Clinical pathway using rapid rehydration for children with gastroenteritis.

OBJECTIVE: To determine in the Emergency Department (ED) the efficacy of a clinical pathway using rapid rehydration for children moderately dehydrated as a result of acute gastroenteritis. METHODS: This was a prospective study using historical controls, set in the ED of the Children's Hospital at Westmead, NSW, Australia. Subjects were aged from 6 months to 16 years presenting with vomiting and diarrhoea for <48 h who were mildly or moderately dehydrated. The intervention was a clinical pathway involving rapid rehydration using N/2 saline + 2.5% dextrose intravenously at 20 mL/kg per h for 2 h, or Gastrolyte R (Aventis Pharma, Lane Cove, NSW, Australia) via nasogastric tube at the same rate. There were 145 children in the prospective intervention group and 170 in the historical control group. The outcome measures were admission rate, percentage of patients discharged from the ED in 8 h or less, rate of re-presentations within 48 h requiring admission, and rate of procedures with intravenous cannula or nasogastric tube. RESULTS: In the moderately dehydrated children, significant reductions were observed in the admission rate and the number discharged in 8 h or less in the intervention group compared with the control group, with no significant difference in the rate of re-presentation and the rate of procedures. In the moderately dehydrated children in the intervention group, the admission rate was 29 of 52 (55.8%) compared with the controls 26 of 27 (96.3%) (P < 0.001) and the number discharged in 8 h or less was 23 of 52 (44.2%) compared with 1 of 27 (3.7%) in the controls (P < 0.01). CONCLUSION: The clinical pathway utilizing rapid rehydration in children moderately dehydrated from gastroenteritis is effective in reducing admission rates and lengths of stay in the ED.

Effectiveness of a croup clinical pathway in the management of children with croup presenting to an emergency department.

OBJECTIVE: The aim of this study was to evaluate the safety and effectiveness of a clinical pathway for croup in an emergency department (ED). METHODOLOGY: This before-and-after intervention study on all consecutive children aged 6 months to 10 years who presented to our ED with moderate/severe croup was conducted over a 6-month period. Children with a clinical croup score (CSS) of 2 or more and resting stridor were considered eligible for entry into the study. Children were treated with either oral dexamethasone, or a combination of oral dexamethasone suspension and nebulized adrenaline. Children were clinically assessed, observed in the emergency short-stay ward and discharged or admitted according to the clinical pathway. The following outcomes were measured: admission rates, hospital re-presentation, length of stay, and adverse clinical events. Children in the post-intervention group were followed up by telephone within 48 h of discharge. RESULTS: There were 157 patients recruited in the pre-intervention group and 110 in the post-intervention group. Significant reductions were reported in the length of stay (18.9 h compared with 5.2 h), hospital admission (52.9% compared with 18.0%) and intensive care admission (10.2% compared with 0.0%) after the introduction of the croup clinical pathway. No children in the study experienced an adverse clinical event. Follow-up interviews of parents indicated that the new treatment strategy was well received. CONCLUSION: The use of the croup clinical pathway in the ED is safe and effective in guiding consistent management, resulting in reduced admission rates, earlier discharge home, and no reported adverse events.

Paediatric walk-out patients: characteristics and outcomes.

OBJECTIVE: To investigate the characteristics and outcomes of patients who walked out from a tertiary children's hospital emergency department (ED) without seeing a medical officer. METHODS: A prospective study of patients who walked-out from the ED of a children's hospital, without seeing a medical officer. Information collected at triage included demographics, presenting problems, time of arrival, time of departure and reason for leaving. Charts were reviewed and those at high risk of serious illness or adverse outcome were contacted by telephone within 24 h. Further information collected during follow up included outcome, such as adverse events and admission to hospital. Data were analysed by comparing the walk-out and non-walk-out groups with regard to demographic variables, presenting problems and outcomes. RESULTS: Over a 29 week period, 1037 (5.5%) patients walked out from the ED of the hospital without seeing a medical officer. Comparisons between the walk-out and non-walk-out patients indicated no differences in terms of demographics. However, significant differences were found between the triage categories, presenting problems and arrival time. Of these, 829 (79.9%) were followed up by telephone. This revealed the predominant presenting problem was non-urgent and infectious in nature and no adverse events occurred. The admission rate for walk-out patients (1.5%) was significantly lower in comparison with the non-walk-out group (6.9%; odds ratio 0.2; 95% confidence interval 0.1-0.3). Walk-out patients who were eventually hospitalized had a shorter mean length of stay than non-walk-out patients (20.4 vs 34.8 h, respectively; t = 17.78, P < 0.0001). CONCLUSIONS: Medical resources are limited and, therefore, some extended waiting in the ED is necessary. Paediatric patients who walk-out of the ED without seeing a medical officer have simple illnesses that resolve without medical intervention or adverse events.

The benefits of using clinical pathways for managing acute paediatric illness in an emergency department.

The aim of this study was to provide an evaluation of the overall effectiveness of using a number of clinical pathways in treating common acute paediatric conditions in an emergency department. This was a before and after study conducted on the effectiveness of three clinical pathways (gastroenteritis, asthma, and croup) in the emergency department of the Children's Hospital at Westmead, conducted over two separate yearly periods January to December 1996 and January to December 1999 representing before and after the introduction of clinical pathways in the emergency department. The main outcomes of the effectiveness of the pathways, namely admission to an in-patient bed, length of hospital stay and re-presentation after discharge from the ED were compared. Other outcomes of interest such as parental satisfaction and patient waiting times were also presented. Any deviation from a key clinical pathway process was reported. A total of 2854 children were managed by a clinical pathway compared to 2680 children managed before clinical pathways were introduced. The admission rate was reduced by threefold (9.1% compared to 23.6%) with a twofold reduction in length of hospital stay (32.7 h compared to 17.5 h). In 3.6% of children using a clinical pathway an unscheduled medical visit or re-presentation to the emergency department occurred after discharge, compared to 4.9% before the use of clinical pathways. No adverse events were reported in these children. In 76 cases deviation from a clinical pathway process was reported. High parental satisfaction was reported for clinical pathways throughout the study. Clinical pathways in this emergency department allowed rapid stabilisation of children, reducing admission rate, with a shortened length of hospital stay and few patients re-presenting after discharge and were well accepted by parents.