EHR-based Decision Support for Pediatric Acute Abdominal Pain in Emergency Care

Abdominal pain is one of the most common reasons for children and adolescents to seek care in
the emergency department (ED). Computed tomography (CT) has been promoted as a method to
improve diagnostic accuracy when evaluating patients with acute abdominal pain. In the past
20 years, CT use has increased dramatically, especially for children receiving care in
general ED settings. Although in some adult cohorts, increased CT use has been associated
with decreased rates of negative appendectomies, similar improvements in health outcomes
among children with acute abdominal pain have not occurred. Negative consequences of CT
include increased costs and substantial exposure to ionizing radiation.

Although appendicitis is the most common surgical emergency in children, its diagnosis
remains a challenge and thus, emergency department (ED) providers increasingly rely on
computed tomography to distinguish appendicitis from other conditions. This project (a) uses
electronic health record (EHR) technology to deliver patient-specific clinical decision
support to ED providers at the point of care, (b) assesses the impact of this intervention on
the use of diagnostic imaging and clinical outcomes, and (c) assesses the impact of the
intervention on the costs of care delivered.

The proposed intervention, referred to as appy-CDS, is specifically designed for widespread
use in EDs and could reduce reliance on advanced diagnostic imaging for pediatric and
adolescent patients with acute abdominal pain while maintaining or improving clinical
outcomes. This cluster randomized trial builds on more than 10 years of work on derivation
and validation of ED-based clinical decision rules, previous successful outpatient and
emergency department clinical decision support interventions, and complex economic and
statistical analyses of risk assessment and ED resource use. In this project, the
investigators aim to extend the benefits of previous efforts by developing and implementing
an interactive, evidence-based clinical decision support tool to optimize care for children
and adolescents presenting to a general or non-pediatric ED with acute abdominal pain. The
results of this project will extend the understanding of how to maximize the clinical return
on massive public and private sector investments being made in sophisticated EHR systems. If
successful, this flexible decision support tool could be adapted and implemented broadly in a
range of acute care settings to both standardize and personalize care delivered to pediatric
patients.

Inclusion Criteria:

- children and adolescents ages 5-20 years with abdominal pain

- internal med, family med, or emergency med trained providers at participating EDs

Exclusion Criteria:

- select comorbid conditions

- previous abdominal surgery

- treated for select comorbid conditions