International Emergency Nursing xxx (2013) xxx–xxx
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The effect of a rapid rehydration guideline on Emergency Department management of gastroenteritis in children Danielle Waddell RN MN GradCert (Emerg), GradDipNurs BN, Registered Nurse, Ian McGrath RN MN(Res), BAppSci, CertCritCare, CertRenalN, Senior Lecturer, Phil Maude RN PhD MN(Res) BHSci, Dip MHN, Cert Addic FANZCMHN, Associate Professor ⇑ School of Health Sciences (Division of Nursing and Midwifery), RMIT University, Australia
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Article history: Received 14 June 2013 Received in revised form 16 September 2013 Accepted 26 September 2013 Available online xxxx Keywords: Rehydration Gastroenteritis Paediatrics Hypovolemia Deydration Hypotonic solutions
a b s t r a c t This study evaluated the use and effect of a rapid rehydration guideline for the management of gastroenteritis in children 6 months to 4 years of age in an Emergency Department (ED). The guideline aims to facilitate rehydration within 4 h of arrival to the ED, using oral or nasogastric fluids. Primary outcome measures were ED Length of Stay (LOS) and hospital admission rates. Documentation of physiological recovery and consistency of re-hydration regimes used were examined as secondary outcomes. Methods: A quasi-experimental design using the medical records of 235 children pre and post intervention was used. Descriptive statistics (frequencies, medians, interquartile ranges) were used to summarize the data. The pre and post-test groups were compared using Chi Square and the Mann Whitney U Test. Results: There was an increase in the ED LOS and in hospital admission rates post implementation of the rapid rehydration guideline in the ED. However, the time frame for initiation of rehydration therapy using oral or nasogastric routes improved post guideline implementation. Conclusion: The need for improvements in the ED management of dehydration secondary to gastroenteritis has been highlighted providing potential benefits to patient care and outcomes. Ó 2013 Elsevier Ltd. All rights reserved.
Introduction This study evaluated the use and effect of a rapid rehydration guideline for the Emergency Department (ED) management of gastroenteritis in children 6 months to 4 years of age. The study was conducted to determine whether the use of a rapid rehydration guideline led to a reduction in the ED LOS for children presenting with gastroenteritis related dehydration. A formal guideline for rapid rehydration of children was developed and implemented. Primary measurement outcomes of this project were the ED Length of Stay (LOS) and rates of hospital admission. Documentation of physiological recovery and consistency of rehydration regimes used were also reviewed. The ED rapid rehydration guideline was developed based on the clinical practice guidelines from the Royal Children’s Hospital, Melbourne and the Southern Health. Gastroenteritis Clinical Path for Children (South and Young, 2002; Southern Health, 2005). The guideline aimed to facilitate rehydration within 4 h of arrival to the ED using oral or nasogastric fluids and to reduce variations ⇑ Corresponding author. Address: School of Health Sciences (Division of Nursing and Midwifery), RMIT University, PO Box 71, Bundoora, Victoria 3083, Australia. Tel.: +61 3 9925 7447; fax: + 61 3 9467 5286. E-mail address: [email protected] (P. Maude).
in care during initial patient assessment. Earlier detection of dehydration and rapid initiation of rehydration for children suffering from gastroenteritis has the potential to improve the provision of a consistent and systematic approach to the initial and ongoing care of paediatric patients with gastroenteritis. Additionally, the potential benefits to the organisation of early identification and treatment of dehydration in children include reduction in clinical risk that occurs with variations in practice and a reduction in adverse events.
Background and literature Dehydration secondary to gastroenteritis in children is a common reason for parents to seek emergency care (Conners et al., 2000). The most common consequence of gastroenteritis is dehydration induced hypovolaemia, primarily due to loss of fluids from vomiting and diarrhea. Children with gastroenteritis are at greater risk for developing dehydration as they have an increased surface area to body volume ratio, resulting in increased insensible fluid losses. Volume depletion (hypovolaemia) reduces the effective circulating volume and, if severe, compromises tissue and organ perfusion (Endom and Kim, 2006). If severe hypovolaemia is not treated in an effective and timely fashion, ischaemic end-organ
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Please cite this article in press as: Waddell, D., et al. The effect of a rapid rehydration guideline on Emergency Department management of gastroenteritis in children. Int. Emerg. Nurs. (2013), http://dx.doi.org/10.1016/j.ienj.2013.09.004
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damage may occur, leading to increased morbidity and mortality (Neville et al., 2006; Endom and Kim, 2006; Beck et al., 2013). Many children with gastroenteritis have mild to moderate dehydration and are discharged following rehydration and a period of observation (Powell et al., 2011). The options available to clinicians when treating volume depletion secondary to gastroenteritis include oral, nasogastric or intravenous fluid administration. Studies comparing nasogastric and intravenous fluid administration have shown that nasogastric rehydration is as effective as intravenous rehydration for children with mild to moderate dehydration (Nager and Wang, 2002; Piescik-Lech et al., 2013). Intravenous fluid replacement to treat paediatric gastroenteritis is expensive, increases need for hospital admission, subjects children to a painful procedure, and places children at risk of associated complications such as electrolyte imbalance, particularly hypernatremia (high sodium levels), and infection (Piescik-Lech et al., 2013). Several researchers suggest early Oral Rehydration Therapy for children with gastroenteritis may reduce severity of dehydration and decrease the use of intravenous fluids (Phin et al., 2003; Westwood, 2011). Fonseca et al. (2004) identified that early intervention for dehydration in infants and children using Oral Rehydration Therapy (ORT) reduced morbidity rates and reduced LOS compared with the use of IV fluid. However, there is a lack of consensus regarding the timing of rehydration. According to Bender and Ozuah (2004) best evidence and expert opinion recommends rapid rehydration using ORT over a 4 h period for children less than 5 years of age with dehydration secondary to gastroenteritis. Bruzzese et al. (2013) recommended a somewhat different approach and suggest rehydration should occur over 2–4 h with either oral and nasogastric fluids. Powell et al. (2011) compared the efficacy of rehydration over 4 and 24 h in children with gastroenteritis and found no differences between the two regimes. According to South and Young (2002) fluid replacement for mild, moderate and severe dehydration in children using oral, nasogastric or Intravenous routes is most commonly given at a rate of 10 ml/kg/h. However, Phin et al. (2003) suggested a rehydration at a rate of 20 ml/kg/h has been shown to decrease the need for admission and ED Length of Stay in children with moderate dehydration secondary to gastroenteritis. The rationale for selection of fluid administration used in children is often unclear with variability in the management of mild to moderate dehydration, Spandorfer et al. (2005) recommended fluids such as gastrolyte™ (an electrolyte rehydration foruma – www.gastrolyte.com.au) as first line therapy for mild to moderate dehydration in children. Inconsistency in the management of children with gastroenteritis results in unnecessary delays in definitive management specifically related to rehydration (Phin et al., 2003). This leads to prolonged waiting time to treatment, contributes to ED overcrowding, increased resource use and unnecessary admissions to hospital. Gastroenteritis induced dehydration in children is a common reason for presentation to Emergency Departments. Timely intervention with rapid rehydration, to correct dehydration, has the potential to reduce the incidence of more severe consequences of dehydration such as severe hypervolemia, and reduce ED Length of Stay and hospital admission rates (Atherly-John et al., 2002; Elliot and Dalby-Payne, 2004; Webb and Starr, 2005; Frith and Elliot, 2007; Lee and Haden, 2007; Putnam et al., 2007).
Ethics Ethics approval was sought from the health service and RMIT University Human Research and Ethics Committee (HREC).
Formal written informed consent was not sought from the patients as the Emergency Department and the Children’s Unit including the Paediatric Short Stay Unit (PSSU) nursing observation charts were only examined and no direct patient contact was necessary. Method A quasi-experimental design using two group’s: a pre test retrospective audit, followed by a period of 3 months to implement the protocol and then post collection of data for 6 months after the implementation of the rehydration guideline. The same audit tool was used with both the pre and post-test groups to collect data in ED at time intervals (on arrival, 1, 2 and 4 hourly). Sample The ED used in this study manages approximately 1000 children with gastroenteritis per year. Of these, 19.5% require hospital admission for ongoing rehydration. The target population was a convenience sample of two hundred and thirty-five (N = 235) children aged 6 months to 4 years who presented to the ED within the data collection periods. The pre-test group included all children presenting to the ED with gastroenteritis in the six month period prior to the implementation of the guideline. The post-test group included all children presenting to the ED with gastroenteritis in six months following implementation of the guideline. Children aged 6 months to 4 years were targeted as they have a high prevalence of gastroenteritis and are the most easily managed using oral/nasogastric fluids. Intervention The guideline was introduced to all ED nursing staff through nursing in-service education The ED nurses were provided with a step-by-step approach to the use of the guideline in the treatment of varying degrees of mild, moderate and severe dehydration in children. Increased knowledge and awareness in the treatment of dehydration in children was also highlighted and further discussed to ensure that these patients were receiving the appropriate triage categories and interventions in a timely manner. Education of the guideline was also given to the ED medical staff. Following the retrospective audit, a three month period was allowed prior to post-test data collection for nursing staff to receive in service education and become familiar with the use of the guideline in clinical practice. Data collection Data was collected from a review of medical records prior to and following the implementation of the guideline. A data collection tool was developed to ensure consistency of data collection. Data collected included the Australasian triage scale (ATS) category and clinical data including physiological status, heart rate, respiratory rate, blood pressure, mucous membranes status (dry or moist), capillary refill (seconds).and fluid regimes used. Data related to the re-hydration regimes used included the type, volume, rate and route of fluid, and if the fluid regime was prescribed. These data were measured on arrival to ED and at 1, 2 and 4 hourly intervals during the ED stay. Demographic data collected included age, gender, time of arrival, time of discharge, discharge destination, waiting times, the ED LOS and the number of hospital admissions.
Please cite this article in press as: Waddell, D., et al. The effect of a rapid rehydration guideline on Emergency Department management of gastroenteritis in children. Int. Emerg. Nurs. (2013), http://dx.doi.org/10.1016/j.ienj.2013.09.004
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Results and analysis Data was analyzed using the computer software package Statistical Package for the Social Sciences (SPSS) 18.0. Descriptive statistics including percentages means and inter quartile ranges were used to summarize the data. Correlations and between group comparisons were explored using appropriate statistical measures including Chi Square and the Mann Whitney U Test. A total of 235 clinical records were reviewed, 118 from the pretest group and 117 following introduction of the guideline. Analysis of the data using one sample Kolmogov–Smirnov test revealed the data was not normally distributed therefore medians (Mdn) and inter-quartile ranges (IQR) are presented and non-parametric analyses used. Triage The ATS categories for each group were examined to determine if there was any difference in triage decisions following implementation of the guideline. The distribution of triage categories per group is presented in Table 1. There was a small increase in allocation of ATS category 2 (to be seen within 10 min) following implementation of the guideline, (n = 0 versus n = 2, 1.7%). There were minimal differences between the two groups in allocation of ATS category 3 (to be seen within 30 min) (n = 26, 22% versus n = 35, 30.4%) and ATS category 4 (to be seen within 60 min) (n = 72, 61% versus n = 70, 59.8%). There was an 8.4% reduction in allocation of ATS category 5 (to be seen within 120 min) following implementation of the guideline.
measurement, 0.3% received a blood pressure measurement, 7.8% capillary refill measurement and 17.9% a mucous membrane assessment. The data related to heart rate is presented in Table 2. Between group comparisons, there was no significant differences in median heart rate. The data relating to respiratory rate is shown in Table 3. The post-test group had a higher median respiratory rate on arrival in the ED (Mdn = 28, versus Mdn = 25) however this difference was not statistically significant (U = 146, p = 0.201). Blood pressures were not measured in the pre-test group and only measured on 2 participants (1.7%) in the post test group so were of little value in this study as a measurement. The data relating to dry mucous membranes is shown in Table 4. There was a small increase in dry mucous membranes in the post test group (n = 7) 15.2%, versus (n = 12) 23.5%, on arrival to the ED. Capillary refill on arrival through to the 4 h interval is presented in Table 5. There was no statistical difference between the pre and post-test group for capillary refill with a median of 2 (seconds) at all times measured.
Fluid administration
Physiological parameters were collected on arrival to the ED and then at 1, 2 and 4 h following presentation to the ED. However, there were many records with missing physiological data. Of the total records audited (N = 235), on arrival only 25% had heart rate measured and or documented, 13.8% received a respiratory rate
The types of fluids used and route of administration are presented in Table 6. Oral fluids were used in 56 children (47.5%) in the pre-test group and 64 children (54.7%) in the post-test group. Although there was a 7.2% increase in the number of children who received oral fluids following implementation of the guideline, this difference was not statistically significant (v2 = 1.233b, df = 1, p = 0.164) however this change is clinically important. Formal prescription of oral fluid regimes occurred in three children (2.5%) from the pre-test group and four children (3.4%) from the post-test group. Again this difference was not statistically significant (v2 = 0.165, df = 1, p = 0.684). There were no significant differences in the types of oral fluids used (Table 6) however there were a large number of children 62 (52.5%) in the pre-test group and 56 (47.9%) children in the post-test group who had no record of receiving any oral fluids during their ED care. When the use of nasogastric fluids was examined, 6 children (5.1%) from the pre-test group and 10 children (8.5%) from the post-test group received nasogastric fluids. Although there was an increase in nasogastric fluid administration for children in the post-test group, this difference was not statistically significant (v2 = 1.110b, df = 1, p = 0.214). All children who received nasogastric fluids were given gastrolyte™. Formal prescription of nasogastric fluids occurred in 4 children (3.4%) from the pre-test group and 7 children (6.0%) from the posttest group. Again this difference was not statistically significant (v2 = 1.854, df = 1, p = 0.396). IV fluids were not used in the pre-test group and were used in 3 children (2.6%) in the post test group. In all cases IV fluids were formally prescribed. In two children from the post-test group, normal saline was used and one child received a half saline and 5% dextrose solution.
Table 1 Triage categories by group.
Table 2 Heart rate by group (per minute).
Patient characteristics The median age of study participants was 13.5 months (IQR = 7–29) in the pre-test group (n = 118) and 14 months (IQR = 8–27.5) in the post-test group (n = 117). This is consistent with the age range in other studies which identified gastroenteritis is most common in children under 5 years of age (King et al., 2003). There were no statistically significant differences in age between groups (U = 6808.50, p = 0.856). In the pre-test group, there were 58 males (49.2%) and 60 females (50.8%). In the post test group, there were 74 males (62.4%) and 44 females (44%). The increased number of males in the post-test group was statistically significant (v2 = 4.175b, df = 1, p = 0.041) however this gender difference should not effect the management of children with gastroenteritis. Physiological characteristics
Pre-test
ATS ATS ATS ATS *
2 3 4 5
Chi Square.
p*
Post-test
N
%
n
%
0 26 72 20
0 22 61 16.9
2 35 70 10
1.7 29.9 59.8 8.5
Pre-test
0.154 0.168 0.852 0.054
On arrival 1h 2h 4h *
p*
Post-test
n
Mdn
IQR
n
Mdn
IQR
47 35 18 9
132 130 129 125
120–140 120–140 120–150 118–162
43 33 28 22
135 130 122 127
120–150 120–149 114–139 120–142
0.387 0.768 0.181 0.827
Mann Whitney U.
Please cite this article in press as: Waddell, D., et al. The effect of a rapid rehydration guideline on Emergency Department management of gastroenteritis in children. Int. Emerg. Nurs. (2013), http://dx.doi.org/10.1016/j.ienj.2013.09.004
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differences were not statistically significant (v2 = 1.797, df = 1, p = 0.180).
Table 3 Respiratory rate by group (per minute). Pre-test
On arrival 1h 2h 4h *
p*
Post-test
n
Mdn
IQR
n
Mdn
IQR
16 19 13 9
25 28 26 25
20–32 22–36 24–34 22–38
24 17 15 17
28 28 32 30
24–36 23–40 26–40 23–38
Discussion 0.201 0.799 0.139 .0534
Mann Whitney U.
Table 4 Frequency of dry mucous membranes by group. Pre-test
On arrival 1h 2h 4h *
p*
Post-test
n
%
n
%
7 2 1 7
15.2 14.3 14.3 100
12 4 2 7
23.5 16.7 15.4 100
0.303 0.846 0.948 n/a
Chi Square.
ED LOS The ED LOS research findings are of particular importance when considering triage and discharge using a protocol. Interestingly, the results suggested that there was a significant increase in the ED LOS in the post-test group (54 min), this is at odds with previous literature which suggests an overall decrease in the ED LOS would occur post implementation of the rapid rehydration guideline. Several factors may have influenced this result. Firstly, there was an 11% overall increase in presentations in the ED during the post-test data collection period which may have contributed to the increase in ED LOS. Secondly, the influence of peak presentations may have resulted in bed blocks in the ED, thereby patients were waiting in the ED longer before being admitted to the ward. Finally, the longer stay may have reflected the apparent increased severity of illness in the post-test group, and is consistent with the higher ATS categories allocated to the patients in this group.
Table 5 Capillary refill by group (seconds). Pre-test
On arrival 1h 2h 4h *
p*
Post-test
n
Mdn
IQR
n
Mdn
IQR
7 12 3 0
2 2 2 0
2–2 2–2 2–2 0
13 24 10 5
2 2 2 2
2–2 2–2 2–2 2–2
n/a n/a n/a n/a
Mann Whitney U.
Table 6 Oral fluids categories by group. Pre-test
Gastrolyte Water Milk None *
p*
Post-test
N
%
n
%
45 5 6 62
38.1 4.2 5.1 52.5
50 3 8 56
42.7 2.6 6.8 47.9
0.473 0.479 0.570 0.473
Chi Square.
ED LOS The ED LOS was audited to determine if the rapid rehydration guideline was associated with a decrease in ED LOS. Analysis of the data revealed the post-test group had a longer median ED LOS (Mdn = 3.76 post, IQR = 1.43–4.63 versus Mdn = 2.86 pre, IQR = 1.13–3.43). This difference was statistically significant (U = 5867, p = 0.047). Discharge destinations The discharge destinations of the children with gastroenteritis were examined to determine if the guideline made any difference in the numbers of children discharged home or admitted. Admission to the paediatric ward was required for 13 children (11%) from the pre-test group and 20 children (17.1%) from the post-test group. 105 children (89%) from the pre-test group were discharged home and 97 children (82.9%) from the post-test group. Between group comparisons of discharge destinations showed that these
Discharge destinations The discharge destinations are also of particular importance when considering the need for admission to hospital at triage and following evaluation of initial treatment. The data indicates a 6.1% increase in hospital admissions in the post test group. The increase in admissions may be related to the opening of the PSSU which occurred following the implementation of the guideline when the post-test data was collected. The PSSU provides for admissions of less than 24 h for appropriate patients such as moderately dehydrated patients requiring ORT and a period of observation. Previously there had been no alternative to admission for patients with mild to moderate dehydration and these patients may have been discharged home earlier than desirable. The increased admission numbers may reflect more cautious approach to monitoring and treatment of dehydration that became available with the introduction of the PSSU. Physiological characteristics The monitoring of nursing observations and vital signs including patient’s heart rate, respiratory rate, blood pressure, capillary refill and mucous membranes status are fundamental nursing assessments performed for paediatric patients presenting with dehydration secondary to gastroenteritis. These assessments identify the degree of dehydration in a child. Best practice guidelines suggest these parameters should be assessed in all children presenting to the ED with symptoms of dehydration (South and Young, 2002; Southern Health, 2005). The study aimed to examine the physiological characteristics at 4 intervals, on arrival and at 1, 2 and 4 h. The audit of the patient records identified a significant amount of missing data during these time frames. The reason for the missing data was unclear. The data may have been measured and not recorded by the ED nursing or medical staff, or the patient may have been discharged prior to the 2–4 hourly recording intervals. If this is correct the lack of documentation by ED nursing and medical staff is concern and could lead to missed clinical diagnoses and delayed treatment. Of more concern is the possibility that these parameters were not measured at any stage. Alarmingly, blood pressure, capillary refill and mucous membrane status measurements made up the
Please cite this article in press as: Waddell, D., et al. The effect of a rapid rehydration guideline on Emergency Department management of gastroenteritis in children. Int. Emerg. Nurs. (2013), http://dx.doi.org/10.1016/j.ienj.2013.09.004
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very high percentage of missing data. These parameters are important for assessing children with dehydration. If these physiological parameters are not measured routinely on children presenting to the ED with dehydration it would be important to clarify why this is not being done. Triage The identification of the degree of dehydration is another important role of the ED nurse. The early identification of dehydration should lead to early initiation of treatment. Therefore using the guideline rapid rehydration is commenced after the initial assessment of the patient. Nurse initiated ORT starts with the use of gastrolyte™ popsicles/icy poles following triage assessment. The results indicated a small but important 4.6% increase in the use of ORT in the post-test group, possibly indicating an increased awareness of the need for early ORT by the triage nurse. Another key feature of the study’s findings is the overall poor compliance with the use of the rapid rehydration guideline. It would be expected to see a higher percentage overall with compliance post implementation of the rapid rehydration guideline, therefore expecting a greater use of oral rehydration. This study identified poor compliance by ED nurses to the rapid rehydration guideline recommendations. This may have contributed to the finding of limited beneficial outcomes associated with ORT. Had the guidelines been followed it is reasonable to conclude a greater number of children would have been treated with ORT and this may have reduced the ED LOS and hospital admissions. Further research on staff compliance with the use of the rapid rehydration guideline is necessary to determine why such recommendations were not followed. It is particularly important for the emergency triage nurse who must identify the degree of dehydration in these patients in order to prioritize definitive care. Delivering optimal care is time critical for children presenting with dehydration. The majority of presentations (60%) were given an ATS category 4 that requires medical intervention within 1 h of presentation. The small increase in the ATS category 2 and 3 in the patients after implementation of the guideline was not statistically significant. Nevertheless, this indicates an improved recognition of sick children in the post-test group. Further research is needed to identify if this was a response from the education that was provided in recognition of severity of dehydration and the implementation of the guideline, or whether it was due to sicker children presenting during the post test data collection periods. Fluid administration There was no statistically significant difference in the number of patients receiving oral fluids while in the ED following the implementation of the guideline. However, there was an increase in the administration of gastrolyte™ in patients who received oral fluids in the post test group. While not reaching statistical significance it is clinically important. This is reflected in the literature which identifies replacement of fluid and electrolyte losses as the critical central elements of effective treatment of dehydration secondary to gastroenteritis (Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis, 1996; Bruzzese et al., 2013). The data also revealed that a large number of children 62 (52.5%) in the pre-test group and 56 children (47.9%) in the posttest group did not receive any oral fluid while in the ED. This raises many issues and identifies clinical risk for deterioration for children that already present to the ED with dehydration. These children were at an even greater risk for deterioration without being treated with oral fluids. Deterioration may have been caused
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by poor compliance with following the rapid rehydration guideline or nurses initiating ORT to children without documentation. Alternatively nurses may not be initiating oral fluids according to the guideline to children that are dehydrated. Limitations The amount of missing data in the medical records was a significant limitation which may have influenced the results of this study. Additionally, the ORT guidelines were not followed explicitly; it is therefore difficult to ascertain how they impacted on ED LOS and hospital admission rates. Another limitation relates to the data collection period for the post-test group. This commenced 3 months following the pre-test group and could be affected by potential of seasonal variation in gastroenteritis presentations. Conclusion This study examined the effect of a rapid oral rehydration guideline on the ED management of gastroenteritis in children. The key findings from this study were an increase in the ED LOS by 54 min with an overall increase in hospital admissions to either the children’s ward or PSSU. There was a small positive increase in the use of Oral Rehydration Therapy by 7.2% post implementation of the rapid oral rehydration guideline. The findings from this study reveal inadequacies in the monitoring and recording of patient data and treatment regimens provided for children presenting with dehydration. There is a need for improved documentation practices and further education in the management of dehydration secondary to gastroenteritis in children in the ED. References Atherly-John, Y.C., Cunningham, S.J., Crain, E.F., 2002. A randomized trial of oral versus intravenous rehydration in a paediatric emergency department. Arch of Pediatric Adolescent Medicine 156 (12), 1240–1243. Beck, C., Choong, K., Puligandla, P., Hartfield, D., Holland, J., Lacoix, J., Friedman, J., 2013. Avoiding hypotonic solutions in paediatrics: keeping your patients safe. Paediatrics and Child Health 18 (2), 94–95. Bender, J., Ozuah, P., 2004. Intravenous rehydration for gastroenteritis: how long does it really take? Pediatric Emergency Care 20 (4), 215–218. Bruzzese, E., Vecchio, A., Guarino, A., 2013. Hospital management of children with gastroenteritis. Current Opinion in Gastroenteritis 29 (1), 23–30. Conners, G.P., Barker, W.H., Mushlin, A.I., Geopp, J.G., 2000. Oral versus intravenous; rehydration prefernces of paediatric emergency medicine fellowship directors. Pediatric Emergency Care 16, 335–338. Elliot, E.J., Dalby-Payne, J., 2004. Acute infectious diarrhoea and dehydration in children. Medical Journal of Australia 181 (10), 565–570. Endom, E.E., Kim, M.S., 2006. Treatment of Hypovolemia (Dehydration) in Children (retrieved 05.09.07, from up-to-date). Fonseca, B.K., Holdgate, A., Craig, J.C., 2004. Enteral vs intravenous rehydration therapy in children with gastroenteritis: a meta-analysis of randomized controlled trials. Arch Pediatric Adolescent Medicine 158, 483–490. Frith, K., Elliot, E.J., 2007. Investigating the child with acute diarrhoea. Medicine Today 8 (8), 44–50. King, C., Glass, R., Bresee, J., Duggan, C., 2003. Managing acute gastroenteritis among children. Mobility and Mortality Weekly Reports 52 (RR16), 1–16. Lee, G.A., Haden, K., 2007. An audit of practice of rehydration in children with gastroenteritis under three years in an Emergency Department. Australasian Emergency Nursing Journal 10 (3), 110–116. Nager, A.L., Wang, V.J., 2002. Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration. Pediatrics 109 (4), 566–572. Neville, K., Verge, C., Rosenberg, A., O’Meara, M., Walker, J., 2006. Isotonic is better than hypotonic saline for intravenous rehydration of children with gastroenteritis: a prospective randomized study. Archives of Diseases in Children 91 (3), 226–232. Phin, S., McKaskell, M., Browne, G., Lam, L., 2003. Clinical pathway using rapid rehydration for children with gastroenteritis. Journal of Paediatircs and Child Health 39 (5), 343–348. Piescik-Lech, M., Sharmin, R., Guarino, A., Szajewska, H., 2013. The management of acute gastroenteritis in children. Alimentary Pharmacology & Therapeutics 37 (3), 289–303.
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Contents lists available at ScienceDirect
International Emergency Nursing journal homepage: www.elsevier.com/locate/aaen
The effect of a rapid rehydration guideline on Emergency Department management of gastroenteritis in children Danielle Waddell RN MN GradCert (Emerg), GradDipNurs BN, Registered Nurse, Ian McGrath RN MN(Res), BAppSci, CertCritCare, CertRenalN, Senior Lecturer, Phil Maude RN PhD MN(Res) BHSci, Dip MHN, Cert Addic FANZCMHN, Associate Professor ⇑ School of Health Sciences (Division of Nursing and Midwifery), RMIT University, Australia
a r t i c l e
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Article history: Received 14 June 2013 Received in revised form 16 September 2013 Accepted 26 September 2013 Available online xxxx Keywords: Rehydration Gastroenteritis Paediatrics Hypovolemia Deydration Hypotonic solutions
a b s t r a c t This study evaluated the use and effect of a rapid rehydration guideline for the management of gastroenteritis in children 6 months to 4 years of age in an Emergency Department (ED). The guideline aims to facilitate rehydration within 4 h of arrival to the ED, using oral or nasogastric fluids. Primary outcome measures were ED Length of Stay (LOS) and hospital admission rates. Documentation of physiological recovery and consistency of re-hydration regimes used were examined as secondary outcomes. Methods: A quasi-experimental design using the medical records of 235 children pre and post intervention was used. Descriptive statistics (frequencies, medians, interquartile ranges) were used to summarize the data. The pre and post-test groups were compared using Chi Square and the Mann Whitney U Test. Results: There was an increase in the ED LOS and in hospital admission rates post implementation of the rapid rehydration guideline in the ED. However, the time frame for initiation of rehydration therapy using oral or nasogastric routes improved post guideline implementation. Conclusion: The need for improvements in the ED management of dehydration secondary to gastroenteritis has been highlighted providing potential benefits to patient care and outcomes. Ó 2013 Elsevier Ltd. All rights reserved.
Introduction This study evaluated the use and effect of a rapid rehydration guideline for the Emergency Department (ED) management of gastroenteritis in children 6 months to 4 years of age. The study was conducted to determine whether the use of a rapid rehydration guideline led to a reduction in the ED LOS for children presenting with gastroenteritis related dehydration. A formal guideline for rapid rehydration of children was developed and implemented. Primary measurement outcomes of this project were the ED Length of Stay (LOS) and rates of hospital admission. Documentation of physiological recovery and consistency of rehydration regimes used were also reviewed. The ED rapid rehydration guideline was developed based on the clinical practice guidelines from the Royal Children’s Hospital, Melbourne and the Southern Health. Gastroenteritis Clinical Path for Children (South and Young, 2002; Southern Health, 2005). The guideline aimed to facilitate rehydration within 4 h of arrival to the ED using oral or nasogastric fluids and to reduce variations ⇑ Corresponding author. Address: School of Health Sciences (Division of Nursing and Midwifery), RMIT University, PO Box 71, Bundoora, Victoria 3083, Australia. Tel.: +61 3 9925 7447; fax: + 61 3 9467 5286. E-mail address: [email protected] (P. Maude).
in care during initial patient assessment. Earlier detection of dehydration and rapid initiation of rehydration for children suffering from gastroenteritis has the potential to improve the provision of a consistent and systematic approach to the initial and ongoing care of paediatric patients with gastroenteritis. Additionally, the potential benefits to the organisation of early identification and treatment of dehydration in children include reduction in clinical risk that occurs with variations in practice and a reduction in adverse events.
Background and literature Dehydration secondary to gastroenteritis in children is a common reason for parents to seek emergency care (Conners et al., 2000). The most common consequence of gastroenteritis is dehydration induced hypovolaemia, primarily due to loss of fluids from vomiting and diarrhea. Children with gastroenteritis are at greater risk for developing dehydration as they have an increased surface area to body volume ratio, resulting in increased insensible fluid losses. Volume depletion (hypovolaemia) reduces the effective circulating volume and, if severe, compromises tissue and organ perfusion (Endom and Kim, 2006). If severe hypovolaemia is not treated in an effective and timely fashion, ischaemic end-organ
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Please cite this article in press as: Waddell, D., et al. The effect of a rapid rehydration guideline on Emergency Department management of gastroenteritis in children. Int. Emerg. Nurs. (2013), http://dx.doi.org/10.1016/j.ienj.2013.09.004
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damage may occur, leading to increased morbidity and mortality (Neville et al., 2006; Endom and Kim, 2006; Beck et al., 2013). Many children with gastroenteritis have mild to moderate dehydration and are discharged following rehydration and a period of observation (Powell et al., 2011). The options available to clinicians when treating volume depletion secondary to gastroenteritis include oral, nasogastric or intravenous fluid administration. Studies comparing nasogastric and intravenous fluid administration have shown that nasogastric rehydration is as effective as intravenous rehydration for children with mild to moderate dehydration (Nager and Wang, 2002; Piescik-Lech et al., 2013). Intravenous fluid replacement to treat paediatric gastroenteritis is expensive, increases need for hospital admission, subjects children to a painful procedure, and places children at risk of associated complications such as electrolyte imbalance, particularly hypernatremia (high sodium levels), and infection (Piescik-Lech et al., 2013). Several researchers suggest early Oral Rehydration Therapy for children with gastroenteritis may reduce severity of dehydration and decrease the use of intravenous fluids (Phin et al., 2003; Westwood, 2011). Fonseca et al. (2004) identified that early intervention for dehydration in infants and children using Oral Rehydration Therapy (ORT) reduced morbidity rates and reduced LOS compared with the use of IV fluid. However, there is a lack of consensus regarding the timing of rehydration. According to Bender and Ozuah (2004) best evidence and expert opinion recommends rapid rehydration using ORT over a 4 h period for children less than 5 years of age with dehydration secondary to gastroenteritis. Bruzzese et al. (2013) recommended a somewhat different approach and suggest rehydration should occur over 2–4 h with either oral and nasogastric fluids. Powell et al. (2011) compared the efficacy of rehydration over 4 and 24 h in children with gastroenteritis and found no differences between the two regimes. According to South and Young (2002) fluid replacement for mild, moderate and severe dehydration in children using oral, nasogastric or Intravenous routes is most commonly given at a rate of 10 ml/kg/h. However, Phin et al. (2003) suggested a rehydration at a rate of 20 ml/kg/h has been shown to decrease the need for admission and ED Length of Stay in children with moderate dehydration secondary to gastroenteritis. The rationale for selection of fluid administration used in children is often unclear with variability in the management of mild to moderate dehydration, Spandorfer et al. (2005) recommended fluids such as gastrolyte™ (an electrolyte rehydration foruma – www.gastrolyte.com.au) as first line therapy for mild to moderate dehydration in children. Inconsistency in the management of children with gastroenteritis results in unnecessary delays in definitive management specifically related to rehydration (Phin et al., 2003). This leads to prolonged waiting time to treatment, contributes to ED overcrowding, increased resource use and unnecessary admissions to hospital. Gastroenteritis induced dehydration in children is a common reason for presentation to Emergency Departments. Timely intervention with rapid rehydration, to correct dehydration, has the potential to reduce the incidence of more severe consequences of dehydration such as severe hypervolemia, and reduce ED Length of Stay and hospital admission rates (Atherly-John et al., 2002; Elliot and Dalby-Payne, 2004; Webb and Starr, 2005; Frith and Elliot, 2007; Lee and Haden, 2007; Putnam et al., 2007).
Ethics Ethics approval was sought from the health service and RMIT University Human Research and Ethics Committee (HREC).
Formal written informed consent was not sought from the patients as the Emergency Department and the Children’s Unit including the Paediatric Short Stay Unit (PSSU) nursing observation charts were only examined and no direct patient contact was necessary. Method A quasi-experimental design using two group’s: a pre test retrospective audit, followed by a period of 3 months to implement the protocol and then post collection of data for 6 months after the implementation of the rehydration guideline. The same audit tool was used with both the pre and post-test groups to collect data in ED at time intervals (on arrival, 1, 2 and 4 hourly). Sample The ED used in this study manages approximately 1000 children with gastroenteritis per year. Of these, 19.5% require hospital admission for ongoing rehydration. The target population was a convenience sample of two hundred and thirty-five (N = 235) children aged 6 months to 4 years who presented to the ED within the data collection periods. The pre-test group included all children presenting to the ED with gastroenteritis in the six month period prior to the implementation of the guideline. The post-test group included all children presenting to the ED with gastroenteritis in six months following implementation of the guideline. Children aged 6 months to 4 years were targeted as they have a high prevalence of gastroenteritis and are the most easily managed using oral/nasogastric fluids. Intervention The guideline was introduced to all ED nursing staff through nursing in-service education The ED nurses were provided with a step-by-step approach to the use of the guideline in the treatment of varying degrees of mild, moderate and severe dehydration in children. Increased knowledge and awareness in the treatment of dehydration in children was also highlighted and further discussed to ensure that these patients were receiving the appropriate triage categories and interventions in a timely manner. Education of the guideline was also given to the ED medical staff. Following the retrospective audit, a three month period was allowed prior to post-test data collection for nursing staff to receive in service education and become familiar with the use of the guideline in clinical practice. Data collection Data was collected from a review of medical records prior to and following the implementation of the guideline. A data collection tool was developed to ensure consistency of data collection. Data collected included the Australasian triage scale (ATS) category and clinical data including physiological status, heart rate, respiratory rate, blood pressure, mucous membranes status (dry or moist), capillary refill (seconds).and fluid regimes used. Data related to the re-hydration regimes used included the type, volume, rate and route of fluid, and if the fluid regime was prescribed. These data were measured on arrival to ED and at 1, 2 and 4 hourly intervals during the ED stay. Demographic data collected included age, gender, time of arrival, time of discharge, discharge destination, waiting times, the ED LOS and the number of hospital admissions.
Please cite this article in press as: Waddell, D., et al. The effect of a rapid rehydration guideline on Emergency Department management of gastroenteritis in children. Int. Emerg. Nurs. (2013), http://dx.doi.org/10.1016/j.ienj.2013.09.004
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Results and analysis Data was analyzed using the computer software package Statistical Package for the Social Sciences (SPSS) 18.0. Descriptive statistics including percentages means and inter quartile ranges were used to summarize the data. Correlations and between group comparisons were explored using appropriate statistical measures including Chi Square and the Mann Whitney U Test. A total of 235 clinical records were reviewed, 118 from the pretest group and 117 following introduction of the guideline. Analysis of the data using one sample Kolmogov–Smirnov test revealed the data was not normally distributed therefore medians (Mdn) and inter-quartile ranges (IQR) are presented and non-parametric analyses used. Triage The ATS categories for each group were examined to determine if there was any difference in triage decisions following implementation of the guideline. The distribution of triage categories per group is presented in Table 1. There was a small increase in allocation of ATS category 2 (to be seen within 10 min) following implementation of the guideline, (n = 0 versus n = 2, 1.7%). There were minimal differences between the two groups in allocation of ATS category 3 (to be seen within 30 min) (n = 26, 22% versus n = 35, 30.4%) and ATS category 4 (to be seen within 60 min) (n = 72, 61% versus n = 70, 59.8%). There was an 8.4% reduction in allocation of ATS category 5 (to be seen within 120 min) following implementation of the guideline.
measurement, 0.3% received a blood pressure measurement, 7.8% capillary refill measurement and 17.9% a mucous membrane assessment. The data related to heart rate is presented in Table 2. Between group comparisons, there was no significant differences in median heart rate. The data relating to respiratory rate is shown in Table 3. The post-test group had a higher median respiratory rate on arrival in the ED (Mdn = 28, versus Mdn = 25) however this difference was not statistically significant (U = 146, p = 0.201). Blood pressures were not measured in the pre-test group and only measured on 2 participants (1.7%) in the post test group so were of little value in this study as a measurement. The data relating to dry mucous membranes is shown in Table 4. There was a small increase in dry mucous membranes in the post test group (n = 7) 15.2%, versus (n = 12) 23.5%, on arrival to the ED. Capillary refill on arrival through to the 4 h interval is presented in Table 5. There was no statistical difference between the pre and post-test group for capillary refill with a median of 2 (seconds) at all times measured.
Fluid administration
Physiological parameters were collected on arrival to the ED and then at 1, 2 and 4 h following presentation to the ED. However, there were many records with missing physiological data. Of the total records audited (N = 235), on arrival only 25% had heart rate measured and or documented, 13.8% received a respiratory rate
The types of fluids used and route of administration are presented in Table 6. Oral fluids were used in 56 children (47.5%) in the pre-test group and 64 children (54.7%) in the post-test group. Although there was a 7.2% increase in the number of children who received oral fluids following implementation of the guideline, this difference was not statistically significant (v2 = 1.233b, df = 1, p = 0.164) however this change is clinically important. Formal prescription of oral fluid regimes occurred in three children (2.5%) from the pre-test group and four children (3.4%) from the post-test group. Again this difference was not statistically significant (v2 = 0.165, df = 1, p = 0.684). There were no significant differences in the types of oral fluids used (Table 6) however there were a large number of children 62 (52.5%) in the pre-test group and 56 (47.9%) children in the post-test group who had no record of receiving any oral fluids during their ED care. When the use of nasogastric fluids was examined, 6 children (5.1%) from the pre-test group and 10 children (8.5%) from the post-test group received nasogastric fluids. Although there was an increase in nasogastric fluid administration for children in the post-test group, this difference was not statistically significant (v2 = 1.110b, df = 1, p = 0.214). All children who received nasogastric fluids were given gastrolyte™. Formal prescription of nasogastric fluids occurred in 4 children (3.4%) from the pre-test group and 7 children (6.0%) from the posttest group. Again this difference was not statistically significant (v2 = 1.854, df = 1, p = 0.396). IV fluids were not used in the pre-test group and were used in 3 children (2.6%) in the post test group. In all cases IV fluids were formally prescribed. In two children from the post-test group, normal saline was used and one child received a half saline and 5% dextrose solution.
Table 1 Triage categories by group.
Table 2 Heart rate by group (per minute).
Patient characteristics The median age of study participants was 13.5 months (IQR = 7–29) in the pre-test group (n = 118) and 14 months (IQR = 8–27.5) in the post-test group (n = 117). This is consistent with the age range in other studies which identified gastroenteritis is most common in children under 5 years of age (King et al., 2003). There were no statistically significant differences in age between groups (U = 6808.50, p = 0.856). In the pre-test group, there were 58 males (49.2%) and 60 females (50.8%). In the post test group, there were 74 males (62.4%) and 44 females (44%). The increased number of males in the post-test group was statistically significant (v2 = 4.175b, df = 1, p = 0.041) however this gender difference should not effect the management of children with gastroenteritis. Physiological characteristics
Pre-test
ATS ATS ATS ATS *
2 3 4 5
Chi Square.
p*
Post-test
N
%
n
%
0 26 72 20
0 22 61 16.9
2 35 70 10
1.7 29.9 59.8 8.5
Pre-test
0.154 0.168 0.852 0.054
On arrival 1h 2h 4h *
p*
Post-test
n
Mdn
IQR
n
Mdn
IQR
47 35 18 9
132 130 129 125
120–140 120–140 120–150 118–162
43 33 28 22
135 130 122 127
120–150 120–149 114–139 120–142
0.387 0.768 0.181 0.827
Mann Whitney U.
Please cite this article in press as: Waddell, D., et al. The effect of a rapid rehydration guideline on Emergency Department management of gastroenteritis in children. Int. Emerg. Nurs. (2013), http://dx.doi.org/10.1016/j.ienj.2013.09.004
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differences were not statistically significant (v2 = 1.797, df = 1, p = 0.180).
Table 3 Respiratory rate by group (per minute). Pre-test
On arrival 1h 2h 4h *
p*
Post-test
n
Mdn
IQR
n
Mdn
IQR
16 19 13 9
25 28 26 25
20–32 22–36 24–34 22–38
24 17 15 17
28 28 32 30
24–36 23–40 26–40 23–38
Discussion 0.201 0.799 0.139 .0534
Mann Whitney U.
Table 4 Frequency of dry mucous membranes by group. Pre-test
On arrival 1h 2h 4h *
p*
Post-test
n
%
n
%
7 2 1 7
15.2 14.3 14.3 100
12 4 2 7
23.5 16.7 15.4 100
0.303 0.846 0.948 n/a
Chi Square.
ED LOS The ED LOS research findings are of particular importance when considering triage and discharge using a protocol. Interestingly, the results suggested that there was a significant increase in the ED LOS in the post-test group (54 min), this is at odds with previous literature which suggests an overall decrease in the ED LOS would occur post implementation of the rapid rehydration guideline. Several factors may have influenced this result. Firstly, there was an 11% overall increase in presentations in the ED during the post-test data collection period which may have contributed to the increase in ED LOS. Secondly, the influence of peak presentations may have resulted in bed blocks in the ED, thereby patients were waiting in the ED longer before being admitted to the ward. Finally, the longer stay may have reflected the apparent increased severity of illness in the post-test group, and is consistent with the higher ATS categories allocated to the patients in this group.
Table 5 Capillary refill by group (seconds). Pre-test
On arrival 1h 2h 4h *
p*
Post-test
n
Mdn
IQR
n
Mdn
IQR
7 12 3 0
2 2 2 0
2–2 2–2 2–2 0
13 24 10 5
2 2 2 2
2–2 2–2 2–2 2–2
n/a n/a n/a n/a
Mann Whitney U.
Table 6 Oral fluids categories by group. Pre-test
Gastrolyte Water Milk None *
p*
Post-test
N
%
n
%
45 5 6 62
38.1 4.2 5.1 52.5
50 3 8 56
42.7 2.6 6.8 47.9
0.473 0.479 0.570 0.473
Chi Square.
ED LOS The ED LOS was audited to determine if the rapid rehydration guideline was associated with a decrease in ED LOS. Analysis of the data revealed the post-test group had a longer median ED LOS (Mdn = 3.76 post, IQR = 1.43–4.63 versus Mdn = 2.86 pre, IQR = 1.13–3.43). This difference was statistically significant (U = 5867, p = 0.047). Discharge destinations The discharge destinations of the children with gastroenteritis were examined to determine if the guideline made any difference in the numbers of children discharged home or admitted. Admission to the paediatric ward was required for 13 children (11%) from the pre-test group and 20 children (17.1%) from the post-test group. 105 children (89%) from the pre-test group were discharged home and 97 children (82.9%) from the post-test group. Between group comparisons of discharge destinations showed that these
Discharge destinations The discharge destinations are also of particular importance when considering the need for admission to hospital at triage and following evaluation of initial treatment. The data indicates a 6.1% increase in hospital admissions in the post test group. The increase in admissions may be related to the opening of the PSSU which occurred following the implementation of the guideline when the post-test data was collected. The PSSU provides for admissions of less than 24 h for appropriate patients such as moderately dehydrated patients requiring ORT and a period of observation. Previously there had been no alternative to admission for patients with mild to moderate dehydration and these patients may have been discharged home earlier than desirable. The increased admission numbers may reflect more cautious approach to monitoring and treatment of dehydration that became available with the introduction of the PSSU. Physiological characteristics The monitoring of nursing observations and vital signs including patient’s heart rate, respiratory rate, blood pressure, capillary refill and mucous membranes status are fundamental nursing assessments performed for paediatric patients presenting with dehydration secondary to gastroenteritis. These assessments identify the degree of dehydration in a child. Best practice guidelines suggest these parameters should be assessed in all children presenting to the ED with symptoms of dehydration (South and Young, 2002; Southern Health, 2005). The study aimed to examine the physiological characteristics at 4 intervals, on arrival and at 1, 2 and 4 h. The audit of the patient records identified a significant amount of missing data during these time frames. The reason for the missing data was unclear. The data may have been measured and not recorded by the ED nursing or medical staff, or the patient may have been discharged prior to the 2–4 hourly recording intervals. If this is correct the lack of documentation by ED nursing and medical staff is concern and could lead to missed clinical diagnoses and delayed treatment. Of more concern is the possibility that these parameters were not measured at any stage. Alarmingly, blood pressure, capillary refill and mucous membrane status measurements made up the
Please cite this article in press as: Waddell, D., et al. The effect of a rapid rehydration guideline on Emergency Department management of gastroenteritis in children. Int. Emerg. Nurs. (2013), http://dx.doi.org/10.1016/j.ienj.2013.09.004
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very high percentage of missing data. These parameters are important for assessing children with dehydration. If these physiological parameters are not measured routinely on children presenting to the ED with dehydration it would be important to clarify why this is not being done. Triage The identification of the degree of dehydration is another important role of the ED nurse. The early identification of dehydration should lead to early initiation of treatment. Therefore using the guideline rapid rehydration is commenced after the initial assessment of the patient. Nurse initiated ORT starts with the use of gastrolyte™ popsicles/icy poles following triage assessment. The results indicated a small but important 4.6% increase in the use of ORT in the post-test group, possibly indicating an increased awareness of the need for early ORT by the triage nurse. Another key feature of the study’s findings is the overall poor compliance with the use of the rapid rehydration guideline. It would be expected to see a higher percentage overall with compliance post implementation of the rapid rehydration guideline, therefore expecting a greater use of oral rehydration. This study identified poor compliance by ED nurses to the rapid rehydration guideline recommendations. This may have contributed to the finding of limited beneficial outcomes associated with ORT. Had the guidelines been followed it is reasonable to conclude a greater number of children would have been treated with ORT and this may have reduced the ED LOS and hospital admissions. Further research on staff compliance with the use of the rapid rehydration guideline is necessary to determine why such recommendations were not followed. It is particularly important for the emergency triage nurse who must identify the degree of dehydration in these patients in order to prioritize definitive care. Delivering optimal care is time critical for children presenting with dehydration. The majority of presentations (60%) were given an ATS category 4 that requires medical intervention within 1 h of presentation. The small increase in the ATS category 2 and 3 in the patients after implementation of the guideline was not statistically significant. Nevertheless, this indicates an improved recognition of sick children in the post-test group. Further research is needed to identify if this was a response from the education that was provided in recognition of severity of dehydration and the implementation of the guideline, or whether it was due to sicker children presenting during the post test data collection periods. Fluid administration There was no statistically significant difference in the number of patients receiving oral fluids while in the ED following the implementation of the guideline. However, there was an increase in the administration of gastrolyte™ in patients who received oral fluids in the post test group. While not reaching statistical significance it is clinically important. This is reflected in the literature which identifies replacement of fluid and electrolyte losses as the critical central elements of effective treatment of dehydration secondary to gastroenteritis (Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis, 1996; Bruzzese et al., 2013). The data also revealed that a large number of children 62 (52.5%) in the pre-test group and 56 children (47.9%) in the posttest group did not receive any oral fluid while in the ED. This raises many issues and identifies clinical risk for deterioration for children that already present to the ED with dehydration. These children were at an even greater risk for deterioration without being treated with oral fluids. Deterioration may have been caused
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by poor compliance with following the rapid rehydration guideline or nurses initiating ORT to children without documentation. Alternatively nurses may not be initiating oral fluids according to the guideline to children that are dehydrated. Limitations The amount of missing data in the medical records was a significant limitation which may have influenced the results of this study. Additionally, the ORT guidelines were not followed explicitly; it is therefore difficult to ascertain how they impacted on ED LOS and hospital admission rates. Another limitation relates to the data collection period for the post-test group. This commenced 3 months following the pre-test group and could be affected by potential of seasonal variation in gastroenteritis presentations. Conclusion This study examined the effect of a rapid oral rehydration guideline on the ED management of gastroenteritis in children. The key findings from this study were an increase in the ED LOS by 54 min with an overall increase in hospital admissions to either the children’s ward or PSSU. There was a small positive increase in the use of Oral Rehydration Therapy by 7.2% post implementation of the rapid oral rehydration guideline. The findings from this study reveal inadequacies in the monitoring and recording of patient data and treatment regimens provided for children presenting with dehydration. There is a need for improved documentation practices and further education in the management of dehydration secondary to gastroenteritis in children in the ED. References Atherly-John, Y.C., Cunningham, S.J., Crain, E.F., 2002. A randomized trial of oral versus intravenous rehydration in a paediatric emergency department. Arch of Pediatric Adolescent Medicine 156 (12), 1240–1243. Beck, C., Choong, K., Puligandla, P., Hartfield, D., Holland, J., Lacoix, J., Friedman, J., 2013. Avoiding hypotonic solutions in paediatrics: keeping your patients safe. Paediatrics and Child Health 18 (2), 94–95. Bender, J., Ozuah, P., 2004. Intravenous rehydration for gastroenteritis: how long does it really take? Pediatric Emergency Care 20 (4), 215–218. Bruzzese, E., Vecchio, A., Guarino, A., 2013. Hospital management of children with gastroenteritis. Current Opinion in Gastroenteritis 29 (1), 23–30. Conners, G.P., Barker, W.H., Mushlin, A.I., Geopp, J.G., 2000. Oral versus intravenous; rehydration prefernces of paediatric emergency medicine fellowship directors. Pediatric Emergency Care 16, 335–338. Elliot, E.J., Dalby-Payne, J., 2004. Acute infectious diarrhoea and dehydration in children. Medical Journal of Australia 181 (10), 565–570. Endom, E.E., Kim, M.S., 2006. Treatment of Hypovolemia (Dehydration) in Children (retrieved 05.09.07, from up-to-date). Fonseca, B.K., Holdgate, A., Craig, J.C., 2004. Enteral vs intravenous rehydration therapy in children with gastroenteritis: a meta-analysis of randomized controlled trials. Arch Pediatric Adolescent Medicine 158, 483–490. Frith, K., Elliot, E.J., 2007. Investigating the child with acute diarrhoea. Medicine Today 8 (8), 44–50. King, C., Glass, R., Bresee, J., Duggan, C., 2003. Managing acute gastroenteritis among children. Mobility and Mortality Weekly Reports 52 (RR16), 1–16. Lee, G.A., Haden, K., 2007. An audit of practice of rehydration in children with gastroenteritis under three years in an Emergency Department. Australasian Emergency Nursing Journal 10 (3), 110–116. Nager, A.L., Wang, V.J., 2002. Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration. Pediatrics 109 (4), 566–572. Neville, K., Verge, C., Rosenberg, A., O’Meara, M., Walker, J., 2006. Isotonic is better than hypotonic saline for intravenous rehydration of children with gastroenteritis: a prospective randomized study. Archives of Diseases in Children 91 (3), 226–232. Phin, S., McKaskell, M., Browne, G., Lam, L., 2003. Clinical pathway using rapid rehydration for children with gastroenteritis. Journal of Paediatircs and Child Health 39 (5), 343–348. Piescik-Lech, M., Sharmin, R., Guarino, A., Szajewska, H., 2013. The management of acute gastroenteritis in children. Alimentary Pharmacology & Therapeutics 37 (3), 289–303.
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