Clinical Pathway Reduces Pediatric CT Use to 22 Percent

Navigating the Diagnostic Hierarchy in Pediatric Appendicitis

Acute appendicitis remains the most frequent surgical emergency in pediatric populations, yet definitive diagnosis is often complicated by atypical clinical presentations that do not mirror the classic migratory pain pattern [1]. While computed tomography (CT) and magnetic resonance imaging (MRI) provide high diagnostic accuracy, with sensitivity and specificity often exceeding 95 percent, the associated risks of ionizing radiation and the frequent requirement for pediatric sedation limit their utility as universal first-line tools [2, 3]. Current evidence supports prioritizing ultrasound as the initial imaging modality to reduce negative appendectomy rates (the surgical removal of a histologically normal appendix), with meta-analyses reporting an odds ratio of 0.44 (95% CI 0.21 to 0.90) for ultrasound-only pathways compared to those utilizing CT after an inconclusive scan [4, 5]. However, the clinical utility of ultrasound is often restricted by high rates of non-diagnostic or indeterminate results, which can reach 35.7 percent in some settings [2]. Consequently, clinical practice guidelines emphasize the implementation of standardized, multidisciplinary pathways to balance diagnostic certainty with patient safety and resource stewardship [6, 7].

Standardizing the Multidisciplinary Workflow

To address these diagnostic challenges, researchers conducted a level III evidence cohort study reviewing all cases of patients aged younger than 19 years diagnosed with appendicitis between 2021 and 2023. The team developed a pediatric appendicitis clinical pathway that prioritized ultrasound as the first-line imaging modality to minimize radiation exposure. Under this standardized workflow, the use of computed tomography (CT) was strictly reserved for specific clinical scenarios: a CT scan was only indicated for patients who had a non-diagnostic ultrasound (an imaging study that fails to clearly visualize the appendix or provide definitive secondary signs of inflammation, such as periappendiceal fat stranding) and where there was explicit agreement between the pediatric emergency medicine and pediatric surgery teams regarding the necessity of advanced imaging. This requirement for interdisciplinary consensus acts as a critical safety check, ensuring that the decision to use ionizing radiation is justified by the clinical gestalt of both the emergency physician and the surgeon.

Meeting National Benchmarks for Radiation Reduction

The primary objective of the multidisciplinary pathway was to align local clinical practice with the standards set by the National Surgical Quality Improvement Program-Pediatric (NSQIP-P). This national quality body recommends that clinicians reduce the use of computed tomography (CT) scans to less than 25 percent in pediatric patients with suspected appendicitis to minimize the long-term stochastic risks associated with ionizing radiation. By the conclusion of the three-year initiative, the researchers successfully met and exceeded this benchmark. The data show that CT utilization steadily decreased from an initial rate of 39 percent to 22 percent by the end of the study period, representing a significant reduction in the reliance on advanced cross-sectional imaging. Throughout the study, ultrasound served as the first-line imaging modality in over 90 percent of total cases, establishing it as the standard initial assessment tool for pediatric patients presenting with right lower quadrant pain. This shift demonstrates that institutional adherence to a diagnostic hierarchy can effectively lower radiation exposure without compromising the ability to identify surgical pathology.

Optimizing Ultrasound and Surgical Integration

The success of the clinical pathway relied heavily on improving the diagnostic yield of initial imaging and refining the technical execution of assessments. Over the three-year study period, the rate of non-diagnostic ultrasounds decreased from 35 percent to 20 percent, a trend that suggests increased institutional proficiency and better integration of ultrasound into the diagnostic workup. By reducing the frequency of inconclusive results, clinicians were able to make more definitive management decisions without immediately defaulting to cross-sectional imaging. Enhanced integration between the emergency department and surgical teams served as a primary mechanism for this change. The study observed that surgical consults performed before a CT scan was ordered increased from 21 percent to 41 percent, effectively doubling the rate of specialist involvement early in the decision-making process. This collaborative approach ensures that the surgical team's clinical assessment is factored into the imaging strategy, placing greater weight on the physical exam and surgical expertise. While ultrasound and CT remained the primary modalities, the researchers also explored the utility of magnetic resonance imaging (MRI) as a radiation-free alternative. In the final phase of the study, specifically during quarter 4 of 2023, two patients underwent an MRI as part of the diagnostic workflow. Although the sample size for this modality remains small, its inclusion demonstrates the potential for MRI to be integrated into future iterations of the clinical pathway as a secondary, non-ionizing option for complex cases.

Efficiency Gains in the Emergency Department

Beyond the primary goal of radiation reduction, the researchers monitored the impact of the new protocol on hospital throughput using emergency department length of stay as a balancing measure (a metric used to track whether improvements in one area of clinical care, such as radiation reduction, negatively affect another, such as wait times). By tracking the total time from patient arrival to disposition, the study aimed to confirm that requiring surgical consultation and prioritizing ultrasound did not extend the duration of the patient's visit. The data indicated that the standardized pathway actually streamlined the diagnostic process. The average emergency department length of stay decreased from 538 minutes to 435 minutes, representing a reduction of 103 minutes per patient over the course of the study. These findings suggest that a clear clinical algorithm can reduce diagnostic uncertainty and accelerate decision-making, ultimately freeing up bed space and resources in high-volume pediatric settings. For the practicing clinician, these results provide evidence that adhering to radiation reduction protocols does not necessitate a trade-off in clinical throughput, provided the workflow is supported by multidisciplinary agreement and standardized imaging sequences.

References

1. Hermanto JS, Timothy AT, Telasman M. A Comprehensive Systematic Review of Diagnostic Approaches in Acute Appendicitis: A Comparative Analysis. International journal of medical science and health research. 2026. doi:10.70070/w4p7yh33

2. Tandoyo AD, Hendwell. Comparative Diagnostic Accuracy of Computed Tomography, Magnetic Resonance Imaging, and Ultrasonography for Acute Appendicitis: A Systematic Review. International journal of medical science and health research. 2025. doi:10.70070/k38zr345

3. Bonomo RA, Tamma PD, Abrahamian FM, et al. 2024 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Complicated Intra-abdominal Infections: Diagnostic Imaging of Suspected Acute Appendicitis in Adults, Children, and Pregnant People. Clinical Infectious Diseases. 2024. doi:10.1093/cid/ciae348

4. Araújo VD, Lopes BC, Petroianu A, Souza IKF. Complementary Computed Tomography to Inconclusive Ultrasonography in Children with Suspected Acute Appendicitis: A Systematic Review and Meta-Analysis. The American surgeon. 2025. doi:10.1177/00031348251371186

5. Lentz B, Fong T, Rhyne R, Risko N. A systematic review of the cost-effectiveness of ultrasound in emergency care settings. The Ultrasound Journal. 2021. doi:10.1186/s13089-021-00216-8

6. Saverio SD, Podda M, Simone BD, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World Journal of Emergency Surgery. 2020. doi:10.1186/s13017-020-00306-3

7. Sanders S, Rathbone J, Bell K, Glasziou P, Doust J. Systematic review of the effects of care provided with and without diagnostic clinical prediction rules. Diagnostic and Prognostic Research. 2017. doi:10.1186/s41512-017-0013-2