An Evaluation of a Community Hospital’s Emergency Department Ultrasonography Processes for the Diagnosis of Acute Pediatric Appendicitis

CONTEXT: Since the 1980s, the use of ultrasonography for suspected acute pediatric appendicitis has become increasingly common. Multiple studies have suggested that ultrasound of the appendix has consistently high sensitivity and specificity when the appendix can be clearly visualized. The authors’ primary objective for this study was to retrospectively evaluate their community-based healthcare system’s processes for detecting acute pediatric appendicitis using ultrasonography. METHODS: This was a retrospective medical chart review study of data over a five-year 2014-2018 period at Mercy Health Muskegon in Muskegon, Michigan. All patients aged 3-18 years who had received an appendix ultrasound during this period were identified using the McKesson Radiology (MS) PACS-Lite computer program. Pediatric appendix ultrasound cases were collected and analyzed for sensitivity, specificity, positive predictive value, negative predictive value with 95% confidence intervals. Acute appendicitis cases had been confirmed based on pathology reports. Secondary measures including white blood cell, body mass index, and body temperature were also included in analyses. RESULTS: In this sample, the overall sensitivity at detecting acute pediatric appendicitis using ultrasonography was relatively low at approximately 42% (95% CI: 21.1 - 66.0%). On the other hand, sample specificity was quite high at 97% (95% CI: 89.9 – 99.5%). The overall positive predictive value (PPV) was 80% (95% CI: 44.2-96.5%) and the negative predictive Value (NPV) was 86% (95% CI: 75.7-92.4%). The occurrence for false positives was 20% (95% CI: 3.5-55.8%). False negatives were 14% (95% CI: 7.6-24.3%). CONCLUSIONS: The use of ultrasonography at the authors’ institution less often accurately identified cases of later-confirmed pediatric appendicitis compared to some earlier published studies. The authors concluded that this could be due to seeing a lower number of more complex/ambiguous cases of pediatric appendicitis or lack of hospital personnel’s pediatric-specific training and/or experience compared to specialty children’s hospitals. It is possible that imaging improvements could be achieved by either or a combination of: offering training sessions for general ultrasound technicians, offering training session for radiologists, and visiting pediatric physicians and ultrasound technicians. A valuable follow-up study would be to track anticipated improvements and lead to formulation of an acute pediatric appendicitis care protocol within the authors’ healthcare system.