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Purpose: The widespread implementation of Acute Care Surgery (ACS) services dedicated to urgent surgical issues has led to significant improvements in both patient flow and care. Despite these advancements, the use of diagnostic computed tomography (CT) continues to increase across all diagnoses. Given the high incidence of appendicitis, the primary aim of this study was to evaluate the impact of implementing an ACS clinical care pathway dedicated to suspected appendicitis on the timing and use of CT, as well as on patient flow through the emergency department (ED).

Methods: All adults within a large urban health care system (Calgary, Alberta, Canada) who presented to any ED (3 hospitals) with a diagnosis of suspected, or actual, appendicitis were analyzed. Three distinct time periods (3 months duration each) were compared (pre-implementation, post implementation, and 12 months (follow-up) post implementation). The pathway assessment included history and physical examination, laboratory testing, and potentially CT or ultrasound). Standard statistical methodology was employed (p<0.05=significance).

Results: Among 1168 ED consultations for ‘appendicitis’ at 3 large centers, 877 (75%) were admitted to the Acute Care Surgery service. This included 349 (pre-implementation), 392 (post-implementation), and 427 (6 month follow-up) patients. Overall, 83% of all patients underwent surgery in less than 6 hours (time between admission request and procedure). There was a significant decrease in the mean wait time from CT scan request to actual CT scan with the implementation of the pathway at all sites (197 vs. 143 minutes; p<0.05). This improvement was sustained at all sites at the 12-month follow-up period (131 minutes; p<0.05). The percentage of CT scans performed in less than 2 hours increased from 3% to 42% with the pathway implementation (p<0.05). The pathway included a short course oral contrast load of 1-2 hours. No decrease in the total number of CT scans (p>0.05) or in the pattern of ultrasonography was noted (p>0.05). The clinical pathway also resulted in a shorter wait time from ED triage to surgical procedure (697 vs. 642 minutes; p<0.05).

Conclusions: Implementation of a clinical care pathway dedicated to suspected appendicitis (based on Alvarado score and/or imaging) can decrease the time to both CT scan and surgical intervention.