Discharge planning for children with perforated appendictis

Optimal management of children with perforated appendicitis remains a controversial clinical problem. Until very recently, the criteria for hospital discharge on our surgical service included the absence of fever and leukocytosis for a period of 48 hours following completion of antimicrobial therapy, uncomplicated wound healing, a normal rectal examination, and unimpaired gastrointestinal function. With the introduction of cost-containment programs, the necessity for the period of inpatient observation following cessation of antibiotics was questioned. The records of 87 consecutive children with perforated appendicitis were analyzed prospectively in order to determine if our discharge policies were medically sound and cost-effective. Seventy-five patients (86%) recovered uneventfully while 12 children required prolonged hospitalization for management of various postoperative complications. The 12 patients who developed complications were all identificable early in the postoperative period because of persistent fever, leukocytosis, and elevated band counts. Of the 75 children who recovered uneventfully, all met standard discharge criteria on the final day of antibiotic therapy with the exception of completing the mandatory 48-hour period of inpatient observation. These children were maintained in the hospital a total of 142 additional days following discontinuation of antibiotics. The average cost per patient day for children with perforated appendicitis during the study period was $506.32, which represented unnecessary hospital charges of $71,897.44. It was concluded that inpatient observation following cessation of antibiotic therapy in children who experience an uneventful recovery from perforated appendicitis is neither necessary nor cost-effective. These patients can be safely discharged when their antibiotics are discontinued. Patients who develop postoperative complications are easily identifiable early in the postoperative period because of persistent fever, leukocytosis, and bandemia.