TaReva Warrick-Stone, DO | FMEM PGY3
The Article:
The Idea:
To determine the effects of adopting transcervical US as the initial imaging study to diagnose pediatric peritonsillar abscesses on median ED length of stay as an indicator of performance.
The Study:
A retrospective cohort study of all ED patients who had a CT or US scan performed on the neck region for suspected peritonsillar abscess at one freestanding tertiary care children’s hospital between Jan 2009 - Apr 2017. The institution adopted a protocol to use transcervical US first for the evaluation of PTAs in May 2013. The ED length of stay before and after implementation of the US-first approach were extracted from the EMR, along with imaging study performed and presence or absence of PTA on imaging. For patients with CT scans, they estimated the radiation dose, and for all patients, they estimated the amount billed and the amount reimbursed. As a balancing measure, they determined whether there were return patient visits within 2 weeks of the index ED visit related to head and neck infections or pain. All US studies were performed in the radiology department by board-certified sonographers trained in the transcervical technique. Images were reviewed and interpreted by pediatric radiologists. The CT studies were done with contrast and were obtained with a 64-slice system either in the ED or in the radiology department, and images were interpreted by pediatric radiologists. All abnormal findings were discussed between the ED physician and an ENT consultant regarding surgical or medical management.
The Findings:
Of the 962 ED patients who had neck imaging studies, 387 were included in the study; 286 were evaluated with US and 101 were evaluated with CT. None of the patients who had US scans required a subsequent CT scan. There were similar rates of positive results for CT (36, 35.6%) and US (99, 34.6%). The mean length of stay was significantly less for patients who had US (347 +/- 145 minutes) compared to CT (426 +/- 171 minutes), with an absolute difference of 79 minutes (95% CI, 44, 113 minutes). The difference was more pronounced in patients with negative results. Patients with negative CT results had a mean LOS of 115 minutes longer than in the US group (95% CI, 70, 160 minutes). The difference between the groups for patients with positive results was 12 minutes (95% CI, –40, 63 minutes), which was not statistically significant. Patients who were evaluated by US scan did not have a statistically significant increased rate of return visits within 2 weeks, 8.0% compared to 5.9% (P = 0.66). The median effective radiation dose of a neck CT scan was estimated at 3.9 mSV compared to no radiation exposure for US. At the time of this study, the mean billed cost of a neck CT scan was $2846, and the hospital was reimbursed on average $1138. The mean billed cost of a transcervical US scan was $1208, and the hospital was reimbursed on average $483 for each study. After implementation of the protocol, significantly more neck US (6.5) were ordered per month than neck CT (2.1) prior to the protocol with a mean difference in studies of 4.4 per month (95% CI, 3.5, 5.4).
The Takeaway:
A transcervical US-first strategy for the evaluation of pediatric peritonsillar abscess is associated with an overall decrease in the ED length of stay, however, this difference was only true for patients who had negative study results as there was no difference in LOS for those patients who were found to have PTAs.