A nurse-driven protocol for oral rehydration therapy in mildly dehydrated pediatric patients

One of the most common diagnoses seen in the pediatric ED is acute gastroenteritis, which accounts for approximately 16% of ED visits. This illness is a result of gastrointestinal inflammation and presents as three or more episodes of diarrhea and/or vomiting and may have accompanying symptoms including fever and abdominal pain.1 Mild or moderate illness should ideally be managed in an outpatient setting with adequate oral rehydration and symptom management; however, parents may defer to the ED for care, which results in an increase in ED congestion, economic costs, and healthcare utilization.1,2 Children and their families may also be at risk for dissatisfaction with their care because of experiencing long ED wait times. Further, ED visits may expose children and families to unnecessary risks associated with being in the hospital such as exposure to infection. This study sought to identify current practices in the treatment of acute gastroenteritis and develop a standardized approach to caring for these patients to improve the patient experience and ultimately decrease the length of stay for the patient in the ED. The problem The development of oral rehydration therapy (ORT) is an established method for management of acute gastroenteritis.3 ORT is as effective as I.V. therapy in the rehydration of a child with mild to moderate dehydration.4 However, ORT is inconsistently administered in the ED, leading to delays in care or prolonged stays in the hospital.5 These inconsistencies include early, off-label use of oral ondansetron prior to attempting ORT and/or delaying ORT initiation until after the physician has seen the child.6 In addition to the inconsistent application of this therapy among providers, a decrease in parental knowledge related to the management of acute gastroenteritis adds to the burden on the healthcare system financially because it can result in an increase in unnecessary ED visits. Positive and impactful education for families on how to manage symptoms of acute gastroenteritis can result in better adherence to treatment plans at home and a decrease in hospital admissions.7 Literature review ORT is recommended by the American Academy of Pediatrics (AAP) as a first-line therapy in children with mild to moderate dehydration.8 However, ORT continues to be utilized inconsistently in EDs in the United States because of various barriers including concern about effectiveness, a perception that ORT is time-consuming, and parental or physician preference.9 Alternative practices that are sometimes used in place of or before ORT include ondansetron and/or I.V. fluid administration. Although the AAP recommends ORT, standardized practice guidelines still do not exist in all pediatric EDs. Critical pathways can help incorporate evidence-based practice recommendations into guidelines for patient care.10 Some tertiary children's hospitals have developed critical pathways for the treatment of children with acute gastroenteritis in the ED.11,12 Clinical practice guidelines exist for the assessment of dehydration in pediatric patients, which create a basis for identifying patients eligible for ORT.13 The aim of this project was to develop a nurse-driven protocol to implement early ORT in pediatric emergency patients with mild dehydration to reduce the length of stay in the ED and other unintended consequences. This project also aimed to initiate early and successful ORT to decrease the amount of ondansetron and/or I.V. fluid therapy needed when treating acute gastroenteritis. Methodology An interdisciplinary shared governance team, led by clinical nurses from the pediatric ED at one East Coast hospital, developed a nurse-driven protocol for the implementation of ORT in pediatric patients entering the ED with mild dehydration. The algorithm for this protocol (see ORTalgorithm) was developed using published guidelines.11,12 The algorithm was designed to be utilized based on the nursing assessment of dehydration.13 In addition, exclusion criteria for use of the protocol were clearly defined and included a toxic-appearing child, bilious emesis, or bloody diarrhea. Once the algorithm was developed, it was reviewed and approved by the pediatric medical director and pediatric hospitalists. After the protocol was approved, education was provided to nurses, physicians, and patient-care technicians on its use. This was accomplished with a variety of methods, including in-person reviews, staff meeting discussions, poster boards, and e-mails. Education occurred over a period of 6 weeks during Spring 2016 before implementation of the protocol. In addition to education, allocation of necessary resources was required for successful protocol implementation. ORT is usually accomplished with recommended sports drinks and/or electrolyte-dense fluids. Adequately stocked amounts of these beverages, as well as syringes and measuring cups, were allocated prior to implementation.Figure: ORT algorithmThe review of the intervention was done through manual chart audits. Because this was an evidence-based practice implementation process, institutional review board approval was not needed. Two primary pieces of evidence were tracked before, during, and after the implementation of this nurse-driven protocol: the time from entry in the ED to initiation of ORT, and total length of stay in the ED. In addition to these two primary indicators, information gleaned from the chart audits included assessment of the severity of dehydration and illness, whether or not the physician prescribed ondansetron, whether or not there was vomiting or other negative outcomes while in the ED, and whether or not the patient required admission. Results Baseline data from 18 charts of pediatric patients seen in the ED with acute gastroenteritis with mild dehydration were collected prior to the implementation of this project. After implementation, data from 15 applicable charts were collected in every 2 months during Summer and Fall 2016 for a total of 45 charts. Result of audits shows the breakdown of data collected during chart audits, including percentage of ondansetron use by the physicians, range and mean time from entry in the ED to ORT, and the mean length of stay in the ED. During the implementation of this protocol, use of ondansetron, length of time from entry in the ED to initiation of ORT, and overall length of stay in the ED decreased. Use of ondansetron decreased from an initial rate of 94.4% to an average of 53%. The time from entry in the ED to initiation of ORT decreased from an initial time of 120 minutes to an average of 52 minutes, which is a 57% overall decrease (see Time [in minutes] from entering the ED to ORT initiation). Finally, length of stay in the ED went from an initial time of 160 minutes to an average time of 125 minutes, which is a 22% overall decrease (see Length of stay in the ED). Discussion This project sought to highlight how nurse-driven protocols can have positive impacts on patient care, especially in EDs. Developing guidelines for practice can provide nurses with the knowledge to initiate safe patient care and reduce lengths of stay in the ED. Shared governance empowers nurses to drive practice, which this project clearly shows.14 The implementation of this protocol also improved the patient and family experience while in the ED. In addition to a decreased length of stay, this protocol also educated and empowered the families with patient teaching about the management of gastroenteritis with ORT. Patients and their families were sent home with education on ongoing ORT, which was described by many families as helpful and encouraging.Table: Result of auditsFigure: Time [in minutes] from entering the ED to ORT initiationHowever, this study did have limitations. Manual chart audits are difficult and time-consuming, and rely on nursing documentation for accuracy of timing. This practice change required nurses to be more precise in how they described their rehydration efforts and the timing of each step of the algorithm. If the documentation was unclear or incomplete, it would have been difficult to ascertain whether or not the algorithm was successfully implemented. The small sample sizes for each group of audits during this pilot may be considered a limitation. Also, while the physicians received ongoing education on the protocol, some physicians were still resistant to the change and continued to prescribe ondansetron before a nurse could implement the protocol. Another limitation that was quickly overcome was the hesitancy of nurses to utilize nurse-driven protocols. While nurse-driven protocols are common in the ED, implementation of new protocols often takes time for nurses to buy-in to the change. In order to overcome this hesitancy, peer-to-peer education was provided in real time to reinforce use of the protocol and ensure the success of this practice change. In order to ensure lasting changes in practice, ongoing monitoring is required.Figure: Length of stay in the EDA final limitation was resistance from some families in coaching their children through ORT. Occasionally, families felt that their children did not want to continue to drink the recommended rehydration fluids and did not push their children to continue, which required ongoing support from the nursing staff and education about proper ORT practices. Implications for practice Nurse-driven protocols can help implement early interventions for patients in the ED.10 Using national recommendations and developing standardized guidelines can empower nurses to intervene with appropriate patients prior to their being seen by a physician.8,11-13 This protocol would be ideal for use in other outpatient settings including primary care practices and urgent care facilities. By sharing this project and its outcomes, it is the authors' hope that it will be utilized in outpatient settings and potentially save a family from an ED visit altogether. Conclusion The results of this project demonstrate the importance of nurse-driven protocols and shared governance in the ED. The project also highlights the need for ongoing research to identify and overcome barriers for physicians to decrease ondansetron prescribing. Because acute gastroenteritis is a leading cause of childhood morbidity and healthcare expenses, continued support and research on best practice guidelines for this population is needed.