Proactive Clinical Auditing and Continuous Surgical Practice Monitoring in Reducing the Rate of Negative Appendectomy in Children

Document Type : Brief Report

Authors

1 Medical Student Dubai Medical University.

2 Department of Paediatric surgery, Al Jalila Children Hospital, Dubai

3 Department of pediatric surgery, Al Jalila children hospital

4 Clinical fellow, department of Pediatric Surgery

5 Consultant Pediatric Surgeon, Al JAlila Children Hospital

6 Department of Pediatric Surgery, Al Jalila children Hospital, dubai

10.22038/psj.2025.91740.1495

Abstract

Introduction:
Acute appendicitis is the most common intra-abdominal paediatric surgical emergency, with appendectomy being its standard treatment. In most centres, acute appendectomy is performed based on clinical diagnosis and hence has been associated with a negative appendectomy rate of 10-25%. Negative appendectomy has been associated with morbidity to the extent of 10-12% and mortality of 1%. We herein present our experience with proactive clinical auditing and a surgical monitoring approach in reducing the rate of negative appendectomy in children.
Materials and Methods:
We conducted a prospective clinical audit in a tertiary pediatric surgical center. All children with suspected acute abdominal pain and suspected appendicitis were treated on a standardized clinical pathway. The diagnostic workup included clinical scoring (Alvarado score), laboratory studies, and imaging (ultrasound and CT, as needed). All cases undergoing appendectomy were evaluated through histopathology. Negative appendectomy cases were reviewed weekly. Diagnostic and management algorithms were modified for subsequent cases.
Results:
Implementation of proactive auditing and continuous monitoring reduced the negative appendectomy rate to below 2%. This compares with the 10-25% rate reported in the literature. Multidisciplinary case discussions and real-time feedback helped identify diagnostic pitfalls. These efforts also refined clinical pathways.
Conclusion:
Proactive auditing and surgical monitoring appear effective in minimizing negative appendectomy rates. This approach improves compliance with diagnostic protocols, enhances surgical decision-making, and reduces morbidity associated with negative appendectomy.

Keywords

Main Subjects

References

  1. Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol. 1990 Nov;132(5):910-25. DOI: 10.1093/oxfordjournals.aje.a115734. PMID: 2239906.
  2. Ferris M, Quan S, Kaplan BS, Molodecky N, Ball CG, Chernoff GW, Bhala N, Ghosh S, Dixon E, Ng S, Kaplan GG. The Global Incidence of Appendicitis: A Systematic Review of Population-based Studies. Ann Surg. 2017 Aug;266(2):237-241. DOI: 10.1097/SLA.0000000000002188. PMID: 28288060.
  3. Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev. 2010 Oct 6;(10):CD001546. DOI: 10.1002/ 14651858. CD001546.pub3. Update in: Cochrane Database Syst Rev. 2018 Nov 28;11:CD001546. DOI: 10.1002/14651858. CD001546.pub4. PMID: 20927725.
  4. Flum DR, Koepsell T. The clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis. Arch Surg. 2002 Jul;137(7):799-804; discussion 804. DOI: 10.1001/archsurg.137.7.799. PMID: 12093335.
  5. Mittal MK, Dayan PS, Macias CG, Bachur RG, Bennett J, Dudley NC, Bajaj L, Sinclair K, Stevenson MD, Kharbanda AB; Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Performance of ultrasound in the diagnosis of appendicitis in children in a multicenter cohort. Acad Emerg Med. 2013 Jul; 20(7):697-702. DOI: 10.1111/acem.12161. PMID: 23859583.
  6. Güller U, Rosella L, McCall J, Brügger LE, Candinas D. Negative appendicectomy and perforation rates in patients undergoing laparoscopic surgery for suspected appendicitis. Br J Surg. 2011 Apr;98(4):589-95. DOI: 10.1002/bjs.7395. Epub 2011 Jan 24. PMID: 21259233.
  7. Kearney D, Cahill RA, O'Brien E, Kirwan WO, Redmond HP. Influence of delays on perforation risk in adults with acute appendicitis. Dis Colon Rectum. 2008 Dec;51(12):1823-7. DOI: 10.1007/ s10350-008-9373-6. Epub 2008 Jun 27. PMID: 18584252.
  8. Samuel M. Pediatric appendicitis score. J Pediatr Surg. 2002 Jun;37(6):877-81. DOI: 10.1053/jpsu.2002.32893. PMID: 12037754.
  9. Doria AS, Moineddin R, Kellenberger CJ, Epelman M, Beyene J, Schuh S, Babyn PS, Dick PT. US or CT for Diagnosis of Appendicitis in Children and Adults? A Meta-Analysis. Radiology. 2006 Oct;241(1):83-94. DOI: 10.1148/radiol. 2411050913. Epub 2006 Aug 23. PMID: 16928974.
  10. Svensson JF, Patkova B, Almström M, Naji H, Hall NJ, Eaton S, Pierro A, Wester T. Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial. Ann Surg. 2015 Jan; 261(1):67-71. DOI: 10.1097/SLA. 0000000000000835. PMID: 25072441.
  11. Buetow SA, Roland M. Clinical governance: bridging the gap between managerial and clinical approaches to quality of care. Qual Health Care. 1999 Sep; 8(3):184-90. DOI: 10.1136/qshc. 8.3.184. PMID: 10847876; PMCID: PMC2483653.
  12. Bowie P, Bradley NA, Rushmer R. Clinical audit and quality improvement - time for a rethink? J Eval Clin Pract. 2012 Feb;18(1):42-8. DOI: 10.1111/j.1365-2753.2010.01523.x. Epub 2010 Nov 18. PMID: 21087366.
  13. Garcia Peña BM, Mandl KD, Kraus SJ, Fischer AC, Fleisher GR, Lund DP, Taylor GA. Ultrasonography and limited computed tomography in the diagnosis and management of appendicitis in children. JAMA. 1999 Sep 15;282(11):1041-6. DOI: 10.1001/jama. 282. 11. 1041. PMID: 10493202.
  14. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009 Jan 29;360(5):491-9. DOI: 10.1056/ NEJMsa 0810119. Epub 2009 Jan 14. PMID: 19144931.
  15. Shieh A, Pham PK, Plouffe NA, Heyming TW. Negative Appendectomies: Evaluating Diagnostic Imaging Techniques at General versus Pediatric Emergency Departments. J Emerg Med. 2023 Mar; 64(3):304-310. doi: 10.1016/j. jemermed. 2022.12.018. Epub 2023 Mar 1. PMID: 36868944
  16. Dreznik Y, Paran M, Sher C, Konen O, Baazov A, Nica A, Kravarusic D. Negative appendectomy rate in the pediatric population: can we reach near-zero rates? An observational study. ANZ J Surg. 2024 Feb;94(1-2):204-207. doi: 10. 1111/ ans.18825. Epub 2023 Dec 11. PMID: 38082452.
  17. Aspelund G, Fingeret A, Gross E, Kessler D, Keung C, Thirumoorthi A, Oh PS, et al. Ultrasonography/MRI versus CT for diagnosing appendicitis. Pediatrics. 2014 Apr;133(4):586-93. DOI: 10.1542/peds.2013-2128. Epub 2014 Mar 3. PMID: 24590746.
  18. Cui W, Liu H, Ni H, Qin X, Zhu L. Diagnostic accuracy of procalcitonin for overall and complicated acute appendicitis in children: a meta-analysis. Ital J Pediatr. 2019 Jul 9;45(1):78. DOI: 10.1186/s13052-019-0673-3. PMID: 31288826; PMCID: PMC6617950.
  19. Patel M, Thomas JJ, Sarwary H. We can reduce negative paediatric appendicectomy rate: A cohort study. Ann Med Surg (Lond). 2021 Oct 5;71: 102901. doi: 10.1016/j. amsu.2021. 102901. PMID: 34691444; PMCID: PMC8517710.

 

 

Journal of Patient Safety & Quality Improvement
Volume 14, Issue 1
January 2026
Pages 51-57

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