• Ross J Fleischman, Miranda K Devine, Marie-Annick N Yagapen, Angela J Steichen, Matthew L Hansen, Andrew F Zigman, and David M Spiro.
• From the *Department of Emergency Medicine, Oregon Health and Science University; and †Division of Pediatric Surgery, Kaiser Permanente Northwest, Portland, OR.
• Pediatr Emerg Care. 2013 Oct 1;29(10):1060-5.

ObjectivesThis study aimed to determine the test characteristics of a pathway for pediatric appendicitis and its effects on emergency department (ED) length of stay, imaging, and admissions.MethodsChildren age 3 to 18 years with suspicion for appendicitis at 1 tertiary care ED were prospectively enrolled, using validated low- and high-risk scoring systems incorporating history, physical examination, and white blood cell count. Low-risk patients were discharged or observed in the ED. High-risk patients were admitted. Those meeting neither low-risk nor high-risk criteria were evaluated by surgery, with imaging at their discretion. Chart review or telephone follow-up was conducted 2 weeks after the visit. A retrospective study before and after was also performed. Charts of a random sample of patients evaluated for appendicitis in the 8 months before and after the pathway implementation were reviewed.ResultsAppendicitis was diagnosed in 65 of 178 patients. Of those with appendicitis, 63 were not low-risk (sensitivity, 96.9%; specificity, 40.7%). The high-risk criteria had a sensitivity of 75.3% and specificity of 75.2%. We reviewed 292 visits before and 290 after the pathway implementation. Emergency department length of stay was similar (253 minutes before vs 257 minutes after, P = 0.77). Computed tomography was used in 12.7% of visits before and 6.9% of visits after (P = 0.02). Use of ultrasound was not significantly different (47.3% vs 53.7%). Admission rates were not significantly different (45.5% vs 42.7%).ConclusionsThe low-risk criteria had good sensitivity in ruling out appendicitis. The high-risk criteria could be used to guide referral or admission. Neither outperformed the a priori judgment of experienced providers.

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