Can Pediatric Emergency Department Nurses Use a Modified Alvarado Score to Accurately Predict Appendicitis?

Abstract

Background: As part of a regional initiative to improve the provision of timely care for children presenting to the Pediatric Emergency Department (PED) with suspected appendicitis, we developed a Pediatric Appendicitis Pathway. The implementation of the pathway included the introduction of an Advanced Nursing Directive (AND). Using a modified Alvarado Score, nursing staff may initiate core interventions for children with suspected appendicitis, including laboratory investigations and fluid management, prior to physician assessment. Objectives: To determine whether Pediatric Emergency Department nurses can use an Advanced Nursing Directive based on a modified Alvarado Score to accurately predict appendectomy. Methods: Using a prospective cohort of children aged 3 to 17 years presenting to our PED with abdominal complaints between March 1 and September 30, 2009 we collected Quality Assessment data regarding the implementation of our Regional Pediatric Appendicitis Pathway. The presence of an AND form in the PED health record identified the children to be included in this study. Data concerning the individual criteria of the AND, the overall AND assessment and the child's clinical course during both the PED visit and subsequent admission were retrieved from the health record. Accuracy, Sensitivity, Specificity, Negative- and Positive- Predictive Values (NPV, PPV) were calculated. Results: 446 AND forms were completed by nursing staff. Of these, nurses assessed 164 children as meeting AND criteria for appendicitis while 282 did not meet criteria. 66 of those who met criteria went on to have an appendectomy. 26 children who did not meet criteria had an appendectomy. 105 children who met criteria went on to have further investigation through diagnostic imaging and/or surgical consult. Nurses were accurate 72.2% of the time using the AND. The AND had a sensitivity of 71.7% and specificity of 72.3%, while the NPV and PPV were 90.8% and 40.2% respectively. Conclusions: Using an evidence-based Advanced Nursing Directive, Pediatric Emergency Nurses were able to predict appendectomy with good accuracy. Nurses were most accurate in predicting which children with abdominal pain were unlikely to require appendectomy and could wait for physician assessment. Using an AND, nurses in our PED are empowered to initiate interventions that may lead to improved patient care and efficiency in the PED.