Introduction

Appendicitis remains the most commonly occurring acute abdominal emergency in both children and adults globally occurring in 5.7-50/100,000 [1]. Although first described by Fitz in 1886, and despite its frequency and perceived simplicity, clinicians are not achieving acceptable diagnostic accuracy with almost 20% of patients undergoing unnecessary surgery [2,3]. Appendicitis presents across a diverse, heterogenous spectrum of acute severity from mild appendicitis to generalised peritonitis. There are further confounders such as age, where perforation risk is greater in younger children (30-75%) and older patients (50-70%) [2,3]. Apart from patient co-morbidities, delay in presentation and variable surgical management contributes to variable outcomes including re-admission rates which can approach 15% at 30 days [4-6].

To improve diagnostic and patient outcomes, pathway-driven surgical care, using combined clinical, laboratory, imaging and scoring systems should be incorporated into clinical care [7-9]. Clinical pathways, initially proposed by Vanhaecht and colleagues in 2007, lead to the development of the European Pathway Association (EPA) in 2008, which defines them to be a “complex intervention for the mutual decision making and organisation of care processes for a well-defined group of patients during a well-defined period” [10]. The Royal College of England has recommended formal pathways for delivery of standardised emergency surgical care and quality improvement [11]. Multiple studies have validated the utilisation of such pathways in improving clinical outcomes in all emergency surgical patients including both adult and paediatric patients presenting with appendicitis [12-16]. Key performance or outcome indicators including negative appendectomy rates and re-admission rates have been used as quality benchmarks in appendicitis. This allows comparison of patient care to set standards, which can, in turn, guide interventions with the aim of improving outcomes [9,16-19].

The aim of this study was to review current evidence base for RIF pain / appendicitis guidelines to develop a decision and management pathway with benchmarking Key Outcome Indicators (KOIs).

Methods

Two systematic reviews of literature were undertaken from January 2011 to December 2021 utilising the PRISMA guidelines to retrieve consensus statements and peer reviewed guidelines for the diagnosis and management of patients presenting with appendicular right iliac fossa pain [20]. Pubmed, EMBASE and Cochrane databases were searched using the key words “appendicitis”, “guidelines”, “consensus”, “adult”, “paediatric”. Web searches and review of citations from relevant articles were also preformed.

The inclusion criteria of the study delineated that the studies should be in English, include guidelines that utilised critical appraisal of literature for development of recommendations, and be available as peer reviewed articles. In cases whereby there were multiple iterations of a guideline, only the most contemporaneous was used. (Figures 1,2). The included guidelines were assessed by using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool which is a framework designed to evaluate the quality of guidelines which can be reported and utilised to develop clinical practice recommendations and policies [21]. Its design comprises of 6 domains - scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence, which take into account 23 outcomes on a Likert scale ranging from 1 to 7 representing strongly disagree to strongly agree respectively. Though no specific criteria are defined to determine each specific point, a guidance document provides instructions on assessing the different domains to delineate key aspects to score the guidelines appropriately. Each domain is then separately scored, and a guideline is deemed “High Quality” if the assessment of at least domain three accomplishes a score greater than 70. Two independent authors scored the guidelines (UK, JF), and a combined score was calculated for each domain. The guidelines deemed as high quality were used to extract statements and recommendations to develop an evidence based clinical pathway.

Development of the Paper-Based Pathway

The development of a paper-based clinical pathway for patients presenting with right iliac fossa pain involved a Multidisciplinary Team (MDT) of surgical consultants, senior surgical trainees and registrars, and surgical nursing staff. Emergency physicians, radiology consultants and the eSOAP team including nurses, research fellows and an information and technology (IT) expert (MB) also formed an integral part of the MDT. Weekly meetings and clinical consensus focussing on evidence-based guidelines, utilisation of robust and cost effective scoring systems, and availability of hospital resources, including operating theatre access, Magnetic Resonance Imaging (MRI) and out of hours CT scanning were all taken into consideration during the design process. A process mapping approach helped formulate a decision tree model for a paper-based guidance tool to stratify patients presenting with right iliac fossa pain and also outline the KOIs (Table 1) that would help in defining quality of care for this cohort [1,19,22,23].

Operators

The pathway was intended to serve as a clinical aid for emergency department physicians and surgeons by guiding assessment, diagnosis, and management of patients with RIF pain with a focus on prompt recognition and diagnosis of appendicitis, with severity stratification. It was designed for use by all levels of seniority with the goal of achieving low variance in care, and achievement of KOIs (Table 1). This paper based pathway was to be labelled and filed in the patients’ medical records and the stage of the pathway clearly marked or encircled.

Implementation

The pathway was implemented on the 1^st of January 2021 and the team continued to meet twice a week to discuss user feedback and modify the pathway accordingly until consensus was reached and a final approved pathway design re implemented on the 1^st of March 2021.

Systematic Review to Determine Key Performance Indicators

Results

The search strategy yielded 1116 articles, and after review of abstracts, and application of inclusion criteria, 10 guidelines were identified for further evaluation (Table 2). The individual domain scores for each guideline are presented in Table 3. Rigour of development domain for six of the guidelines yielded a result greater than 70 and hence they were deemed as high-quality guidelines used to formulate statements and recommendations for the development of a clinical pathway. Four guidelines achieved a score below 70 and were not used in pathway designed. The lowest average scores were seen in the domains of stakeholder involvement and applicability with scores averaging to 46.95 and 48.5 respectively.

Development of the Right Iliac Fossa Decision Tree Model

The statements from the guidelines were tabulated utilising the levels of evidence and grades of recommendations (Appendix 1). The WSES and most other articles [1,26,27,30]. utilised the GRADE scoring methodology and the SFCD/SIAD French guidelines [24] developed a grading system for evidence based on the type of evidence where high quality evidence from meta-analysis was deemed grade A, retrospective studies were grade B, case studies were grade C and finally expert opinion was deemed the lowest type of recommendation where the evidence was weak. Based on these recommendations, the team developed the final decision tree process as follows:

Initial Presentation

The beginning of the pathway was outlined by the patient of acute right iliac fossa pain presenting to the primary care physician or the emergency department triage. The focus of the clinicians during this initial presentation would be to carry out a robust history and clinical examination followed by relevant laboratory tests to finally deem the patient either suitable for discharge back into the community, or referral onto a specialist service such as surgery, gynaecology or paediatrics (Figure 3).

Surgical Review

Appendicitis risk scoring systems are used as clinical adjuncts to aid in diagnosis; Appendicitis Inflammatory Response (AIR) score for males, Adult Appendicitis Score (AAS) for females and Shera score for paediatrics [32]. Following this, patients are assigned one of five distinct triaging categories (Figure 4).

Five Triaging Categories Defined

1. Possible appendicitis: The patient may have right iliac fossa pain but no guarding or rebound tenderness along with normal laboratory results. The male patient may have a low AIR score of less than 5 and a female may have an AAS score less than 10. The female paediatric patient aged 5-15 years may have a Shera score of less than or equal to 3. The male paediatric patient between the age of 5-10 years may have a Shera score of less than or equal to 3, and the age group between 11-15 may have a Shera score of less than or equal to 2
2. Probable appendicitis: These patients may have Right iliac fossa pain with rebound tenderness, guarding, or rigidity. The inflammatory markers would be raised, where the White Cell Count (WCC) is above 13000 and C- Reactive Protein (CRP) is above 10. The male patients may have an AIR score between 5-8 and the females may have an AAS score between 11-15
3. Definite appendicitis: Patients who have signs of rebound tenderness and guarding in the right iliac fossa with a raised WCC above 15000 and a CRP above 20 along with an AIR score above 8 for males, AAS score greater than or equal to 16 and children with a Shera score above 3 may be triaged to this category.
4. Appendicular mass: If the patient has similar features as the previous category along with fullness in the right iliac fossa on clinical examination and a history of duration of symptoms greater than 48 hours, this diagnosis may be considered.
5. Peritonitic patient: These patients may have signs of generalised peritonism on clinical exam along with the features of appendicitis.

Management

Management is guided by triaging category. All patients with likely appendicitis are admitted to hospital. These patients are kept fasting to facilitate possible surgery. Antibiotics may be considered in patients with a definitive appendicitis or after discussion with the senior surgeon on call. Fluid resuscitation and oxygen should follow the local sepsis protocol, followed by a chest x-ray if clinically indicated. Abdominal x-rays should not be done routinely (Figure 3). Once the patients have been triaged based on the proposed five categories, the management of the first two categories would be to reassess in six to eight hours with the consideration of a pelvic ultrasound especially for female patients. The diagnosis of definitive appendicitis in patients below the age of 35, may proceed to laparoscopic appendectomy, and patients above 35 may be considered for a CT scan. Patients with appendicular mass may have a step up approach of imaging with ultrasound followed by CT, and accordingly a laparoscopic appendectomy as an index operation or initial radiological drainage followed by interval appendectomy. Peritonitic patients should be managed by prompt surgical intervention (Figure 4).

Key Outcome Indicators

The systematic review yielded a total of 2470 results, out of which 246 were selected for review after application of the inclusion criteria. From these 246 abstracts, 9 articles were deemed eligible for our review as they contained generic information on key performance indicators for appendicitis [9,17,18-38]. From these articles, the KOIs were tabulated (Appendix 2) and a consensus meeting determined the KOIs for the audit and measurement of the performance of the pathway once implemented. These included 3 domains; 1. Care Process, that dealt with pathway enrolment and use of scoring systems, 2. Surgical Outcomes, which suggested laparoscopic approach with conversion to open rates below 3% and negative appendectomy rates below 10%, and finally, 3. Adverse events, which included 30-day re-admission rates following appendectomy to be less than 5% (Table 3).

Discussion

We identified six high quality guidelines using the AGREE II tool where the guidelines displayed a high standard in the rigour of development domain, and utilised their recommendations to develop a clinical pathway to facilitate clinicians in providing standardised patient care with optimal outcomes [12,16]. A rigorous process of systematic review was used to screen for guidelines to use in pathway design. These were then appraised and quality assessed using the readily available and user friendly AGREE II tool [21]. This tool has many benefits, as it helps delineates guidelines into defined, easily assessable domains which can be scored to provide an evaluation of quality, but the tool itself lacks clear thresholds or cutoffs to define guidelines as high, moderate, or low quality. Therefore, the more appraisers that a guideline may have, the better its scoring and quality assurance may be. Also, the experience of the appraisers and their clinical knowledge and practice also influences their scoring, and hence these biases still exist when the guidelines are appraised, and hence further research with increased number of appraisers may improve the guideline appraisal process.

Clinical pathways for appendicitis are not universal and multiple recommendations exist in different guidelines, and therefore, our study tailored a pathway based on expertise and resources from our institution [1,8,10,16]. The pathway is designed as a streamline for the patient journey from presentation to definitive treatment for those presenting RIF pain. Swift review of the low-risk group and discharge as appropriate leads to an increase in patient turnaround times. The high risk group would be recognised promptly with usage of a robust care pathway, with early antibiotics and theatre for standardised treatment and reduced complications. These important measures like patient demographics, time from triage to surgery, type of surgical approach, length of hospital stay, negative appendectomy rates and re admission rates along with complications, would be recorded onto a registry for further review on a digitalised platform which would generate annual reports and correlate these findings with the local morbidity and mortality meetings data to further audit the acute surgical care provided to patients presenting with appendicitis and over all improve outcomes related to patients, clinicians, and nursing staff. Key outcome indicators are a measurement metric that allows outcomes to govern patient care and helps shift focus of research to relevant measurable parameters that are well established and reproducible [39,40]. We utilised the previous literature and local expertise to determine KOIs for our study and hence have a system in place to audit our pathway. This is a limitation in our study, as the key to developing KOIs is through specific methodology like the Delphi or the modified Delphi method, where panels of experts determine the KOIs through multiple survey processes, and hence future research in determining KOIs could be undertaken after the audit of our pathways [41,42].

Conclusion

Appraisal of guidelines to establish an evidence base for the development and implementation of a robust pathway incorporating clinical, laboratory and radiological findings, which will be measurable against established key performance indicators, should set a template to improve quality care in appendicitis.

Figures

Tables

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