P2D383: Reducing Postoperative CT Imaging for Children with Complicated Appendicitis: A Pediatric Surgical Quality Collaborative QI Project

Purpose/Objectives: Postoperative computed tomography (CT) imaging in complicated appendicitis exposes children to a source of ionizing radiation which has been associated with increased risk of developing a future malignancy. The Pediatric Surgery Quality Collaborative (PSQC) CT Reduction Workgroup engaged in semi-structured interviews with high and low CT usage children’s hospitals in an effort to develop postoperative CT reduction strategies. Our global aim is to reduce aggregate postoperative CT usage for children with complicated appendicitis from 14% to 10% by 2026 among PSQC member hospitals.

Design/Methods: The PSQC exists as a quality improvement partnership between member children’s hospitals and American College of Surgeons National Surgery Quality Improvement Program Pediatric (ACS NSQIP-P). Postoperative CT imaging for patients with complicated appendicitis among 47 PSQC hospitals was assessed from de-identified NSQIP-P data collected between April 2020-March 2021. Based on this assessment, 15 hospitals were invited to participate in a structured interview, and 12 hospitals agreed to participate: 3 hospitals were high outliers, 5 hospitals were low outliers, and 4 hospitals were in the expected range for postoperative CT usage. Key stakeholders, including pediatric surgeons, radiologists, interventional radiologists, quality improvement team members, and NSQIP-P surgical clinical reviewers, discussed complicated appendicitis postoperative practices. Qualitative analysis of interview transcripts was performed deductively and inductively based on the Theoretical Domains Framework (TDF).

Results: Five of twelve TDF domains appeared to have the greatest influence on postoperative imaging practices: skills, beliefs about capabilities, intentions or goals, memory and decision points, and environment. For each domain, we identified factors influencing CT scan use and developed fishbone and key driver diagrams (Figures 1 and 2) to demonstrate potential change concepts and strategies to implement change. Children’s hospitals with lower rates of postoperative CT utilization for complicated appendicitis tended to have more care standardization related to postoperative management and imaging, utilize non-CT imaging modalities, and have radiation stewardship champions in pediatric surgery and/or radiology.

Conclusion/Discussion: Hospitals with low and high postoperative CT usage inform best practices around care standardization, enhancing alternative imaging infrastructure, and commitment to radiation stewardship, all of which provide strategies to reduce postoperative CT imaging reliance in complicated appendicitis.