Reduction in Resources and Cost for Gastroenteritis Through Implementation of Dehydration Pathway

Abstract

OBJECTIVES: Management decisions for patients with gastroenteritis affect resource use within pediatric emergency departments (EDs), and algorithmic care using evidence-based guidelines (EBGs) has become widespread. We aimed to determine if the implementation of a dehydration EBG in a pediatric ED resulted in a reduction in intravenous (IV) fluid administration and the cost of care. METHODS: In a single-center quality improvement initiative between 2010 and 2016, investigators aimed to decrease the percentage of patients with gastroenteritis who were rehydrated with IV fluids. The EBG assigned the patient a dehydration score with subsequent rehydration strategy on the basis of presenting signs and symptoms. The primary outcome was proportion of patients receiving IV fluid, which was analyzed using statistical process control methods. The secondary outcome was cost of the episode of care. Balancing measures included ED length of stay, admission rate, and return visit rate within 72 hours. RESULTS: A total of 7145 patients met inclusion criteria with a median age of 17 months. Use of IV fluid decreased from a mean of 15% to 9% postimplementation. Average episode of care–related health care costs decreased from $599 to $410. For our balancing measures, there were improvements in ED length of stay, rate of admission, and rate of return visits. CONCLUSIONS: Implementation of an EBG for patients with gastroenteritis led to a decrease in frequency of IV administration, shorter lengths of stay, and lower health care costs.

Trends in Management of Children With Acute Gastroenteritis in US Emergency Departments

“…Because ED visits for children with AGE are increasing, knowledge translation initiatives are urgently needed to optimize ondansetron use and reduce excessive use of intravenous fluids. Ondansetron-supported ORT for appropriately selected children can achieve intravenous rehydration rates of 9%, more than 3-fold lower than 2018 national estimates.…”

Variables Associated With Intravenous Rehydration and Hospitalization in Children With Acute Gastroenteritis

“…Children rate intravenous insertion as one of the most painful aspects of hospital care, influencing future reactions to painful events . Compared with ORT, intravenous rehydration is associated with phlebitis, longer hospital stays, and major adverse events, and is one of the risk factors most strongly associated with ED revisits, presumably because it reinforces the decision to seek ED care and reduces the educational focus on ORT . Although quality improvement initiatives have been able to reduce intravenous rehydration rates, in many institutions, use remains frequent .…”

“…Compared with ORT, intravenous rehydration is associated with phlebitis, longer hospital stays, and major adverse events, and is one of the risk factors most strongly associated with ED revisits, presumably because it reinforces the decision to seek ED care and reduces the educational focus on ORT . Although quality improvement initiatives have been able to reduce intravenous rehydration rates, in many institutions, use remains frequent . Thus, a better understanding of the factors associated with intravenous rehydration is needed to identify approaches to mitigate use.…”

Successful Implementation of Workflow-Embedded Clinical Pathways During the COVID 19 Pandemic

“…10,18 Clinical pathways reduce in-hospital complications and readmission rates as well as result in shorter hospital length of stays and a reduction in overall health care costs. 5,19,20 As hospital systems across the country became overwhelmed by the sheer number of resources needed due to the COVID-19 pandemic, our clinical pathways provided standardized care and resources across many care settings. These novel noninterruptive digitally embedded pathways in the EHR, using a third-party vendor software platform, were unique as providers could access the most up-to-date evidence-based guidance, apply easy-tofollow flowchart diagrams pathway to place orders, and provide patient care.…”

“…Although operationalizing evidence-based guidelines has been shown to be challenging, clinical pathways have been shown to improve patient outcomes by decreasing unnecessary variation in provider care 10,18. Clinical pathways reduce in-hospital complications and readmission rates as well as result in shorter hospital length of stays and a reduction in overall health care costs 5,19,20. As hospital systems across the country became overwhelmed by the sheer number of resources needed due to the COVID-19 pandemic, our clinical pathways provided standardized care and resources across many care settings.…”