The implications of missed opportunities to diagnose appendicitis in children

Objectives The purpose of this study was to determine the fraction of children with acute appendicitis who had recent false-negative diagnoses and to analyze the association of a missed diagnosis of appendicitis with patient outcome. Methods The records of all 816 patients who underwent appendectomy for suspected appendicitis at a free-standing children's hospital between 2007 and 2010 were reviewed. A patient admitted or evaluated in the emergency department (ED), discharged without a diagnosis of appendicitis, and then readmitted with histopathologically confirmed appendicitis within 3 days was considered to have a “missed diagnosis.” Outcomes for this missed group were compared to those of the remainder of the appendectomy cohort. Results Thirty-nine patients with appendicitis (4.8%) were missed at initial presentation. The most common initial discharge diagnoses were acute gastroenteritis (43.6%), constipation (10.3%), and emesis (10.3%). The median duration from the initial evaluation to the appendicitis admission was 28.3 hours (interquartile range [IQR] = 17.0 to 39.6 hours). A missed diagnosis was associated with a longer median hospitalization (5.8 days [IQR = 4.0 to 8.1 days] vs. 2.5 days [IQR = 1.8 to 4.6 days]; p < 0.001), higher rate of perforation (74.4% vs. 29.0%; p < 0.001), higher complication rate (28.2% vs. 10.4%; p = 0.002), and higher rate of reintervention (20.5% vs. 6.2%; p = 0.003). Conclusions Of children diagnosed with appendicitis, 4.8% may have had a missed opportunity for earlier diagnosis. These false-negative diagnoses are associated with higher rates of perforation, postoperative complications, and need for postoperative interventions, as well as longer hospitalizations. Resumen Las Implicaciones de las Oportunidades Perdidas para Diagnosticar Apendicitis en Ninos Objetivos El proposito de este estudio fue determinar el porcentaje de ninos con apendicitis aguda que tuvieron un diagnostico falso negativo, y analizar la asociacion de un diagnostico perdido de apendicitis con los resultados del paciente. Metodologia Se revisaron las historias clinicas de todos los 816 pacientes en los que se llevo a cabo una apendicectomia por sospecha de apendicitis en un hospital pediatrico entre 2007 y 2010. Se considero tener “un diagnostico perdido” a aquellos pacientes ingresados o evaluados en el servicio de urgencias (SU), dados de alta sin el diagnostico de apendicitis y despues reingresados con apendicitis confirmada histopatologicamente en los tres primeros dias. Los resultados de este grupo perdido se compararon con el resto de la cohorte de apendicectomia. Resultados Treinta y nueve pacientes con apendicitis (4,8%) se perdieron en la atencion inicial. Los diagnosticos iniciales de alta mas comunes fueron gastroenteritis aguda (43,6%), estrenimiento (10,3%) y vomitos (10,3%). La mediana de duracion desde la evaluacion inicial hasta el ingreso por apendicitis fue de 28,3 horas (RIC 17,0 a 39,6 horas). Un diagnostico perdido se asocio con una mediana de hospitalizacion mas prolongada (5,8 dias [RIC 4,0 a 8,1 dias] vs 2,5 dias [RIC 1,8 a 4,6 dias] p < 0,001) y unos porcentajes mayores de perforacion (74,4% vs. 29,0%; p < 0,001), complicacion (28,2% vs 10,4%; p = 0,002) y reintervencion (20,5% vs. 6,2%; p = 0,003). Conclusiones De los ninos diagnosticados con apendicitis, un 4,8% pueden haber tenido una oportunidad perdida para el diagnostico precoz. Estos diagnosticos falsos negativos se correlacionan con mayores porcentajes de perforacion, complicaciones postoperatorias y la necesidad de reintervenciones, asi como con un mayor tiempo de hospitalizacion.