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TABLE 1
Criteria for the Original Alvarado Score and Our Advanced Nursing Directive Modified Alvarado Criteria
Alvarado Score Criteria (MANTRELS) AND Modified Alvarado Criteria
Migratory RLQ pain Any complaint of right lower quadrant pain by patient
Anorexia Decreased appetite (anorexia)
Nausea/Vomiting Nausea and/or vomiting
Tender in RLQ Any tenderness in the RLQ with palpation by examiner
Rebound Pain Rebound tenderness in the RLQ (i.e. Positive Jump Test/Positive Pothole Test).
Elevation of Temperature (>37.3C) Elevated temperature and/or history of fever (38C)
Leukocytosis (>10 000)
Shift to Left (neutophilia >75%)
PART B Implementation
The patient must also have 3 or more of the following
On December 1, 2008, we implemented our AND for sus-
screening criteria:
pected appendicitis. As part of our continuing quality
Any complaint of right lower quadrant pain assessment process, we performed an initial assessment of
Nausea and/or vomiting the utilization of our AND over a 6-month period from
Decreased appetite (anorexia) March 1 to August 31, 2009. Table 2 provides descriptive
Elevated temperature and/or history of fever (38.0C) details concerning the use of our AND. Our pediatric
emergency department is the tertiary pediatric referral cen- 2. Bhatt M, Joseph L, Ducharme F, Dougherty G, Mcgillivray D. Prospec-
ter for Southern Alberta, Western Saskatchewan, and East- tive validation of the pediatric appendicitis score in a Canadian pediatric
emergency department. Acad Emerg Med. 2009;16:591-6.
ern British Columbia, Canada, with a 2009 census of
3. Blond G, Tully S, Chan L, Bradley R. Use of the MANTRELS score in
60,000 patient visits. childhood appendicitis: a prospective study of 187 children with abdom-
inal pain. Ann Emerg Med. 1990;19:1014-8.
Summary 4. Goldman R, Carter S, Stephens D, Antoon R, Mounstephen W, Langer
J. Prospective validation of the pediatric appendicitis score. J Pediatr.
In response to a clinical safety review, we have implemen- 2008;153:278-82.
ted an AND to empower our pediatric emergency nurses to 5. Kharbanda A, Taylor G, Fishman S, Bachur R. A clinical decision rule
identify and initiate care directives for children with sus- to identify children at low risk for appendicitis. Pediatrics. 2005;116:
pected appendicitis. Future quality assessment and research 709-16.
studies will focus on the accuracy of the AND in predicting 6. Samuel M. Pediatric appendicitis score. J Pediatr Surg. 2002;37:877-81.
which children will have imaging studies or an appendect- 7. Schneider C, Kharbanda A, Bachur R. Evaluating appendicitis scoring
omy as well as the impact of the AND on key pediatric ED systems using a prospective pediatric cohort. Ann Emerg Med.
2007;49:778-84, 784.e1.
flow measures.
FIGURE 1
Nursing protocol for child with suspected appendicitis. Courtesy of Erin deForest.
FIGURE 2
Alberta Children's Hospital (ACH) pediatric appendicitis care map. Printed with permission from Greg McKernan Graphic Design.
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