PC1256: Reducing Radiation Exposure in Pediatric Patients with Abdominal Pain

Purpose/Objectives:

Introduction: Computed tomography scans (CT) are widely utilized to evaluate abdominal pain in the emergency department (ED). However, there is an increased risk of malignancy from radiation, especially in the pediatric population. Therefore, it is important to judiciously order CT scans in this population.
In this study, we seek to understand the current management of pediatric abdominal pain regarding appendicitis at our institution, with the goal of reducing radiation exposure in favor of ultrasonography. Our AIM is to decrease rates of CT scans in children presenting to the ED with abdominal pain by 10% over the next 12 months.

Design/Methods: Methods: We performed a chart review to generate baseline CT scan rates for patients aged 2-17 that presented to the ED with abdominal pain from June 2018 to May 2021, excluding patients with inflammatory bowel disease, trauma, or pregnancy.
A multidisciplinary team was formed with pediatric surgeons, hospitalists, and emergency physicians. We are now completing PDSA cycles to reach our goal: (1) building consensus on best practice for evaluation of appendicitis at our institution, (2) standardizing evaluations with the use of a mutually agreed-upon clinical pathway, (3) team education, (4) peer-to-peer feedback, and (5) just-in-time education.
We will track our progress by analyzing run charts of CT scans and ultrasound rates monthly. Our outcome measure will be the rate of CT scans performed. Our balancing measures will include perforation rates and 72-hour revisits to the ED, aiming to keep these rates stable or decreased. Ordering provider was assessed to target interventions in PDSA cycles 3-5.

Results:

Results: From June 2018 to May 2021, we found CT rates increased from 15% to 22%. The ultrasound rate also increased from 22% to 35%. The rate of ultrasounds that went on to have CT scans similarly increased from 20% to 25%. Interestingly, 36.6% of CTs are ordered by general ED physicians, 25.6% are ordered by ED advanced practice providers, 24.4% are ordered by residents, and 13.4% are ordered by pediatric EM physicians. The average rate of 72-hour revisits to the ED was stable at 5.5%. The rate of appendicitis with perforation was stable between 1-3%.

Conclusion/Discussion:

Conclusion: While CT scans increased by 7%, we saw a greater increase in ultrasounds by 13%, suggesting more providers are preferentially ordering ultrasounds over CT scans. However, we have identified some barriers to the process which can be demonstrated through the parallel increase we found in the ordering of ultrasounds that still go on to have CT scans.
We have implemented the clinical pathway within our institution and will be monitoring for improvement in CT ordering practice. We plan to complete the above PDSA cycles toward our aim of lowering CT rates by 10%, employing additional intervention ideas as needed.