Implementation of an Emergency General Surgery Care Pathway for Acute Appendicitis: A Quality Improvement Initiative

Abstract

Background:

Antibiotics and appendectomy are the mainstays of therapy for acute appendicitis, but wide variation exists in antibiotic choice, duration, and guideline adherence. Despite recommendations favoring narrow-spectrum agents, broad-spectrum antibiotic use remains high. This multi-site quality improvement initiative aimed to implement a standardized care pathway to improve antibiotic stewardship.

Methods:

A multi-disciplinary task force developed and implemented an evidence-based pathway across six hospitals within a large health system. Data were compared for patients treated 12 months before and after implementation. The primary outcome was empirical broad- versus narrow-spectrum antibiotic use. Secondary outcomes included duration of therapy and balancing measures such as length of stay, 30-day readmission, and cost.

Results:

Among 1,279 patients with acute appendicitis (619 pre- and 660 post-intervention), empirical narrow-spectrum use increased significantly (14.2%–18.5%, p = 0.04), with corresponding decreases in broad-spectrum use (82.1%–78.2%, p = 0.09). Statistical process control charts revealed special cause variation, including sustained increases in narrow-spectrum prescribing. Clinical outcomes were unchanged: no differences were observed in length of stay (1.5 d [IQR: 0.9–2.8] versus 1.6 d [IQR: 0.9–2.9]; p = 0.62), 30-day readmission (7.9% vs. 7.1%, p = 0.60), infection-related readmission (1.1% vs. 1.6%, p = 0.57), or technical direct cost ($4,700 [IQR: $3,712–$6,680] versus $4,559 [IQR: $3,470–$6,759]; p = 0.183).

Conclusion:

A standardized care pathway significantly improved antibiotic selection for acute appendicitis without negatively impacting outcomes or costs. This initiative illustrates the feasibility of scalable, evidence-informed interventions to promote stewardship across diverse clinical settings.