BACKGROUND AND OBJECTIVE Acute appendicitis is the most common pediatric surgical emergency, with approximately 70 000 cases annually in the United States. Preoperative antibiotic regimens vary widely. Prior to 2024, our institution used cefoxitin or meropenem based on perceived perforation status. To align with evidence supporting narrow-spectrum regimens, we implemented a standardized antibiotic protocol, aiming to increase use of recommended first-line preoperative antibiotics—intravenous ceftriaxone and metronidazole (CRO-MTZ)—for pediatric emergency department (PED) patients undergoing appendectomy for acute appendicitis from 0% to 75% within 8 months. METHODS Our “Appendicitis Antibiotic Bundle” interventions included targeted education, pathway revision, and electronic health record updates. The primary measure was administration of CRO-MTZ. Secondary measures included preoperative antipseudomonal antibiotic use and antibiotic cost. Balancing measures were PED and hospital length of stay (LOS) and surgical site infections (SSIs). Statistical process control methods were used for analysis. We evaluated measures for both PED and all appendicitis patients, including those transferred from other facilities. RESULTS Administration of CRO-MTZ increased from 0% to 86% for PED and to 77% for all appendicitis patients. Preoperative antipseudomonal antibiotic use decreased from 19.1% to 5.5% in PED patients. The hospital-wide appendicitis SSI rate declined from 4.0% to 1.4%. There was a 21% decrease in preoperative antibiotic costs, a 25-minute reduction in PED LOS, and a 9.9-hour reduction in hospital LOS. All measures achieved special cause variation. CONCLUSIONS Associated with standardizing preoperative antibiotics for acute appendicitis, we noted reduced broad-spectrum antibiotic use and cost without increasing SSIs or LOS.
OBJECTIVES Urine cultures are frequently collected in hospitalized children for urinary tract infection (UTI) screening, despite often being unnecessary, invasive, and resource intensive. We aimed to decrease the proportion of unnecessary urine cultures in admitted children aged 90 days to 24 months from 65% to 45% over 1 year. METHODOLOGY The Model for Improvement guided problem understanding and change ideas. The main intervention included a 2-step UTI screening pathway previously implemented at our institution’s emergency department with emphasis on completing point-of-care urinalysis (UA) on noninvasive urine bag sample. If positive for pyuria, bladder catheterization was performed for urine culture. Additional interventions included electronic medical record order set, education, interdisciplinary collaboration, and alignment with the institution’s Choosing Wisely program. The primary outcome was the proportion of urine cultures completed without preceding positive UA screen. The balancing measure was the number of missed UTIs. Analysis used Statistical Process Control charts. RESULTS Baseline data (April 2020-March 2021) demonstrated that 65% of urine cultures were collected without a preceding positive UA. Postintervention data (April 2021-January 2025) demonstrated a decreased proportion of urine cultures collected without preceding positive UA screen from 65% to 22%. Special cause variation was detected 1 year following implementation of the pathway with sustained change during the study period. There was no increase in missed UTIs. CONCLUSIONS Process standardization using 2-step UTI screening pathway reduced unnecessary invasive urine culture collection in hospitalized children. The novel spread of this initiative to inpatient pediatric units aligns with best practices promoting high-value care.
