An Advanced Nursing Directive for Children With Suspected Appendicitis: Protocol for a Quality Improvement Feasibility Study

Background Pediatric appendicitis accounts for an estimated 7% to 10% of abdominal pain cases in the emergency department (ED). The diagnosis is time-consuming, and the investigative process depends on physician assessment, resulting in delays in diagnosis and therapeutic management. The utility of an advanced nursing directive (AND) to expedite this process is unclear and needs further exploration. Objective This study aims to describe key components of ED flow in patients with suspected appendicitis seen at a pediatric ED and pilot a directive that allows ED nurses to perform an order set that includes blood work, urine tests, analgesics, fluids, and an abdominal-pelvis ultrasound prior to physician assessment. Methods This study involves conducting a retrospective chart review alongside a quality improvement initiative to compare key ED flow metrics before and after AND implementation. Primary outcome measures include median time from ED triage assessment to ultrasound completion, analgesia administration, blood work results, and time to disposition (consult or discharge), alongside other key ED flow metrics for suspected appendicitis. Secondary outcomes will involve patient and caretaker satisfaction surveys. Descriptive statistics will be used to summarize the data. For differences in proportions, a chi-square test will be used. The Student t test will be used for continuous variables. A variable-controlled run chart will be performed to assess impact on ED flow metrics. Patient and family satisfaction surveys are administered immediately after the directive encounter and 7 days afterward. Results There are currently 3900 patients who have been screened, 344 patients who have been enrolled, and 90 patients who have received the medical directive since implementation in June 2020. Interim results on reduction of time to diagnostic and therapeutic ED flow parameters and satisfaction surveys are expected to be published in February 2022. The final study endpoint will be in June 2022. Conclusions This study proposes a novel protocol for improving the diagnosis and treatment of suspected pediatric appendicitis through implementation of an evidence-based AND. This model may provide a standardized, international pathway for management of common pediatric and adult emergencies. International Registered Report Identifier (IRRID) RR1-10.2196/33158


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PROJECT SUMMARY:Given the strong evidence suggesting that ANDs (advanced nursing directives) expedite and improve quality of patient care in the ED without increasing ED resource utilization, we will investigate the effect of a new AND on patients presenting to the ED with suspected appendicitis. This QI initiative is novel as our proposed AND will empower nurses to order advanced imaging studies (ultrasound) in patients who meet specific evidence-based criteria for suspected appendicitis, a step further than what is previously reported in the literature. It will have an impact on systems and patient level outcomes, leading to potential cost savings and improved care. The purpose of this submission to the HHS New Investigator Fund (NIF) competition is to fund this single center QI project as a proof of concept and a first step towards a multi center project to standardize and improve the ED approach for patients with suspected appendicitis.
STRENGTHS: Dr. Eltorki has a strong publication and presentation history. His letters of support indicate his commitment to and his ability to carry out this research project. It is refreshing to see a multi-disciplinary project and his support of his staff. The before/after design is an excellent choice for this project. It is also good to see that he has a program of research planned and will follow this with a large multi-centre study. Applications that demonstrate scientific excellence with the highest weighted score out of 10 will be awarded grants.

PROJECT SUMMARY:
Focus is to implement and validate an evidence-informed Advance Nursing Directive (AND) for suspected appendicitis to reduce wait times by 20% (compared to current practice) in children 3-17 who present to the ED at MCH with abdominal pain. Secondary outcomes include improved pain management, decreased length of stay, reduce costs and parental anxiety. This is a single center time series analysis methodology to assess before and after the AND. It will establish proof of concept and serve as pilot for a multi-centre study. The MCH has ~ 800 visits per year for abdominal pain that is investigated for appendicitis.Currently diagnosis is dependent on physician assessment.There is strong evidence that AND are effective. This AND will include the ordering of imaging which has not been previously reported. The two phases of the PDSA cycles are planned before and after implementation of the AND. Educational sessions, visual care map will be used to disseminate the AND and gain uptake. All patients with RLQ cough, jump or percussion and ileofossal tenderness and symptoms < 4 days are eligible. Some exclusions apply. Time to discharge is recorded electronically.Study will run for one year.

STRENGTHS:
Study builds on and leverages an established strong collaborative interprofessional environment. Potentially significant patient important outcomes. The applicant completed a survey of nurses in the ED to determine their interest in developing a appendicitis AND: the majority supported. IT has also received enthusiastic endorsement from the MCH Family Council.

WEAKNESS(ES):
Pediatric Emergency Medicine Research Enrichment Program: flat fee of $5,500: Please justify further. The proposal refers to this as a pilot study and QI study: while it is directed at improving quality of care and patient experience, it seems easily to fit into a research category.