Simple signage and targeted education can lead to process improvement in acute appendicitis care

Rex Atwood*, Patrick Benoit, William Hennrikus, Laura Kraemer, Rathnayaka Mudiyanselage Gunasingha, Angela Kindvall, Elliot Jessie, Carolyn Gosztyla, Matthew Bradley

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


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.

Original languageEnglish
Article numbere002327
JournalBMJ Open Quality
Issue number4
StatePublished - 24 Oct 2023
Externally publishedYes


  • Health professions education
  • Healthcare quality improvement
  • Surgery


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