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PEDIATRIC UPDATE

IMPLEMENTATION OF AN ADVANCED NURSING


DIRECTIVE FOR SUSPECTED APPENDICITIS TO
EMPOWER PEDIATRIC EMERGENCY NURSES
Authors: Erin Kate deForest, BKin, BScN, RN, and Graham Cameron Thompson, MD, FRCPC, FAAP,
Calgary, Alberta, Canada
Section Editors: Donna Ojanen Thomas, RN, MSN, Joyce Foresman-Capuzzi, RN, BSN, CEN, CTRN, CPN, CCRN, SANE-A, EMT-P,
and Michelle Tracy, RN, MA, CEN, CPN

Earn Up to 8.0 CE Hours. See page 291.

Background article we report the use of our AND to empower pediatric


emergency nurses in the frontline care of children with
Increasing wait times in the pediatric emergency depart-
abdominal complaints.
ment can lead to delayed recognition and treatment of sig-
nificant medical and surgical illness. During the fall of
2007, the former Calgary Health Region (currently Alberta Purpose of AND
Health Services, Calgary Zone) called a clinical safety
review for the care of the patient with suspected appendi- Our AND was developed to (1) assist pediatric emergency
citis. Using a multidisciplinary approach including pedia- nurses in identifying children who would likely need
tric and adult representation from the departments of further investigation for suspected appendicitis and (2) to
emergency medicine, surgery, diagnostic imaging, and nur- empower pediatric emergency nurses to initiate investiga-
sing, we identified system delays as a potential contributor tions and management before pediatric emergency physi-
to the adverse outcomes in patients presenting with appen- cian assessment. The important components of the AND
dicitis. To address this issue, a Pediatric Appendicitis Com- included standardized assessment measures by use of set
mittee was convened. Representation from infectious criteria, a defined care plan if criteria are met (as described
diseases, anesthesia, and pharmacy services was added to later), and the option to seek assistance when necessary.
the previously mentioned participants. Over a 1.5-year per- Use of this AND is intended for verbal children aged 3
iod, we developed and implemented a pediatric appendici- to 17 years.
tis care map, of which a key component is our advanced
nursing directive (AND) for suspected appendicitis. In this
Development of AND

After reviewing previously validated appendicitis scoring


systems, including but not limited to the Alvarado
Score, 1 the Pediatric Appendicitis Score, 2-4 and the
Erin Kate deForest, International Member, Emergency Nurses Association, is a
Low Risk Appendicitis Score,5 we chose by consensus
Nurse Clinician and the Pediatric Appendicitis Committee Nursing Repre- to use a modification of the Alvarado Score to be con-
sentative, Pediatric Emergency Department, Alberta Childrens Hospital, Cal- gruent with our adult colleagues within the Calgary
gary, Alberta, Canada. Health Region. The Alvarado Score has shown reason-
Graham Cameron Thompson is Clinical Outreach Educator/Assistant Profes- able sensitivity and specificity in children6,7 and is used
sor, Pediatric Emergency Medicine, University of Calgary/Alberta Childrens in our AND as a screening tool, not an absolute diagnos-
Hospital, Calgary, Alberta, Canada.
tic test. Because the nursing assessment occurs before
For correspondence, write: Graham Cameron Thompson, MD, FRCPC,
FAAP, Alberta Childrens Hospital, 2888 Shaganappi Trail NW, Calgary
laboratory investigations, Alvarado criteria based on com-
AB T3B 6A8, Canada; E-mail: graham.thompson@albertahealthservices.ca. plete blood count results were not included. The criteria
J Emerg Nurs 2010;36:277-81. for the presence of fever was increased from 37.3C to
0099-1767/$36.00 38.0C because children with a temperature below
Copyright 2010 Emergency Nurses Association. Published by Elsevier Inc. 38.0C are not considered febrile at our institution.
All rights reserved. Table 1 compares the original Alvarado Score with our
doi: 10.1016/j.jen.2010.02.015 modified score.

May 2010 VOLUME 36 ISSUE 3 WWW.JENONLINE.ORG 277


PEDIATRIC UPDATE/deForest and Thompson

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%)

AND, advanced nursing directive; RLQ, right lower quadrant.

For a patient meeting these screening criteria, an emer-


TABLE 2 gency nurse is able to perform the following procedures
Utilization of AND for Suspected Appendicitis before emergency physician assessment/orders:
No. Establish intravenous access with double lumen Y
Number of patients aged 3-17 years seen 28,833 connector
from March 1 to August 31, 2009 at Obtain blood work (glucometer check, complete blood
ACH pediatric emergency department count/differential, electrolyte levels)
Number of AND checklists completed 446 Initiate a 20-mL/kg bolus of 0.9% normal saline solu-
Number meeting criteria and starting AND 164 tion (maximum, 1 L), and then run 0.9% normal sal-
ine solution at maintenance rate
ACH, Alberta Children's Hospital; AND, advanced nursing directive. Collect a midstream urine sample for urine dip/routine
and microscopy (R&M), and send for culture if the
urine dip is positive; perform a point-of-care pregnancy
test (beta-human chorionic gonadotropin) test for all
AND Criteria female patients aged 10 years or older; and inform
patient not to void after initial urine sample in case a
The following criteria (part A and part B) are required for a full bladder is needed for abdominal ultrasound
nurse to initiate care as directed by the AND. Ensure patient remains NPO
PART A Nursing staff may complete an AND during triage
The patient must meet 1 of the following clinical signs: assessment, during primary assessment upon arrival to a
Any tenderness in the right lower quadrant with palpa- patient care room, or at any time during patient care.
tion by examiner The AND has been graphically produced both as a stan-
Rebound tenderness in the right lower quadrant (eg, dalone document (Figure 1) and as the leading component
positive jump test/positive pothole test) of our overall pediatric appendicitis care map (Figure 2).

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

278 JOURNAL OF EMERGENCY NURSING VOLUME 36 ISSUE 3 May 2010


deForest and Thompson/PEDIATRIC UPDATE

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.

Submissions to this column are encouraged and may be sent to


Acknowledgment Donna Ojanen Thomas, RN, MSN
The ACH Pediatric Appendicitis Committee is grateful for the significant donna.thomas@imail.org
contributions of Greg McKernan Graphic Design (Calgary, AB) in the crea- or
tion of the ACH Pediatric Appendicitis Pathway. Joyce Foresman-Capuzzi, RN, BSN, CEN, CTRN, CPN, CCRN,
SANE-A, EMT-P
joyceforesmancapuzzi@rcn.com
REFERENCES or
1. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Michelle Tracy, RN, MA, CEN, CPN
Ann Emerg Med. 1986;15:557-64. jmtracy2001@yahoo.com

May 2010 VOLUME 36 ISSUE 3 WWW.JENONLINE.ORG 279


PEDIATRIC UPDATE/deForest and Thompson

FIGURE 1
Nursing protocol for child with suspected appendicitis. Courtesy of Erin deForest.

280 JOURNAL OF EMERGENCY NURSING VOLUME 36 ISSUE 3 May 2010


May 2010
VOLUME 36 ISSUE 3

deForest and Thompson/PEDIATRIC UPDATE


WWW.JENONLINE.ORG

FIGURE 2
Alberta Children's Hospital (ACH) pediatric appendicitis care map. Printed with permission from Greg McKernan Graphic Design.
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