Journal of Medical Systems

, 42:257 | Cite as

Importance of Compliance Audits for a Pediatric Complicated Appendicitis Clinical Practice Guideline

  • Mehul V. RavalEmail author
  • Alan B. Kwan
  • Curtis D. Travers
  • Kurt F. Heiss
Systems-Level Quality Improvement
Part of the following topical collections:
  1. Systems-Level Quality Improvement


Clinical practice guidelines (CPG) have been shown to decrease practice variation, reduce resource use, and improve patient outcomes. The purpose of this study was to audit compliance of a pediatric complicated appendicitis CPG to identify areas for continued improvement. A comprehensive complicated appendicitis CPG was implemented in a children’s hospital system. Outcomes were compared for 48 months pre- (01/2012 to 12/2015) and 28 months post-implementation (01/2016 to 04/2018). A detailed compliance audit was nested within the post-implementation period in 60 consecutive patients from 11/2017 to 03/2018. Feedback was provided to care providers throughout the audit. Overall, 2370 children with complicated appendicitis were identified (1366 pre-CPG and 1004 post-CPG). The CPG resulted in decrease in mean length of stay from 5.3 days to 4.5 days (p = 0.751), postoperative returns to the system (13.0% to 10.1%, p = 0.030), and readmissions (5.3% to 4.3%, p = 0.237). Central line use decreased from 11.2% to 5.5% (p < 0.001) and antibiotic selection improved from 47.0% to 84.1% (p < 0.001). On audit, only 15% (9/60) had full CPG compliance and 49% (29/60) received recommended antibiotic durations. Compliance increased from 7% to 23% with audit-derived feedback. After stratifying by appendicitis severity, audits resulted in improved antibiotic duration compliance for patients with severe appendicitis (38.1% to 66.7%, p = 0.07) and postoperative ambulation for patients with lower grade disease (37.5% to 83.3%, p = 0.06). Audit cycles on a complicated appendicitis CPG and feedback to providers improved CPG compliance and more granular outcomes of interest.


Appendicitis Pediatric surgery Quality improvement Audits 



The authors would like to thank the multidisciplinary QI team at Children’s Hospital of Atlanta for their assistance on this project and to the surgeons in the Division of Pediatric Surgery for participating in the QI process.

Author Contributions

Raval: concept development, study design, data collection, drafting manuscript, critical revision of manuscript.

Kwan: study design, data collection, critical revision of manuscript.

Travers: study design, data analysis, creating tables, critical revision of manuscript.

Heiss: concept development, study design, critical revision of manuscript.


This study was funded in part using and internal Children’s Healthcare of Atlanta Quality Improvement Award.

Compliance with Ethical Standards

Declaration of Interest

The authors reports no proprietary or commercial interest in any product mentioned or concept discussed in this article.

Conflict of Interest

Mehul V. Raval declares that he has no conflict of interest.

Alan B. Kwan declares that he has no conflict of interest.

Curtis D. Travers declares that he has no conflict of interest.

Kurt F. Heiss declares that he has no conflict of interest.

Research Involving Human Participants and/or Animals

Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Approval was obtained from the Emory University Internal Review Board (#00077519) before the retrospective data review.

Informed Consent

Not applicable based on the retrospective nature of the study.

Supplementary material

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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Pediatric SurgeryAnn & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University School of Medicine, Surgical Outcomes and Quality Improvement Center (SOQIC)ChicagoUSA
  2. 2.Division of Pediatric Surgery, Department of SurgeryEmory University School of Medicine, Children’s Healthcare of AtlantaAtlantaUSA
  3. 3.Division of PediatricsEmory University School of MedicineAtlantaUSA

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