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Simple signage and targeted education can lead to process improvement in acute appendicitis care
  1. Rex Atwood1,
  2. Patrick Benoit1,
  3. William Hennrikus1,
  4. Laura Kraemer2,
  5. Rathnayaka Mudiyanselage Gunasingha1,3,
  6. Angela Kindvall1,
  7. Elliot Jessie1,
  8. Carolyn Gosztyla1,
  9. Matthew Bradley2
  1. 1Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
  2. 2Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
  3. 3General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
  1. Correspondence to Dr Rex Atwood;{at}


Introduction An institution-wide protocol for uncomplicated acute appendicitis was created to improve compliance with best practices between the emergency department (ED), radiology and surgery. Awareness of the protocol was spread with the publication of a smartphone application and communication to clinical leadership. On interim review of quality metrics, poor protocol adherence in diagnostic imaging and antimicrobial stewardship was observed. The authors hypothesised that two further simple interventions would result in more efficient radiographic diagnosis and antimicrobial administration.

Materials and methods Surgery residents received targeted in-person education on the appropriate antibiotic choices and diagnostic imaging in the protocol. Signs were placed in the emergency and radiology work areas, immediately adjacent to provider workstations highlighting the preferred imaging for patients with suspected appendicitis and the preferred antibiotic choices for those with proven appendicitis. Protocol adherence was compared before and after each intervention.

Results Targeted education was associated with improved antibiotic stewardship within the surgical department from 30% to 91% protocol adherence before/after intervention (p<0.005). Visible signs in the ED were associated with expedited antimicrobial administration from 50% to 90% of patients receiving antibiotics in the ED prior to being brought to the operating room before/after intervention (p<0.005). Diagnostic imaging after the placement of signs showed improved protocol adherence from 35% to 75% (p<0.005).

Conclusion This study demonstrates that smartphone-based applications and communication among clinical leadership achieved suboptimal adherence to an institutional protocol. Targeted in-person education reinforcement and visible signage immediately adjacent to provider workstations were associated with significantly increased adherence. This type of initiative can be used in other aspects of acute care general surgery to further improve quality of care and hospital efficiency.

  • Health professions education
  • Healthcare quality improvement
  • Surgery

Data availability statement

Data are available upon reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Protocols for management of acute appendicitis are becoming increasingly common. However, most protocols do not include process improvement initiatives to assess for protocol compliance and how to address areas of potential improvement.


  • This study demonstrates the positive effects of low-cost, easy-to-implement educational and physical measures which improved protocol compliance and ultimately patient care.


  • This study may affect streamlined surgical protocols that lack process improvement arms by demonstrating the power of simple interventions with targeted education and physical signs. This may lead to improved compliance, decreased costs and improved patient outcomes.


Acute appendicitis is one of the most common indications for emergency general surgery. The disease produces an average cost to the US healthcare system of $7.8 billion despite its low associated morbidity and mortality.1 In order to optimise care within clinical best practices and to avoid costs associated with unnecessary variation, institutions have been developing evidence-based protocol and quality metrics for the care of acute appendicitis.2–4

In 2016, the authors’ institution implemented an outpatient laparoscopic appendectomy (OLA) protocol as part of a process improvement (PI) initiative that was designed to reduce treatment variability, increase efficiency and improve quality of care delivered to emergency general surgery patients.5–7 For patients who meet inclusion criteria, the OLA protocol specifies preferred initial imaging modalities for suspected acute appendicitis, antibiotic selection, postoperative analgesia, diet progression, discharge criteria and follow-up expectations. The protocol was implemented safely and resulted in a significant decrease in patient length of stay without an increase in adverse events.5 As part of an ongoing PI initiative, interval review of captured metrics indicated significant variability of diagnostic imaging and antibiotic prescription in the diagnostic and preoperative phases of care. These variations led to inappropriate use of overly broad antibiotics as well as imaging studies requiring a longer emergency department (ED) stay, increasing the overall hospital stay.

Identifying these areas for PI across the departments of emergency medicine, radiology and general surgery, the authors hypothesised that a brief session of targeted surgery resident education and the addition of easy-to-read reference signs in strategic locations immediately adjacent to relevant provider workstations would result in improved protocol adherence and higher quality management of acute appendicitis.


To avoid provider variability in preoperative antibiotics and diagnostic imaging, the OLA protocol specifies cefoxitin, or, for penicillin-allergic patients, ciprofloxacin plus metronidazole, in accordance with institutional antibiotic sensitivities and current Surgical Infection Society guidelines.8 Antibiotics prescribed outside of the institutional protocol were considered to be inappropriate. The diagnostic imaging specified by the OLA protocol is CT scan with intravenous contrast only (no oral contrast) for suspected acute appendicitis, barring contraindications to intravenous contrast. At the time of the initial enactment of the OLA protocol in 2016, it was formally added to the library of clinical practice guidelines in the institutional clinical practice guideline smartphone application and the protocol was circulated among the leadership of each contributing department (general surgery, emergency medicine and radiology) to be distributed to their respective providers.

After an initial interim quality review identified poor protocol adherence in diagnostic imaging and antibiotic stewardship, an overall review was undertaken to better understand potential areas for improvement. Interviews with surgical residents, who act as the initial surgical consultants, noted that antibiotics and imaging studies were often obtained prior to surgical consultation. Additional review of data identified protocol compliance also lagged early in the academic year, raising concerns of lack of protocol knowledge in residents rising to new roles. Multiple possible interventions were considered, to include Electronic Medical Record (EMR) modification, education, protocol/cost display and policy change, as outlined in multiple articles.9 10 The EMR is an online record system containing patient information such as vital signs, imaging, and laboratory analysis as well as nurse and physician notes. Of the available options the investigators chose protocol display with both signs and a smartphone accessible app as well as targeted education due to the low barriers of implementation. Targeted education was provided to the surgical residents most commonly taking care of OLA patients. This education was incorporated into pre-existing weekly academic lectures. A simple sign describing the OLA protocol, highlighting the appropriate antibiotic selection and optimal initial diagnostic imaging, was placed in an easily visible location in the physician work area of the ED. Brief educational sessions were additionally held with the radiology and emergency medicine departments. A similar sign specifying the preferred diagnostic imaging was placed in the radiology reading rooms.

Electronic medical records of patients with appendicitis who presented to the ED and who underwent appendectomy from the time of the implementation of the OLA protocol in January 2016 through the completion of the 2020 calendar year were identified from department surgical case logs and retrospectively reviewed. Patients presenting to the ED prior to imaging were included according to the criteria detailed in table 1.

Table 1

Outpatient laparoscopic appendectomy protocol inclusion and exclusion criteria

Data were compiled to include imaging studies obtained, the antibiotic treatment prescribed, patient allergies and the setting within the hospital that the antibiotic was administered (ED or operating room (OR)). Diagnostic imaging modality and antibiotic prophylaxis were classified as ‘appropriate’ (according to the protocol) or ‘inappropriate’.

Comparisons were made between the years prior to intervention and the years after intervention. In the case of targeted education of surgical residents, results from 2016 (prior to protocol implementation) were compared with 2017, 2018, 2019 and 2020 (post protocol implementation intervention) using χ2 and Fisher’s exact tests. Χ2 and Fisher’s exact tests were also used to measure the effect of the sign placement. In this case, 2016, 2017, 2018 and 2019 (before intervention) were compared with 2020 (after intervention). A p value <0.05 was considered statistically significant. We used the Standards for Quality Improvement Reporting Excellence checklist when writing our report.11 Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.


Two hundred and two patients met inclusion criteria for the study. Patient volumes through the OLA protocol ranged from 33 to 55 patients per year.

Antibiotic stewardship

In 2016, the first year of implementation of the OLA protocol, 79% of patients with uncomplicated appendicitis eligible for the OLA protocol were prescribed inappropriate antimicrobial prophylaxis. The most commonly prescribed antibiotic for these patients was piperacillin/tazobactam (47%).

Antibiotic prescribing by surgical residents was adherent to the protocol 30% of the time prior to targeted surgical resident education in January 2017, and 91% of the time after this intervention (p<0.005) (figure 1). There was a significant improvement in antibiotic stewardship by the surgery residents (p=<0.005) in each of the 4 years following the educational intervention (95% protocol adherence in 2017 (n=19), 85% in 2018 (n=13), 95% in 2019 (n=21), 67% in 2020 (n=3)).

Figure 1

Surgical resident antibiotic stewardship before and after targeted education in January 2017. These antibiotics were ordered by the surgical team and administered to the patient in the operating room prior to surgery. Antibiotic selection was classified as ‘appropriate’ (according to the protocol) or ‘inappropriate’.

Antibiotic protocol adherence by ED providers generally increased over the course of the studied period from 20% in 2016 to 90% in 2019; this trend in antibiotic stewardship preceded the posting of highly visible signs in January 2020 (figure 2). However, the proportion of patients who received antibiotics in the ED significantly increased after the signs were posted in January 2020 (p<0.005). After posting the signs, 90% of cases (27/30) received antibiotics in the ED (figure 3).

Figure 2

Emergency medicine provider antibiotic stewardship by year. These antibiotics were ordered by emergency medicine providers and given in the emergency department prior to patient transport to the operating room. Antibiotic selection was classified as ‘appropriate’ (according to the protocol) or ‘inappropriate’.

Figure 3

Setting of antibiotic administration by year. ‘OR’ refers to antibiotics ordered by surgical providers and administered in the operating room preoperatively. ‘ED’ refers to antibiotics ordered by emergency medicine providers and administered in the emergency department prior to patient transport to the operating room.

Imaging compliance

After signs were posted there was a significant improvement (p<0.005) in protocol imaging adherence. In 2020, 75% of patients diagnosed with acute appendicitis underwent a CT with intravenous contrast. In 2016, 2017, 2018 and 2019, CT with intravenous contrast was used 6%, 48%, 42% and 46% of the time, respectively (figure 4).

Figure 4

Selected imaging modality proportions by year. w/IV, with intravenous contrast; w/PO, with per oral contrast.


PI is a dynamic and sustained endeavour that requires iterative evaluation and strategic implementation to improve the efficiency of care. Mitigation of diagnostic delays and antimicrobial resistance both factor into the quality and cost of care of acute appendicitis. Interim data analysis from the PI initiative for the OLA protocol revealed the need for improved compliance in antibiotic prescription and diagnostic imaging. Simple interventions consisting of targeted educational reinforcement for surgical residents along with clear and visible physical signage in key emergency and radiology department locations were effective strategies for improving protocol adherence when added to the existing smartphone application and direct communication to department leadership. This intervention is simple to introduce, which is a major strength of the method.

Posting visible protocol guidance in essential locations led to significant improvement in the appropriate selection of imaging for the diagnosis of acute appendicitis. Avoiding the unnecessary delay of obtaining the oral contrast agent saves several hours of time from triage to OR, without compromising diagnostic sensitivity or specificity in appropriately selected patients.12 13 Finally, adding signage in the radiology reading room provided a second check feature so the radiologist could confirm that the protocol-specified study was ordered with the requesting ED provider.

Similar to other groups, we found that adherence to guidelines for antibiotic treatment prior to surgery varied greatly within the institution, with 79% of outpatient appendectomies receiving inappropriate antibiotic prophylaxis in 2016.14 After targeted surgical resident education in January 2017, antibiotic stewardship significantly improved in the 4 years following this intervention with a peak compliance rate reaching over 90% from surgical house staff. There was an apparent decrease in compliance in 2020, but because of improved prescribing rates from ED physicians, there were only three cases in total in which surgeons ordered preoperative antibiotics in that year. It may be expected, however, to see a decrease in institutional compliance as the interval since targeted education on the protocol increases and as residents come through the programme. Scheduled interval education is likely required to sustain long-term compliance. Moving forward, the durability of the resident targeted education programme on antibiotic stewardship will be assessed. Because this study was performed in a teaching institution, the results may not be as applicable to facilities where house staff are not present.

Posting of visible protocol guidance in the ED was associated with improved rates of antimicrobial administration to 90% in the ED (vs being delayed until the OR), thus decreasing the time from diagnosis of appendicitis to antibiotic administration. The improved adherence in the selection of antibiotics in the ED preceded the implementation of the physical signage with 94% of patients receiving cefoxitin or ciprofloxacin/metronidazole in 2019. These data are likely confounded by the fact that emergency providers and surgical providers sometimes, but not always, collaborate on antibiotic selection prior to prescription, and the study interventions directed at each population were not synchronised, leading to some cross-over effects that the analysis was not able to define. Likewise, the data did not specify whether antibiotics were prescribed before or after imaging was obtained. With some diagnoses possibly in question, it is possible the providers erred on the side of early broader antimicrobial coverage until CT imaging was obtained.

Our study does have several important limitations worth mentioning. First, we offer a single institution study. Given the simplicity of the published interventions, a future work of using this protocol at additional facilities would be a good next step. Additionally, our study occurred in a military treatment facility, which may offer limitations to applicability to other healthcare settings. While our chosen interventions were based on ease of implementation, it is also important to note that too many signs or too many clinical practice guidelines may overwhelm physicians and may possibly lead to worsened compliance due to oversaturation of workstations.


The authors have demonstrated that creating a detailed OLA protocol, periodically assessing adherence, and taking strategic actions to rectify shortcomings has improved hospital efficiency and quality of care in the management of patients with uncomplicated acute appendicitis. Similarly, detailed protocols are being implemented for other common acute surgical diseases. With care taken to clearly communicate and provide easy reference to the protocols, this model is a simple way to greatly improve quality and efficiency of care. The OLA protocol and the interventions to improve compliance have applicability in other cases in emergency general surgery. Next steps include creation of additional protocols for other appropriate cases in healthy patient populations.


  • Smartphone application-based clinical practice guideline publication achieved suboptimal adherence.

  • Communication to clinical leadership achieved suboptimal protocol adherence.

  • Targeted resident education improved protocol adherence.

  • Posting of highly visible signs in provider work areas improved protocol adherence.

  • Simple but creative periodic reinforcement can sustain quality improvement.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

Institutional approval for the use of data from human subjects was obtained for this study from the Walter Reed National Military Medical Center Institutional Review Board, including a waiver of informed patient consent.



  • Contributors RA, PB and WH assisted with study design, implementing study interventions, data collection and writing/editing of the manuscript. LK and RMG assisted with data collection, data analysis, interpretation and writing of the manuscript. AK assisted with implementing study interventions, data collection and analysis. CG, MB and EJ assisted with study design, institutional approval, editing and review of data analysis. RA is the acting guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.