O2141: Regional transfer of children with appendix-related concerns on outside abdominal cross-sectional imaging

Background: Pediatric radiologists are often tasked with reinterpreting, or overreading, outside imaging in children transferred to tertiary care centers for appendix-related concerns. Abdominal cross-sectional imaging such as computed tomography (CT) and magnetic resonance imaging (MRI) performed at outside facilities can often be remotely overread by pediatric radiologists. Despite patient- and system-related burdens of unnecessary patient transfers, there is limited data on pediatric radiologist overreads of outside CT or MRI in children with concern for an abnormal appendix. In this study, we aimed to identify the negative overread rate at our institution and describe clinical features and outcomes of this cohort.

Methods: We retrospectively reviewed all children transferred from statewide outside facilities to our standalone tertiary care children’s hospital from June 2018 to July 2023 for appendicitis-related concerns. We collected clinical and radiology data for patients with negative overreads and used descriptive statistics to report findings.

Results: Out of 1,041 appendicitis-related transfers during the five-year study period, 128 had outside appendix US alone, 24 had no outside imaging, and 889 had outside abdominal CT or MRI (Figure 1). Of the CT and MRI cohort, 103 (11.5%) patients were not diagnosed with appendicitis upon pediatric radiologist review. Most of these patients (85.4%) were transferred from community hospitals outside of our university-system, 102 (99%) underwent CT, and 1 patient had an MRI. Thirty-nine patients (37.9%) were given pre-transfer antibiotics, primarily due to concern for appendicitis (92.3%). Other acute findings were noted on pediatric radiologist re-evaluation in 37.9% of patients, with thickened bladder (23.1%) and increased stool burden (25.6%) being the most common findings. Additional imaging was performed post-transfer to our institution in 30 (29.1%) patients as follows: appendix US (56.7%), abdomen US (3.3%), right upper quadrant US (13.3%), testicular US (3.3%), and pelvic US (40%). Sixty-seven (65%) patients discharged home from the emergency department (ED) with the remainder admitted to pediatric surgery, gastroenterology, or hospitalist services. The median [IQR] length of stay at our institution was 6.9 [4.2, 16.2] hours. While 6.8% of patients returned to the ED within six months of discharge, only one patient underwent post-discharge appendectomy.

Conclusion: During the study period, we found that 11.5% of patients with appendix-related concerns on outside CT or MRI had negative overreads by pediatric radiologists at our institution. Despite barriers, teleradiology has the potential to transform appendicitis-related transfers by enabling pediatric radiologists to provide clarity in diagnosis and better inform transfer decision-making at outside facilities. Instituting such a protocol requires further research in a large cohort and buy-in from stakeholders including pediatric surgeons and radiologists, community ED physicians, and hospital administrators. The financial and social burdens incurred by these potentially avoidable transfers could be significant, warranting further investigation.