Clinical Pathway Produces Sustained Improvement in Acute Gastroenteritis Care

Pediatrics. 2017 Oct;140(4):e20164310. doi: 10.1542/peds.2016-4310. Epub 2017 Sep 7.


Background and objectives: 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.

Methods: Cases were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. We used statistical process control to analyze process and outcome measures for 2 years before and 10 years after pathway implementation.

Results: 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.

Conclusions: 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.

MeSH terms

  • Acute Disease
  • Adolescent
  • Antiemetics / therapeutic use*
  • Child
  • Child, Preschool
  • Combined Modality Therapy
  • Critical Pathways*
  • Emergency Service, Hospital / standards*
  • Emergency Service, Hospital / statistics & numerical data
  • Female
  • Fluid Therapy / methods*
  • Fluid Therapy / standards
  • Fluid Therapy / statistics & numerical data
  • Gastroenteritis / therapy*
  • Humans
  • Infant
  • Length of Stay / statistics & numerical data
  • Male
  • Ondansetron / therapeutic use*
  • Outcome and Process Assessment, Health Care
  • Quality Improvement / statistics & numerical data*


  • Antiemetics
  • Ondansetron