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Three Part Question

In [children with suspected appendicitis] is [POC US as good as radiology departmental ultrasound or CT scanning] at [safely shortening LOS in the emergency department]?

Clinical Scenario

An 8-year-old boy presents to the emergency department with right lower quadrant abdominal pain with features suggestive of appendicitis. The surgeons are not immediately available and suggest imaging of the right iliac fossa. There is a delay before either ultrasonography or CT scanning can be carried out by the diagnostic radiology department. You wonder if point-of-care ultrasound (POC US) might result in a quicker decision and therefore a shorter length of stay (LOS) for the child.

Search Strategy

Medline using NHS Evidence 1946 to date of searching 22/04/2015: exp APPENDICITIS/ AND (exp POINT-OF-CARE SYSTEMS/ OR POC,ti, ab) AND exp Length of stay/AND (exp Child OR exp Infant OR exp Adolescent) 1 result (in table).

Embase using the NHS Evidence 1974 to date of searching 22/04/2015: exp ACUTE APPENDICITIS/ OR exp APPENDICITIS/ AND exp POINT OF CARE TESTING/ OR POC,ti,ab AND exp length of stay/ [Limit to: Human and English Language and (Human Age Groups Child unspecified age or Preschool Child 1 to 6 years or School Child 7 to 12 years or Adolescent 13 to 17 years)] 2 results, 1 unique no relevancies.

The Cochrane Library Issue 4 of 12, April 2015: MeSH descriptor: [Appendicitis] explode all trees AND MeSH descriptor: [Point-of-Care Systems] explode all trees. 3 results no relevancies (adults only).

Search Outcome

One article answered the question. This is included in the table

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Elikashvili et al, 2014 United States	150 patients, 21 years old and younger	Prospective, cohort	LOS	LOS (mean) POC US: 154 min RUS: 288 min CT: 487 min	Study conducted in one single center Convenience sample of patients Unknow data concerning time of day of enrolment
			Sensitivity(Se)/Specificity(Sp) experienced operator POC US (>25 exams) vs radiology ultrasound (RUS)	POC US experienced (n=61) Se 80%/Sp 97.8% RUS (n=117) Se 62.5%/Sp 99.3%

Comment(s)

Considering that the mean time needed to perform point-of-care ultrasound (POC US) was 7  min (95% CI 6.2 to 7.8), LOS could be reduced by 127  min when compared with radiology ultrasound (RUS) and 326  min compared with patients waiting for a CT. This would have a beneficial impact on LOS in the ED if surgery department members would accept to manage their patients based on the POC US results without further imaging studies. Of course, data on LOS are useful only if the diagnostic test characteristics (Se/Sp) are preserved through the imaging process of POC US. Specificity and sensitivity of POC US were similar to what is achieved in radiology department for appendicitis when done by experienced operators (>25 examinations). Specificity was similar to RUS, making it a good imaging modality to rule in appendicitis.

Editor Comment

LOS, length of stay; POC US, point-of-care ultrasound; RUS, radiology ultrasound.

Clinical Bottom Line

Perform point-of-care abdominal ultrasound has sufficient specificity to be used to reduce LOS of paediatric patients in the ED with positive results for appendicitis. It is insufficiently sensitive to be used to rule out appendicitis.

References

1. Elikashvili I, Tay ET, Tsung JW . The Effect of Point-of-care Ultrasonography on Emergency Department Length of Stay and Computed Tomography Utilization in Children With Suspected Appendicitis Acad Emerg Med 2014;21:163–70.