Direct Transfer of Pediatric Appendicitis Patients Is Associated with a High False Positive Rate Upon Referral to a Tertiary Children’s Hospital Despite Increased Computed Tomography Exposure
Purpose: Many patients with suspected appendicitis are initially evaluated at outlying hospitals and then transferred to a tertiary care pediatric hospital for surgical management. We sought to evaluate whether diagnosis prior to transfer provides a reliable basis for direct admission to a Pediatric Surgery (PS) service.
Methods: Patients transferred during calendar year 2018 with the principal diagnosis of acute appendicitis were compared based on the service accepting the patient: Emergency Department (ED) or PS. Data were evaluated using a Student’s t-test.
Results: Overall patient characteristics were consistent among ED and PS transfers, with each group having statistically similar age, gender, duration of symptoms, and white blood cell (WBC) count (Table 1). Because imaging confirmation was required for direct admission to PS, the number of patients accepted directly to PS underwent significantly more computed tomography (CT) (80.2% vs 54.1%, p=.0003). Despite diagnostic ‘confirmation’ with cross-sectional imaging, 14.7% of those patients admitted directly to PS were found to be false positives upon physical examination and imaging review. Approximately half (49.2%) of the patients denied direct admission and transferred to the ED did not require an operation.
Conclusion: Direct admission of patients with confirmed appendicitis has theoretical benefit in avoiding visits to an overburdened ED, while saving families cost and time. However, a significant proportion of referred patients do not require admission or operation. A protocol which encourages cross-sectional imaging before pediatric surgical evaluation may subject children to unnecessary radiation and may still result in a significant number of non-surgical admissions. Routine ED transfer allows PS evaluation, targeted imaging, and discharge for non-surgical patients. This approach decreases costs for the families whose children received a false positive diagnosis at a referring facility, while preserving inpatient bed availability. A multicenter retrospective study is needed to evaluate diagnostic accuracy, analyze costs, and confirm these findings.