A quality improvement project targeting postoperative hospital revisit rates after pediatric appendicitis

Abstract

Background:

High rates of hospital revisits after pediatric appendectomy are costly to the health care system, patients, and families. We sought to trial a bundle of interventions targeted at reducing the rate of unnecessary revisits to hospital in this population.

Methods:

In February 2021, a working group of relevant stakeholders was created. In June 2021, the group developed and implemented interventions to reduce revisits in a staggered fashion. Interventions included increased education provided to patients and their families, as well as nursing staff, revised discharge pamphlets, and a post-discharge phone call from our nurse practitioner. We tracked revisit rates prospectively using run charts with comparison to historical controls.

Results:

We tracked revisit rates from July 2018 to October 2022. A total of 793 appendectomies were performed. There was a downward trend in revisit rates, from 16.7% before interventions to 13.4% after intervention implementation, for a relative reduction of 20%. In the postintervention period, 193 appendectomies were performed, with 78.0% contacted by our nurse practitioner in the early postoperative period. Of those contacted, 74% received the discharge pamphlet and 98.7% of respondents expressed that the phone call was useful. Almost all respondents stated they would want the follow-up phone call if they were to have another child with appendicitis.

Conclusion:

Simple, low-cost interventions aimed at improving education at time of discharge after pediatric appendectomy were associated with a reduction in unnecessary hospital revisits. Ongoing efforts are required to sustain results and assess efficacy of bundle elements to determine if additional initiatives may be beneficial in further reductions of revisits.

With the combination of increasing health care costs and finite resource availability, there is an urgent need to identify options to deliver higher-value care. The Canadian Institutes for Health Information has tracked hospital spending trends across Canada (excluding Quebec and Nunavut) and has identified the emergency department as a source of substantial expenditures.¹ Over a 15-year period, the cost per emergency department visit increased by almost 2.4 times, with the total direct costs associated with visits up to a high of $2.4 billion annually in 2020/21. Over that same time period, the number of emergency department visits have also seen a notable increase from 5.4 million visits to just under 14 million visits annually.² Although the emergency department is an important resource for urgent care, identifying alternative options for patients to access care for less urgent issues may unload unnecessary burden from an already taxed system.

Rates of 30-day unplanned hospital revisits are often used as a measure of quality of care provided to patients, as they may indicate inadequate care at the time of discharge. These revisits place a substantial burden on the emergency department from a cost and resource utilization perspective. In addition, hospital revisits increase stress and time off school and work for patients and their families.

In an effort to characterize the conditions that contribute to the burden on the emergency department in association with revisits within pediatric surgery, Cameron and colleagues³ performed an analysis of 2012–2015 data from the Pediatric Health Information System database. They found that, of the 30 most commonly performed pediatric general surgeries, 4 procedures contributed to more than half of the resource burden associated with revisits after discharge from surgery. The top 4 fiscal-inducing procedures associated with revisits to the emergency department were appendectomy for complicated and uncomplicated appendicitis, along with gastrostomy tubes and fundoplication. The authors suggested that health care teams should target their quality improvement efforts at these procedures to have the greatest impact.

Appendicitis is the most common pediatric abdominal emergency;^4–8 its lifetime risk is around 7%–8%, with the highest incidence occurring between the ages of 10 and 19 years.^6,7 Appendectomy is the standard of care for both uncomplicated and complicated appendicitis. It is the most common surgery performed in pediatric patients in Canada and is among the top 4 reasons for admission to hospital among all surgical and medical diagnoses within the pediatric age group.⁹ Given its incidence and nature of therapy, it is not surprising that appendectomy for both complicated and uncomplicated appendicitis contributed to roughly 30% of cost and resource utilization associated with postsurgical hospital revisits.³

In concert with the literature, we identified a high rate of hospital revisits after pediatric appendectomy at our institution. Historical reports from the National Surgical Quality Improvement Program-Pediatric (NSQIP-P), a nationally validated, risk-adjusted, outcomes-based program that seeks to measure and improve the quality of surgical care, indicated that our institution had a revisit rate as high as 20% and our patients were 40%–50% more likely to have a revisit than those at the average NSQIP-P hospital. These unnecessary hospital revisits after appendectomy suggest inadequate care transitions and provide an opportunity to target higher-value care. The goal of this quality improvement project was to implement a bundle of interventions to reduce unnecessary revisits among pediatric patients after appendectomy for uncomplicated and complicated appendicitis by 30% over a 1-year period.

Methods

This quality improvement project used an interrupted time-series design to evaluate revisit rates among pediatric patients (aged < 18 yr) after appendectomy for uncomplicated and complicated appendicitis before and after targeted interventions. We conducted the project between July 2018 and October 2022. Reporting of this project followed the principles of Standards for Quality Improvement Reporting Excellence.¹⁰

In February 2021, after review of historical reports from NSQIP-P, a working group of relevant partners was convened to develop and implement a bundle of interventions to target a reduction in unnecessary revisit rates post pediatric appendectomy. The working group included pediatric surgeons, the surgery nurse practitioner (NP), surgery quality improvement facilitators, a general surgery resident, the pediatric surgery research coordinator, and the NSQIP-P surgical clinical reviewer. Throughout the initiative, the working group collaborated with a patient and family advisor from the Patient Experience Office, the clinical informatics office, and nurse managers and clinical educators on both the inpatient wards and the post-anesthetic recovery room.

Baseline data collection

Between March and June 2021, 2 audits were completed to collect baseline data and inform development and implementation of interventions. First, we reviewed all patients identified from the January 2021 NSQIP-P semiannual report (inclusive of patients from July 2019 to June 2020) with a revisit after appendectomy to assess reasons for return. This identified postoperative pain, fever, diarrhea or constipation, and surgical site infections as common concerns. Next, the surgery NP completed an informal audit of both the nursing and surgical team discharge instructions, which indicated that the instructions given were dependent on the nurse, while information provided by surgical residents was often more applicable to adult populations.

Based on information garnered from the audits, a driver diagram was created and used to create a goal-oriented project (Figure 1). The working group developed and implemented a bundle of interventions to improve discharge instructions and enhance information transfer to patients and families in support of their transition of care to home.

Fig. 1.

Driver diagram for change ideas to target a reduction in rates of pediatric postappendectomy hospital revisits. ED = emergency department; NP = nurse practitioner. See Related Content for accessible version.

Interventions

The first intervention was implemented in June 2021 and consisted of in-the-moment nursing education. The NP engaged patients and their families at the time of discharge, along with bedside nursing staff. Information reviewed included pain control, return to play or school, dressing care, signs and symptoms that would require a return visit to hospital, follow-up, and contact information for any questions or concerns

The second element of the bundle was a newly developed discharge instruction pamphlet to help reinforce the discharge information provided verbally. This pamphlet was written in English at a grade 8 reading level and included identical information to that provided verbally at the time of discharge, including surgery office and NP contact information. The working group developed the content, which was then reviewed by the patient partner to ensure all relevant information was included and presented in a family-friendly manner. This pamphlet was made widely available for distribution to families at the time of discharge throughout the hospital beginning in July 2021.

The third intervention was also instituted in July 2021 and consisted of a follow-up phone call from the surgery NP, ideally within 72 hours of discharge. If the patient or family members were unavailable at the time of the call, the NP left a message. The NP made 3 attempts to contact the family. A standardized script was created and reviewed by the patient partner to ensure the applicability of questions. The goal of these phone calls was to assist in the transition of care to home and provide early follow-up in an effort to preemptively address concerns at home and avoid unnecessary hospital visits. The script included several quality control questions to help garner whether these phone calls were beneficial to the patient and family.

Data collection

This project combined 2 different data collection strategies. The first included all pediatric patients who underwent appendectomy between July 2018 and October 2022 at our institution. Historical outcome data were collected by the NSQIP-P surgical clinical reviewer, along with data obtained from previous NSQIP-P semiannual reports. Several factors (i.e., delayed release, overlap of data, reporting 6-month intervals) contributed to challenges in measuring our project outcomes using the semiannual reports. As a result, unadjusted data from the surgical clinical reviewer were used to track revisit rates. The second data collection method involved prospective data collection, completed by the NP, which began in July 2021 and continued until June 2022, after implementation of the 3 interventions.

Outcomes

The data collection included outcome, structure, process, and balancing measures to fully evaluate the success of the interventions. The primary outcome measure was the hospital revisit rate, defined according to the NSQIP-P manual as admission to hospital within 30 days of surgery or a postoperative emergency department visit based on the Target Appendectomy variable.^11,12 We then reviewed all case occurrences within the postintervention group to stratify revisits and readmissions into causes related to or unrelated to the appendectomy. We further stratified related revisits as either necessary or unnecessary. We deemed revisits unnecessary if patients did not require any investigation or intervention other than reassurance or over-the-counter medications such as acetaminophen or ibuprofen. Structural measures for this project included the utilization of postdischarge follow-up phone calls and the discharge instruction pamphlet. Process measures included the percentage of families reached with the postdischarge phone call and the percentage of families who received the discharge pamphlet. Finally, we tracked balancing measures, such as the amount of time to complete the postdischarge phone calls and hospital length of stay for the primary admission for appendicitis.

Statistical analysis

We used descriptive analysis to report frequencies for categorical variables, and the mean, median, interquartile range (IQR), and standard deviation (SD) for continuous variables. We separated the annual hospital revisit rates into tertiles, beginning in July, to allow for reporting using run charts. We used the independent sample t test and the Kruskal–Wallis test to compare statistical differences between continuous variables. We used χ² tests to compare categorical variables. To determine statistical significance, an α level of 0.05 was used. We completed analyses using SAS Software (version 9.4; SAS Inc.) and Microsoft Excel with QI Macros (2022).

Ethics approval

We obtained research ethics board exemption for this quality improvement project.

Results

In total, 792 appendectomies were completed between July 2018 and the first tertile of 2022/23. Figure 2 displays the overall rate of revisit along with the rate of revisits for uncomplicated appendicitis by tertile. The preintervention period spanned from the first tertile of 2018/19 to the second tertile of 2020/21. The postintervention period spanned from the third tertile of 2020/21 to the first tertile of 2022/23. The preintervention revisit rate was 16.7%. The project target was a 30% reduction from the preintervention rate. After the interventions, revisit rates were reduced by almost 20% (19.8%) to a rate of 13.4% (Appendix 1, Table 1, available at www.canjsurg.ca/lookup/doi/10.1503/cjs.009024/tab-related-content). Revisit rates specifically for uncomplicated appendicitis remained fairly consistent in the preintervention (13.5%) and postintervention periods (13.2%). Revisit rates for complicated appendicitis reduced from 30.0% in the preintervention period to 12.6% in the postintervention period (Figure 3). Irrespective of the differences in revisit rates, there was no difference in the average postoperative length of stay (p = 0.1), with a mean of 1.5 (SD 2.3) days before interventions and a mean of 1.3 (SD 1.7) days after the interventions began. More specifically, there was no change in average length of stay for complicated appendicitis (preintervention: 3.8 [SD 3.8] d v. postintervention: 3.2 [SD 2.2] d; p = 0.49). However, the average length of stay for uncomplicated appendicitis decreased significantly in the postintervention period (0.7 [SD 0.8] d), compared with the preintervention (1.0 [SD 1.1] d; p < 0.001).

Fig. 2.

Run chart depicting the rate of postappendectomy revisits for all pediatric patients (control limit [CL] = 15.3, upper CL = 31.1, lower CL = 0.0) and for those who had uncomplicated appendicitis (CL = 13.4, upper CL = 37.1, lower CL = 0.0), by tertile. *Creation of the working group (February 2021). †Beginning of the audit period (March and June 2021) and start of in-the-moment nursing education (June 2021). ‡Implementation of discharge pamphlet (July 2021) and start of nurse practitioner follow-up phone calls (July 2021). T = tertile. Supporting data are presented in Appendix 1, Table 1, www.canjsurg.ca/lookup/doi/10.1503/cjs.009024/tab-related-content.

Fig. 3.

Run chart depicting the rate of postappendectomy revisits for all pediatric patients (control limit [CL] = 15.3, upper CL = 31.1, lower CL = 0.0) and for those who had complicated appendicitis (CL = 22.7, upper CL = 54.1, lower CL = 0.0), by tertile. *Creation of the working group (February 2021). †Beginning of the audit period (March and June 2021) and start of in-the-moment nursing education (June 2021). ‡Implementation of discharge pamphlet (July 2021) and start of nurse practitioner follow-up phone calls (July 2021). T = tertile. Supporting data are presented in Appendix 1, Table 1, www.canjsurg.ca/lookup/doi/10.1503/cjs.009024/tab-related-content.

During the postintervention tracking period (2021/22), 193 appendectomies were performed, of which 28.5% were considered complicated appendicitis by NSQIP standards. The median age of patients was 10.9 (IQR 8.3–14.3) years and most patients were male (59.0%) (Table 1). Patients with complicated appendicitis had a significantly longer length of hospital stay (3 [IQR 2–5] d) than those with uncomplicated appendicitis (1 [IQR 0–1] d; p < 0.001). Additionally, sepsis and systemic inflammatory response syndrome was more prevalent in complicated cases (p < 0.001). The rate of surgical site infections was low, with only 4.7% of patients developing surgical site infections, including superficial, deep, or organ space infections. There was no significant difference in the rate of revisits or readmissions by appendectomy type.

Table 1.

Demographic characteristics for all pediatric patients who underwent appendectomies in the 2021/22 postintervention tracking period

Characteristic	No. (%) of patients*			p value
	Overall n = 193	Uncomplicated n = 138	Complicated n = 55
Patient age, yr, median (IQR)	10.9 (8.4–14.3)	11.1 (8.7–15.3)	10.3 (7.3–12.8)	0.08
Sex				0.6
Male	114 (59.0)	80 (58.0)	34 (61.8)
Female	79 (41.0)	58 (42.0)	21 (38.2)
Length of stay, d, median (IQR)	1 (1–2)	1 (0–1)	3 (2–5)	< 0.0001
Length of postoperative stay, d, median (IQR)	1 (0–1)	1 (0–1)	3 (1–4)	< 0.0001
Diagnosis of systemic inflammatory response syndrome or sepsis				< 0.0001
No	85 (44.0)	73 (52.9)	12 (21.8)
Yes	108 (56.0)	65 (47.1)	43 (78.2)
Surgical site infections				0.1
No	184 (95.3)	134 (97.1)	50 (90.9)
Yes	9 (4.7)	4 (2.9)	5 (9.1)
Superficial	4 (2.1)	4 (2.9)	0 (0.0)
Deep	0 (0.0)	0 (0.0)	0 (0.0)
Organ	5 (2.6)	0 (0.0)	5 (9.1)
Revisit to hospital within 30 d				0.3
No	164 (85.0)	115 (83.3)	49 (89.1)
Yes	29 (15.0)	23 (16.7)	6 (10.9)
Unrelated	11 (37.9)	10 (43.5)	1 (16.7)
Related, unnecessary	3 (10.3)	2 (8.7)	1 (16.7)
Related, necessary	15 (51.7)	11 (47.8)	4 (66.6)
Readmission to hospital within 30 d				0.2
No	183 (94.8)	133 (96.4)	50 (90.9)
Yes	10 (5.2)	5 (3.6) 5	(9.1)
Unrelated	1 (10.0)	0 (0.0)	1 (20.0)
Related	9 (90.0)	5 (100.0)	4 (80.0)

IQR = interquartile range.

^*Unless indicated otherwise.

Overall, 29 (15.0%) patients had a revisit to hospital after discharge (Table 1). Of those 29 patients who had a revisit, 23 had uncomplicated appendicitis while 6 had complicated appendicitis. Eleven (37.9%) of the 29 revisits were found to be for unrelated causes (i.e., humeral fracture, jaw pain, COVID-19). Of the 18 revisits related to surgery, only 3 were deemed to be unnecessary, where no investigation or intervention was provided. The most common reasons for revisits that were related to the appendectomy and deemed to necessitate revisit included surgical site infections, ileus or bowel obstruction, nausea or vomiting, and hemorrhage. Of all the patients with a revisit, 10 (34.5%) were subsequently readmitted to hospital, with all but 1 (90.0%) patient admitted for issues related to their surgery.

Of the 22 patients who had a revisit and were contacted by the NP, all spoke with the NP before discharge and 72.7% received the discharge pamphlet. In 59.1% of cases, this follow-up call occurred before the patient revisited the hospital. These patients presented to the hospital with infections or surgical site infections (n = 6, 46.2%), abdominal pain (n = 3, 23.1%); unrelated issues such as viral infection and asthma (n = 2, 15.4%); nausea, vomiting, or constipation (n = 1, 7.7%); and other related issues (n = 1, 7.7%). Among patients for whom the follow-up phone call occurred after revisit, 3 (33.3%) had abdominal pain, 3 (33.3%) had infections, 2 (22.2%) had other related symptoms (e.g., postoperative hemorrhage, ileus), and 1 (11.1%) had unrelated issues (e.g., COVID-19).

Nurse practitioner follow-up phone call

Of the 193 patients who underwent appendectomies in 2021/22, 150 (77.7%) answered or returned the follow-up phone call and spoke to the NP. Forty-three patients were missed because the NP was not made aware of the patients, inaccurate contact information was on file, or the call was not returned by the family. Of the 150 families who were reached by phone, 74.0% received the discharge pamphlet. The median length of the follow-up call was 5.5 (IQR 3.0–9.0) minutes. Almost all the families felt the call was beneficial (98.7%) and 99.3% said that they would want this call again if another of their children had an appendectomy.

Discussion

Appendicitis is the most common pediatric surgical emergency; ^4–7 thus, there is motivation to optimize and standardize the care of these patients to improve care and reduce costs. We found a high revisit rate among these patients at our institution and endeavoured to develop interventions for reduction. Increased bedside education by nursing staff at discharge, a reinvigorated discharge pamphlet addressing common concerns, and a postdischarge phone call with our NP were trialed. These interventions aimed to target inappropriate transmission of discharge instructions and provide options to contact surgical providers by phone either via the surgeon’s office or the NP.

Our institution practises same-day discharge in most instances of uncomplicated appendicitis. Although outpatient management of these patients has clear benefits, success of this protocol is contingent on appropriate caregiver education and patient selection.^4,7,13 Here, we demonstrate simple, low-cost interventions that enhance this process.

Employing NSQIP, we obtained a directive to track all patients who underwent appendectomies. This allowed us to be more precise in tracking outcomes. Our results suggest a trend toward reducing the revisit rates for these patients. As a balancing measure, we tracked the hospital length of stay, which did not differ statistically between pre- and postintervention groups but trended toward an overall reduction in hospital length of stay in the postintervention group. This reflects our ongoing practice of same-day discharge with uncomplicated appendicitis, which was instituted late in 2020, and likely the lack of change in postoperative management of complicated appendicitis on the ward. This suggests that conducting this project did not affect management of the initial hospital course.

Revisit rates remain a concern and potentially avoidable health care cost.³ Reasons for revisit can vary from true postoperative concerns — such as fever, vomiting, and abdominal pain — to simple complaints of steri-strips falling off early or completely unrelated issues, such as a broken arm. It is important to recognize, however, that this number will never reach zero. Based on the nuances of the NSQIP-P program, unrelated revisits to hospital within 30 days of surgery will still be counted against an institution and may unintentionally inflate reported rates. For instance, this was identified in the third tertile of 2021/22 where 3 of the 14 revisits were found to be for unrelated reasons, corresponding to the spike in rates during that tertile. For the purposes of this manuscript, we chose to present the full data, including unrelated revisits, akin to how NSQIP-P outcomes are presented, as opposed to removing these cases from the analysis, as this is the format we will continue to use to monitor outcomes for the future. This also points to the necessity of reviewing case occurrence data when institutions are facing signalling spikes in their NSQIP reports to gain a more fulsome understanding of the outcomes data. We demonstrated this by reviewing all revisit cases in the postintervention group to categorize revisits for causes that were related or unrelated to the surgery; we further stratified the related visits into necessary or unnecessary revisits. The aim of this project was to reduce the number of related but unnecessary revisits, of which there were only 3 in the postintervention group.

Further rationale for why revisit rates will never reach zero, nor should we aspire for that rate, is that patients needing further assessment and treatment for true issues should not be discouraged to return for warranted reasons. It is imperative that patients who need further treatment are not missed. In fact, on some occasions, the presentation to the emergency department occurred as a result of direct recommendations from the NP during the follow-up phone call as there were concerns that could not be fully assessed over the phone. Lastly, caregivers are instructed to contact the NP or surgeon’s office directly on weekdays. On weekends and evenings, however, access to surgical consultation is accessible only through the emergency department, making this the more likely choice. It is demonstrated here that these low-cost interventions correctly identify and mitigate avoidable revisits while leaving valid postoperative concerns unaffected.

It is difficult to quantify the contribution of each individual intervention to the primary outcome of post-appendectomy revisit rates. Furthermore, different interventions may have had differing contributions to the primary outcome measure for complicated and uncomplicated appendicitis. Previous studies have found a 2-fold higher revisit rate among patients with complicated appendicitis, compared with uncomplicated appendicitis.⁵ In our postintervention data, our rates of revisit were actually lower for complicated appendicitis than for uncomplicated appendicitis. We can rationalize this result by suggesting that the interventions provided in hospital played a more important role for the complicated appendicitis group. Our NP would have been involved with discharging most of the patients with complicated appendicitis from the ward (although patients discharged on the weekend would not have been discharged by the NP). As a result, these patients would have a higher likelihood of receiving the discharge pamphlet and more standardized discharge education. This is in contrast to patients with simple appendicitis, who are most commonly discharged from the recovery room and are unlikely to receive discharge education from the NP, and who were more variably given the discharge pamphlet. Moving forward, we will incorporate an order to provide the discharge pamphlet into the discharge order set in an effort to more consistently distribute the pamphlet.

One institution has attempted similar interventions targeted at reducing rates of revisits after pediatric appendectomy. ¹⁴ They developed and instituted a postdischarge text messaging system that automatically messaged caregivers on predetermined postdischarge days. If there were further questions or concerns, they were automatically set up with a visit with a telehealth provider or given the contact information of their surgeon’s office. This system did show a reduction in visits to the emergency department; however, the authors recognized that not all institutions have the resources or capability to develop a similar system, specifically, one that can provide real-time assessment by telehealth physicians. Our institution had these limitations and as such, we aimed to develop a similar style of follow-up that could be managed with fewer resources.

The postintervention period coincided with the COVID-19 pandemic and there may be some confounding effects of the pandemic on our results. It was well known that patients had a degree of anxiety and aversion to seeking medical care during the pandemic which, in some instances, led to a delay in diagnosis. However, anecdotally, once patients and families understood the diagnosis and required treatment within the hospital, they became less averse to seeking medical attention, recognizing that supportive care at home would be insufficient for management of their diagnosis. As a result, we suspect the aversion to seeking medical care during the pandemic had more effect on initial diagnosis than revisit rates. For further context, the revisit rates for the 2 tertiles (third tertile of 2019/20 and first tertile of 2020/21) corresponding to the first 8 months of the pandemic (March 2020 to October 2020) had among the highest revisit rates within the project period. Finally, we have reviewed revisit rates from subsequent NSQIP reports since the culmination of this study until August 2024 and have found that the overall revisit rate after pediatric appendectomy has remained consistent at 14%. The revisit rate for uncomplicated appendicitis has shown a continued minor decline since the completion of the project period, with a most recent rate of 10.5%. Unfortunately, the revisit rate for complicated appendicitis has approached preproject levels at 25.5%. These numbers confirm our speculation that the interventions led primarily by the NP (phone call follow up and in-hospital discharge education) played a important role for patients with complicated appendicitis as our NP has been on maternity leave for the past year and a half. The lower revisit rate with uncomplicated appendicitis in the past 2 years also suggests that the COVID-19 pandemic may not have been a notable confounding variable. Most pediatric patients with appendicitis had uncomplicated appendicitis and these rates continue to show a steady decline even after the impact of the pandemic.

Both the distribution of discharge materials and the follow-up phone call with the NP had relatively good rates of uptake between 70% and 80%. These metrics should continue to be tracked to ensure the progress that has been made does not regress with staff turnover. Future work should focus on optimizing the delivery of discharge materials through automatic distribution to all pediatric patients undergoing appendectomy. Second, systematic tracking of patients needing a postdischarge phone call is being explored to help increase rates of phone call follow-ups by the NP. Furthermore, the discharge instruction pamphlet will be translated into common languages. It will also be updated to incorporate feedback received through the course of this project, along with further enhancements to instructions related to common revisit reasons that continue to present in our emergency department. Direct cost savings from these interventions is also being explored. It is interesting to note that the phone call follow-ups provided by the NP took an average of 5.5 minutes. For the total 193 appendectomies performed in the year, the time needed to call all families would equate to 1061.5 minutes or 17.7 hours or 1% of an annual full-time equivalent NP position. The simple and low-cost nature of the described interventions should allow other institutions to model their improvement strategies around our approach and further improve care transitions for postoperative patients.

Limitations

Limitations to this project included inherent issues with NSQIP data, including difficulties in determining the reason for revisit to hospital. The NSQIP does not routinely collect reason for revisit, meaning visits to the emergency department for upper respiratory tract infection, trauma, or true postsurgical concerns are similarly recorded. Although we investigated the reason for revisit in the postintervention period for the purposes of the project, this was dependent on documentation from the emergency department or other services involved. In addition, patients may be brought to the emergency department for a multitude of concerns that are similarly difficult to capture. Although we have specified when certain interventions began, this project was likely susceptible to the Hawthorne effect, as people became aware of many of these interventions and unofficially implemented them into their practice before their official release. As a result, we consider our postintervention period as commencing once the working group was established in February 2021 as audits and change ideas had quickly begun after this time point, potentially affecting the data. Another limitation of this study is the informal nature of the first intervention, with no quantifiable measurement of the consistency of information delivery to families at the time of discharge. The discharge pamphlet is currently available only in English, and we do not have data on whether a translator was used for in-person discharge instructions for patients and caregivers who were not proficient in English.

Conclusion

Overall, we developed effective strategies to decrease unexpected revisits to the hospital among pediatric patients who underwent appendectomy. Strategies include enhancements in bedside education at the time of discharge, NP phone calls, and an updated, pediatric-specific postappendectomy discharge pamphlet. These low-cost interventions were specifically chosen to allow accessible generalizability to all centres performing pediatric appendectomies. As same-day discharge after uncomplicated appendicitis increases, minimizing unnecessary revisits to hospital will have more economic and patient care implications.