Background In our trust, historically paediatric patients presenting with abdominal pain raising suspicion of appendicitis were referred to surgeons and assessed in the Paediatric Assessment Unit. These patients faced long wait times for management plan by surgeons:

• covering theatres/adult wards and intensive care

• waiting for blood and imaging investigation results before finalizing a plan.

This led to delays and affected flow of patients through the PAU and the ward capacity. The Paediatric team decided to bring about a change in the abdominal pain referral pathway by proposing to see all patients referred with abdominal pain and refer to surgeons if deemed appropriate.

We collected data over 2 periods: 2018 and 2020, with the implementation of the new pathway in 2019

Aim To assess:

• Time to first review by a team (paediatric vs surgical)

• Percentage of patients

• With abdominal pain referred to each team

• Who had blood tests and imaging requested by each team

• Discharged, observed, referred and admitted by each team

Methods

• Sample period: 4 weeks in 2018 and 6 weeks in 2020

• Inclusion criteria: all paediatric patients referred with abdominal pain to PAU

• Exclusion criteria: anyone with previous appendectomy or re attending.

• Data collection: retrospective.

• Case notes: reviewed for referral record, review times, and initial diagnosis

• Electronic patient management system: reviewed for blood test and imaging investigation requested and discharge summaries

Results Primary care referral rose from 36% in 2018 to 47% in 2020 with a concurrent shift in ED referral from 53% to 37% in 2020 showing the effect of the new pathway. 26% of referrals were made to Paediatric team in 2018 vs 87% in 2020

Majority of patients were seen within 4 hours by the Paediatric team in both episodes 86% vs 85%. There was very slight improvement in Surgical team review time 78% vs 80%.

There was an increase in discharges to 58% by the surgical team in 2020 from 35% in 2018. However, we also saw the increase in referral by the Paediatricians to Surgeons from 7% to 33%

There was an impressive drop in blood investigation requested by the Surgical team from 90% to 58%. Requests for imaging by surgical teams declined from 33% to 17%.

88% of the referred patients with abdominal pain had medical diagnosis at discharge and did not need any surgical intervention

Summary Re-auditing after implementing new abdominal pathway shows:

• Overall patient flow through PAU has improved as more patients are being discharged.

• Appropriate reduction in laboratory investigation 2018 vs 2020 (both by surgical team from 90% to 58% and Paediatric team from 43% to 17%)

• Optimization of imaging resources by surgical team from 33% to 17%

• 88% of patients with abdominal pain had a medical diagnosis at discharge.

Conclusion

• Abdominal pain is a common presentation in the paediatric population, mostly benign and self–limiting.

• Abdominal pain should be assessed by general paediatricians first and then referred to surgical colleagues if deemed appropriate to avoid unnecessary investigations and imaging.