Clinical Pathway Produces Sustained Improvement in Acute Gastroenteritis Care

• Published in: Pediatrics (Evanston) 2017-10, Vol.140 (4), p.1
• Main Authors: Rutman, Lori, Klein, Eileen J, Brown, Julie C
• Format: Article
• Language: English
• Subjects: Acute Disease; Adolescent; Age; Antiemetics - therapeutic use; Child; Child, Preschool; Children; Children & youth; Combined Modality Therapy; Critical Pathways; Dehydration; Diarrhea; Emergency medical services; Emergency Service, Hospital - standards; Emergency Service, Hospital - statistics & numerical data; Female; Fluid Therapy - methods; Fluid Therapy - standards; Fluid Therapy - statistics & numerical data; Fluid Therapy - utilization; Gastroenteritis; Gastroenteritis - therapy; Humans; Infant; Intravenous administration; Length of Stay - statistics & numerical data; Male; Medical treatment; Ondansetron - therapeutic use; Outcome and Process Assessment (Health Care); Pediatrics; Process control; Quality Improvement - statistics & numerical data; Rehydration; Rotavirus; Statistical process control; Vomiting
• ISSN: 0031-4005; 1098-4275
• DOI: 10.1542/peds.2016-4310

Despite widespread use of the rotavirus vaccine in the last decade, dehydrating illnesses impact almost 2 billion children worldwide annually. Evidence supports oral rehydration therapy as a first-line treatment of mild to moderate dehydration. Ondansetron has proven to be a safe and effective adjunct in children with vomiting. We implemented a clinical pathway in our pediatric emergency department (ED) in January 2005 to improve care for this common condition. Our objective in this study was to determine the long-term impact of the pathway for acute gastroenteritis (AGE) on the proportion of patients receiving intravenous (IV) fluids and ED length of stay (LOS) for discharged patients. Cases were identified by using diagnosis codes. We used statistical process control to analyze process and outcome measures for 2 years before and 10 years after pathway implementation. We included 30 519 patients. We found special cause variation with a downward shift in patients receiving IV fluids after initiation of the pathway and later with addition of ondansetron to the pathway from 48% to 26%. Mean ED LOS for discharged patients with AGE decreased from 247 to 172 minutes. These improvements were sustained over time. Implementation of a clinical pathway emphasizing oral rehydration therapy and ondansetron for children with AGE led to decreased IV fluid use and LOS in a pediatric ED. Improvements were sustained over a 10-year period. Our results suggest that quality-improvement interventions for AGE can have long-term impacts on care delivery.