Appendicectomy Audit – South West Surgery in Children

Appendicectomy Audit: interrogating the decision to operate in children who had an appendicectomy procedure performed due to suspected appendicitis across the South West.

In 2024, members of the SW SIC ODN General Surgery & Urology Working Group agreed to carry out a patient level audit to understand current practice around the use of ultrasound in children (aged 0 – 18) presenting with suspected appendicitis and the level in which shared care between general surgeons and paediatricians is being adopted in centres across the region.

Audit Summary:

Aims: identify if ultrasound is used routinely for children with suspected appendicitis and if shared care is routine practice.

Hospital Eligibility: all hospitals located in the South West Surgery in Children ODN regional footprint will be included.

Audit Team: A consultant lead and a student, trainee or similar colleague will be identified from each participating provider.

Inclusion Criteria: children (0 – 18) who had an appendicectomy during the agreed timeframe will be included within the audit.

Timeframe: the audit will be retrospective, reviewing patients who presented between 1st April 2024 and 30th September 2024.

Findings: data will be reviewed and findings will be shared via the General Surgery & Urology Working Group in 2025.

Colleagues who are members of the SW SIC ODN can access project documents on the NHS Futures platform here.

Learn more about the audit below:

Background

The SW SIC ODN General Surgery & Urology Clinical Working Group aims to support the development of regional paediatric surgical services and related pathways. In 2021 the group developed Suspected Appendicitis Pathway Best Practice Recommendations which were reviewed as part of a pathway audit that identified a number of areas for potential improvement including coding of data, access to imaging, and considerations regarding shared decision making alongside post operative pathways.

It was identified that the coding for appendicectomy procedures was not always captured accurately which did not allow an accurate review of activity or negative appendix rates across the region, and the network team worked with local clinicians and clinical coding teams across the South West to address this.

Despite improvements in data quality and the best practice being broadly agreed at a regional level, the negative appendix rate in the region has not changed notably in the past 3 years and Model Hospital data shows the South West to have a negative appendix rate of over 11% compared with national average of 7%.

In 2022 the Getting It Right First Time (GIRFT) team published a national paediatric acute abdominal pain and appendicectomy best practice recommendations which refers to four areas of improvement:

Providing better training of general surgeons in paediatric surgery to improve leadership and outcomes in non-specialist trusts
Ensuring that the care of each child with possible appendicitis in non-specialist trusts is shared between general surgeons and paediatricians
Improving use of 7-day diagnostic imaging
Caring for children within defined care pathways.

Following discussion, the SW SIC ODN General Surgery & Urology Working Group (led by Mr Tim Rogers, Co-Clinical Chair) have agreed to support a patient-level audit to try to understand if points 2 & 3 (shared care arrangements and use of diagnostic imaging) are being delivered across the region, and therefore if this might present an opportunity to improve the region's negative appendix rates.

Aims & Objective

The aim of this audit is to review regional practice against the two of the areas of improvement outlined in the GIRFT paediatric acute abdominal pain and appendicectomy best practice. The overarching objectives for undertaking this audit are:

Explore the use of pre-operative ultrasound in patients presenting with suspected appendicitis
Explore if shared care is being used in the assessment of children presenting with suspected appendicitis (specifically shared care between surgical and paediatricians informing management pre-operatively)
Explore if there is a relationship between pre-operative ultrasound utilisation and surgical/pathology findings/outcome
Explore if there is a relationship between shared care paediatric assessment and surgery/pathology findings/outcome
Does the use of ultrasound pre-operatively and/or a shared care approach to assessment influence other factors such as length of stay?

Methods

The project will be undertaken retrospectively auditing children aged 0 - 18 years who underwent an appendicectomy procedure in hospitals across the South West between 1^st April 2024 and 30^th September 2024. The following inclusion and exclusion criteria apply:

Inclusion criteria	Exclusion criteria
Paediatric patient (under 18 years of age when procedure was undertaken)	Patients 18 and over when procedure was performed
Appendicectomy coded as being performed in specified time frame	Any other surgical procedure or outside timeframe

A data collection template has been developed by the audit coordinators and approved by the SW SIC ODN General Surgery & Urology Clinical Working Group. Each participating hospital will have a nominated trainee, registrar, or other local data collection lead to co-ordinate and support the audit, and a named Consultant Lead who agrees to provide oversight.

The data collection lead will submit patient data (anonymised) into the data collection template and return to the SW SIC ODN for review and analysis.

Expected Outcomes

Initial outcomes:
• Identify if ultrasound is being used routinely for patients presenting with suspected appendicitis
• Identify if shared care is being part of routine practice for the management of patients presenting with suspected appendicitis

Wider benefits:
• Potential opportunities to identify improvements in regional suspected appendicitis pathway
• Potential to support reduction in negative appendix rate which will reduce unnecessary surgical procedures being undertaken (which has quality, patient experience and cost saving implications)

Supporting Documents

Appendicectomy Audit Project Summary
Appendicectomy Audit Protocol
Data collection template (to be emailed to participating colleagues)

Audit Coordinators & Contact Details

Mr Tim Rogers – Co-Clinical Chair of SW SIC ODN GS&U Clinical Working Group
Simon Courtman – Clinical Director, SW SIC ODN
Catherine Carpenter-Clawson– Network Manager, SW SIC ODN
Angus Mitchel – Surgical Trainee
Ana Guillot Lozano – Medical Student
Sharuk Sami – F1

Please contact the SW SIC ODN Team (swsicodn@uhbw.nhs.uk) to learn more about this project.