Current Diagnostic Approaches and Challenges in the General Emergency Department Evaluation of Suspected Pediatric Appendicitis: A Qualitative Study

Abstract

Background. Pediatric abdominal pain accounts for more than 1 million emergency department (ED) visits annually, and appendicitis is the most common surgical emergency. Guidelines recommend ultrasound as the initial imaging study for diagnosing pediatric appendicitis. However, because of the variability in both the availability and interpretation of pediatric ultrasounds in general EDs, clinicians may potentially overuse computed tomography (CT). Shared decision making (SDM) and clinical decision support (CDS) tools may help avoid unnecessary CTs; however, it is not clear to what extent such tools are used. Our objective was to describe the current diagnostic approaches and challenges faced by physicians in general EDs when assessing potential pediatric appendicitis. Understanding the nuances specific to this context may help inform the creation of more universally applicable diagnostic guidelines and CDS tools. Methods. We conducted semi-structured interviews with physicians practicing in general EDs to assess the current approaches and challenges in diagnosing pediatric appendicitis. We sought input on the use of existing CDS tools such as the pediatric appendicitis risk calculator (pARC) and the role of SDM. We analyzed interview transcripts using a thematic approach. Results. We conducted 15 interviews and identified 5 themes: 1) the limited availability of ultrasound often precludes routine use, 2) physicians tend to rely on gestalt over CDS tools, 3) guidelines regarding the transfer of patients to pediatric centers are needed, 4) the pARC could be improved with the integration of general ED-specific recommendations, and 5) physicians described using SDM frequently, but conceptualization and execution varied. Conclusion. Physicians in general EDs identified challenges in the current approaches to diagnosing pediatric appendicitis. A diagnostic pathway that incorporates validated CDS and general ED-specific recommendations could optimize the process, enhance SDM, and potentially reduce unnecessary CTs. Highlights: Diagnosing pediatric appendicitis is challenging, especially in general EDs where pediatric resources are often limited. Physicians in general EDs reported that current imaging techniques and clinical decision support tools often fail to meet the needs of their setting. Physicians often rely on their own experience and often incorporate family preferences (via shared decision making) into their diagnostic planning. Physicians in general EDs reported that better guidelines and community-specific diagnostic algorithms and clinical decision support tools would improve patient care.