Presentation of patients with right iliac fossa pain - factors affecting the diagnostic pathway and evaluation of a clinical decision support tool

Abstract

Right iliac fossa (RIF) pain is the largest source of acute referrals to the general surgical take. Most previous studies concentrate on retrospective analysis of patients who have had an appendicectomy. This study has two aims. The first is to investigate the factors affecting the diagnostic pathway of all patients referred with RIF pain. The second is to implement and evaluate a clinical decision support tool (CDST) integrated into a specific RIF pain clerking proforma. All patients over the age of 15, without a previous appendicectomy, who were referred acutely to the general surgeons were eligible for the study. Data was collected prospectively on all patients during initial, pilot and implementation stages. 605 patients were included in the study. 292 patients were included in the evaluation of the clinical decision support tool. The majority of patients presenting with RIF pain do not have appendicitis. The most frequent diagnosis is non-specific abdominal pain. Use of the CDST significantly improved the agreement of the senior clinician plan with that of the junior clinician’s plan (p=<0.0001). There is no change in the frequency of imaging requests with the CDST but the proportion of CT scans being requested by junior clinicians is significantly increased (p=0.0342). This study provides new and updated information on the factors affecting the diagnostic pathway of patients presenting with RIF pain. It is the largest study to look at this cohort and is more applicable to current practice than the previous studies. The implementation of a novel CDST has been shown to significantly improve the decision making of junior clinicians when used within a specific RIF pain pathway. Further work needs to be done with a larger study to look for further improvements to the diagnostic pathway and to understand and improve the poor uptake by junior doctors.

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ORCID for Timothy Underwood: orcid.org/0000-0001-9455-2188

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