain and tenderness, nausea or vomiting, and fever, as well as blood test results for some children. The families involved in the study were contacted by phone to establish if they had returned to hospital within the following two weeks. They were also asked about their satisfaction with the care given.

If children are in pain, or there is further concern from the family, they are advised to re-present to hospital immediately. The results show that it is safe to discharge patients at low risk of appendicitis with early planned review within 24 hours. For the child and their family, this means less time spent in hospital and less disruption. For the hospital, it relieves the load on surgical staff and reduces costs. The PAS score provides a common language between doctors so they can easily prioritise those patients who are at a higher risk.

This successful model of care has the potential to be implemented at other hospitals, with the full potential realised if it were integrated as part of an agreed model of care between EDs across New South Wales and other states and territories.

Key results

• 283 patients aged between five and 16 with abdominal pain and a low risk for appendicitis were enrolled in the study and discharged from ED.
• 92% of those sent home recovered at home without further hospital care.
• Of the 8% who re-presented to hospital, five patients (1.7%) needed an operation, and four had appendicitis (1.4%).