Dr. Freedman is currently with the Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, and the Department of Pediatrics, and Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta.
Presented at the Pediatric Academic Societies annual meeting, Boston, MA, May 2012.
LMK received project funding from the SickKids Summer Research (SSuRe) program. The project did not receive any financial support from other sources.
The authors have no potential conflicts of interest to disclose.
Although leading organizations have developed gastroenteritis management guidelines, little is known about emergency department (ED) use of clinical tools to improve outcomes. Our objective was to describe pediatric gastroenteritis clinical decision tools employed in EDs in the province of Ontario and to determine if a greater number of clinical decision tools are employed in academic, high-volume institutions staffed primarily by emergency medicine (EM)-trained physicians.
A cross-sectional, Internet-based survey was distributed in the summer of 2010 to medical directors and managers of Ontario EDs. Domains included patient population, general resources, and gastroenteritis-specific strategies. Copies were requested of all gastroenteritis-specific strategies to enable a content review.
A total of 133 (83%) of 160 eligible participants responded. Practice guidelines, pathways, or order sets; medical directives; and printed discharge instructions were reported to be in use at 38 of the 133 (29%), 69 of 133 (52%), and 105 of 133 (79%) of the responding institutions, respectively. Oral rehydration therapy (ORT) is routinely initiated at triage in only 51 of the 133 of the EDs (38%). High-volume institutions are more likely to have clinical practice guidelines, pathways, or order sets (p = 0.001) than low- and medium-volume EDs. Physician training in EM was associated with the presence of medical directives for nursing administration of antiemetics and antipyretics (p = 0.04). Review of clinical practice guidelines, pathways, and order sets showed that only six of 27 gastroenteritis-specific strategies reviewed were correctly classified, and 20 (74%) met prespecified quality criteria.
Clinical decision tools designed to improve pediatric gastroenteritis management are not commonly implemented. Such strategies are more common in high-volume EDs and those staffed primarily by physicians with EM training.
Encuesta acerca de los Recursos del Servicio de Urgencias y las Estrategias Empleadas en el Tratamiento de las Gastroenteritis Pediátricas
Aunque las principales organizaciones han desarrollado guías clínicas para el manejo de las gastroenteritis, se conoce poco sobre el uso de las herramientas clínicas para mejorar los resultados en el servicio de urgencias (SU). El objetivo fue describir las herramientas de decisión clínica para las gastroenteritis pediátricas en los SU en la provincia de Ontario (Canadá) y determinar si se utiliza un número mayor de herramientas de decisión clínica en instituciones universitarias con alta frecuentación supervisadas principalmente por médicos con formación en medicina de urgencias y emergencias (MUE).
Se distribuyó una encuesta transversal electrónica en el verano de 2010 a los gerentes y directores médicos de los SU de Ontario. Los dominios incluyeron la población de pacientes, los recursos y las estrategias específicas en la gastroenteritis. Se solicitaron copias de todas las estrategias específicas sobre gastroenteritis para posibilitar una revisión de su contenido.
Respondieron 133 tres (83%) de 160 participantes posibles. Se documentó el uso de guías de práctica clínica, vías clínica o conjuntos de órdenes, directivas médicas e instrucciones al alta en 38 (29%), 69 (52%) y 105 (79%) de las 133 instituciones respondedoras, respectivamente. El tratamiento con rehidratación oral (TRO) se inicia de forma rutinaria en el triaje en sólo 51 de los 133 (38%) SU. Las instituciones con alta frecuentación tienen con mayor probabilidad guías de práctica clínica, vías clínicas u órdenes de tratamiento (p = 0,001) que los SU de frecuentación baja o intermedia. El médico con formación en MUE se asoció con la presencia de directrices médicas para la administración de antieméticos y antipiréticos por enfermería (p = 0,04). La revisión de las guías de práctica clínica, vías clínicas u órdenes de tratamiento mostró que sólo 6 de las 27 estrategias específicas de gastroenteritis revisadas eran correctamente clasificadas, y 20 (74%) cumplieron con los criterios de calidad predefinidos.
Las herramientas de decisión clínica diseñadas para mejorar el manejo de la gastroenteritis pediátrica no están comúnmente implementadas. Dichas estrategias son más frecuentes en SU de alta frecuentación y en aquellos SU supervisados principalmente por médicos con formación en MUE.
Gastroenteritis remains a leading cause of morbidity in North American children, resulting in substantial economic costs and health care utilization. To promote standardized and appropriate treatment, pediatric gastroenteritis management guidelines have been published by several organizations, including the World Health Organization and the Centers for Disease Control and Prevention. Despite their promotion of oral rehydration therapy (ORT), it remains underused in North America.[3, 4] This suggests that guidelines are not being implemented effectively at the local level and highlights the need to close the research-to-practice gap.
Successful knowledge translation strategies have proven that the implementation of evidence-based gastroenteritis guidelines can be facilitated through use of clinical decision tools. Examples include 1) clinical practice guidelines (CPGs) that provide broad frameworks for diagnosis, assessment, and management rather than specific protocols; 2) clinical pathways that standardize treatment for a specific clinical problem by providing a detailed algorithm of treatment steps, with reference to timeframes or criteria-based progression; and 3) order sets, which are groupings of medical orders that standardize treatment based on established guidelines. These clinical decision tools incorporate the best available evidence to improve quality of care provided for a defined problem within a given population, institution, or community.
Because little is known of the prevalence of clinical decision tools in the context of pediatric gastroenteritis, we sought to determine their presence in the province of Ontario, Canada. We hypothesized that there would be differences in use based on hospital characteristics, with higher prevalence in academic, large-volume emergency departments (EDs) staffed primarily by physicians with emergency medicine (EM) training (referred to as emergency physicians [EPs] herein). We also sought to evaluate the quality of available tools, as published gastroenteritis CPGs are regarded as being of only “fair” quality.
Study Design and Population
We conducted an Internet-based cross-sectional survey of EDs in Ontario, Canada. Participants provided informed consent online prior to proceeding to the questionnaire. Study approval was provided by the Hospital for Sick Children's Research Ethics Board.
Emergency departments in the province of Ontario, Canada, were eligible for participation in our survey, which was distributed between June and September 2010. Eligible institutions were those with on-site physicians that were capable of providing comprehensive care to patients < 18 years of age with gastroenteritis.
Survey Content and Administration
The survey was developed in accordance with guidelines for the design and conduct of self-administered surveys for clinicians. After completing a literature review, a local panel of experts assisted in item generation, reduction, and pretesting. The complete electronic survey was then piloted with attention paid to flow, format, areas of redundancy, and length.
The final 27-question survey included dichotomous, numerical response, and Likert scale-like questions (survey is available in Data Supplement S1, available as supporting information in the online version of this paper). The survey content addressed gastroenteritis-specific clinical decision tools and other common ED practices (e.g., medical directives for nursing administration of medication). Additional survey domains included patient population, medical staff training, availability of pediatric consultation, and short-stay units.
Definitions of clinical decision tools, based on medical subject headings of the National Library of Medicine, were embedded within the survey. A CPG was defined as “a set of directions or principles to assist the health care practitioner with patient care decisions about appropriate diagnostic, therapeutic, or other clinical procedures for specific clinical circumstances.” To simplify classification, pathways and order sets were grouped together and defined as “schedules of medical and nursing procedures, including diagnostic tests, medications, and consultations.”7
The survey was distributed to ED medical directors and administrative managers. Recipients were previously identified as the most appropriate individuals to respond for their institutions in the Ontario Hospital Report. The survey used an Internet-based survey tool (SurveyMonkey; http://www.surveymonkey.com).
A modified Dillman technique was employed, including the use of an advance introductory letter, e-mail reminders, and if necessary, a telephone call. Initial recipients who felt they were not the most appropriate persons to complete the survey were asked to designate alternate respondents. Our survey was closed to new responses as of December 31, 2010.
When participants indicated the existence of clinical decision tools in their responses, copies were requested. All documents received were classified by two authors (SBF, AB) as CPGs, pathways, or order sets. Quality was assessed based on three principles: 1) ORT should be used for children with all but severe dehydration, 2) dehydration severity should dictate treatment, and 3) pathways and order sets must be embedded into care to result in clinical benefit. All disagreements between the authors were resolved via discussion until consensus was achieved.
Data were imported directly into Microsoft Excel (Microsoft Corp., Redmond, WA) and then into Stata (version 9.2, StataCorp, College Station, TX). Based on the reported numbers of patients treated annually, ED volume was categorized as small (< 20,000 patients/year), medium (20,000–50,000 patients/year), or large (> 50,000 patients/year). Where relevant information was missing (n = 3), hospitals were categorized using data from the Ontario Ministry of Health and Long-Term Care and the Ontario Joint Policy and Planning Committee (JPPC).[14, 15] Patient volumes for non-responding EDs were obtained from the JPPC or via hospital websites. Institutions were further classified as “academic” and “nonacademic” based on membership in the Council of Academic Hospitals of Ontario. EDs were deemed to be staffed primarily by EPs if the most common certification among physicians was one of the following: Certification in The College of Family Physicians–Emergency Medicine (CCFP-EM), Fellow of The Royal College of Physicians of Canada–Emergency Medicine (FRCPC-EM), American Board of Emergency Medicine (ABEM), or FRCPC–Pediatrics with pediatric EM fellowship.
Responses were analyzed using standardized tabulations with percentages used to summarize categorical data. Categorical variables were compared using the chi-square test or Fisher's exact test, as appropriate. All statistical analyses were two-sided and a p-value of < 0.05 was considered statistically significant, without adjustment for multiple comparisons.
Survey responses were received from 133 of 160 eligible EDs (83%; Figure 1). Responding and nonresponding institutions were similar in terms of academic status and annual patient volume (Table 1). Respondents for 38 of 133 (29%) participating institutions reported the presence of short-stay units (e.g., observation, holding, or clinical decision units), where patients can be temporarily observed and/or treated when their conditions are expected to be brief. A designated, separately staffed area to treat low-acuity patients (e.g., fast track or urgent care program) was reported by 58 of 133 EDs (44%). Ten of 133 (8%) responding institutions have low-acuity treatment clinics outside of their EDs, to which appropriate cases are diverted at triage without being registered as ED patients. Pediatric consults (i.e., from pediatricians or supervised pediatric residents/fellows) are available, 24 hours per day, 7 days per week in 81 of 133 (61%) responding hospitals. In 37 of these 81 institutions, the consulting physicians are in-house; in the remaining 44 the consulting physicians are on-call and may be located outside the hospital.
Table 1. Characteristics of Responding EDs, With Comparison to Nonresponding Institutions
ABEM = American Board of Emergency Medicine; CCFP-EM = Certification in The College of Family Physicians–Emergency Medicine; FRCPC-EM = Fellow of The Royal College of Physicians of Canada–Emergency Medicine; FRCPC-Pediatrics = Fellow of The Royal College of Physicians of Canada–Pediatrics
EP = emergency physician; NA = not available; PEM = pediatric emergency medicine.
p-values are for comparison between responding and nonresponding EDs, based on the chi-square test or Fisher's exact test.
Patient volume data available for 17 of 27 nonresponding EDs.
A total of 54 CPGs, pathways, or standardized order sets (33 CPG, 21 pathways or standardized order sets) were reported to be in use at 38 of the 133 (28%) responding EDs. Although the presence of a CPG, pathway, or standardized order set was more common in large-volume EDs (p = 0.001), ORT, the most fundamental intervention, is initiated at triage in only 51 of 133 (38%) EDs and did not vary by ED characteristics. Medical directives for nursing administration of medication are more common in institutions staffed primarily by EPs (p = 0.04); overall, 52% (69 of 133) of the responding EDs have such directives in place. Directives for antipyretics (i.e., acetaminophen, ibuprofen) exist in 65 EDs (49%), and antiemetics (i.e., ondansetron, dimenhydrinate), in 21 (16%). A total of 105 of 133 (79%) provide preprinted discharge instructions or information pamphlets on gastroenteritis to families at the time of discharge. The majority (76 of 105; 72%) of the instructions provided are institution-specific.
Table 2. Distribution of ED Strategies and Resources According to Hospital Characteristics
CPG = clinical practice guideline; ORT = oral rehydration therapy.
p-values are based on the chi-square test or Fisher's exact test.
CPG or pathway/order set, n (%)
Medical directive, n (%)
Initiation of ORT at triage, n (%)
Printed discharge instructions, n (%)
Quality of ED Gastroenteritis Clinical Tools
Copies of 26 CPGs, clinical pathways, and standardized order sets were obtained from 25 of the 38 institutions that reportedly employ them. For the remaining 13 sites, nine notified us they were incorrect in their survey response (seven had medical directives, but not CPG/pathway/order sets, and two in fact had nothing), and four sites did not send their documentation. Five of the 26 (19%) CPG/pathways/order sets obtained were correctly classified. Ten pathway/order sets were classified as CPGs, while 11 sites reported having both CPGs and pathway/order sets, document review identified only pathways/order sets, and no CPGs. The 26 CPG/pathways/order sets were analyzed for quality and patient use. Quality review of the 26 documents determined that 19 of the 26 (73%) met the a priori quality criteria, and 15 of the 26 (58%) met quality criteria and were used “most” or “all/nearly all” of the time.
Cross-sectional survey data from 133 EDs in Ontario show that considerable interinstitution variation exists and that clinical decision tools relevant to the care of children with gastroenteritis are not routinely available. Moreover, ORT, a basic treatment with a strong evidence base and wide support among health organizations, is not initiated at triage in most responding EDs. While academic status did not appear to be strongly associated with resource availability, hospital volume and physician training were associated with the presence of clinical decision tools and medical directives.
The overall paucity of clinical tools may be the most striking finding from our study, highlighting the gap between evidence and practice; the latter is a consistent finding in health services research. Because the traditional approach of passive diffusion of knowledge through the publication of guidelines has not been successful in altering clinical practice, a more active process of clinical tool generation, with treatments tailored to specific groups of children presenting with specific complaints at specific institutions, is required. Such a process, employing effective administrative and educational strategies, is necessary to overcome barriers to the implementation of the best available care.
Our quality analysis revealed that consistent with a recent study of ED asthma pathways in Ontario, few of the documents received were accurately classified as CPGs or pathway/order sets. Our quality assessment was designed to include only elements for which there is uniform agreement for inclusion in gastroenteritis documents designed to improve care. Nonetheless, only 73% of the documents provided met basic quality requirements and, of these, 15% were reported as not being routinely used. These findings are consistent with the work of Lo Vecchio et al., who appraised the quality of published pediatric gastroenteritis CPGs and concluded that their overall quality was only “fair.” Clearly, health gains cannot be achieved employing CPGs that are not scientifically valid.
To our knowledge, this study is the first to explore the availability and quality of gastroenteritis-specific clinical decision tools in a population-based sample of hospitals. We additionally correlated the existence of these resources with ED characteristics. Our finding that the prevalence of clinical decision tools and medical directives is associated with both patient volume and physicians training is not surprising, as these institutions are more likely to invest time and resources to improve the efficiency and quality of care provided to children with common illnesses. Although lower-volume institutions may not find such investment to be valuable, such institutions may have the greatest need for guiding documents. Future attempts to augment the availability of resources such as pathways and CPGs should involve collaborative efforts between centers—particularly large EDs with smaller ones, which perhaps have fewer financial and human resources to dedicate to the development of clinical decision tools. The challenge to such collaborative projects is that internally developed guidelines are more likely to be highly effective.20 Nonetheless, educational “outreach” visits, peer-to-peer teaching, and multimodal interventions have all shown promise in other areas of clinical practice.
First, unmeasured differences between responding and nonresponding EDs may have introduced bias. However, our comparison, based on available data, detected no significant differences in terms of academic status or patient volume, and our response rate was greater than 80%. Second, the survey was completed by ED medical directors and administrative managers. Although these respondents have been identified as the most appropriate individuals to answer on behalf of their institutions, our analysis showed that CPGs and clinical pathways were often misclassified. It is unclear whether this misclassification resulted from a general lack of understanding of clinical decision tools or a lack of knowledge of local clinical decision tools that are in place. Further research should be conducted to explore knowledge, awareness, and adherence to decision tools by ED staff.
Our estimates of resource and strategy prevalence may be inaccurate as a result of misclassification. There is no reason to believe, though, that any misclassification would be systematically different based on patient volume, academic status, or training of physicians. For this reason, we have chosen to compare prevalence of resources/strategies based on “raw” numbers, as reported in the survey. Last, our survey did not enable us to explore decision tool development, dissemination, and implementation. Such details would better enable us to link the existence of strategies to potential improvement in outcomes. It is important to note that this study did not include clinically relevant outcome data. Thus, we cannot make any direct inferences to the quality of care provided based solely on the results of our survey.
Strategies designed to standardize the care of children with gastroenteritis are not commonly implemented. These strategies, while not consistently more prevalent in academic centers, were more likely to be in existence in large-volume EDs and those staffed primarily by physicians with specialty training in emergency medicine. Further research is necessary to determine if the existence of institution-specific clinical decision tools and other resources is associated with improved outcomes.
The authors are grateful for all the assistance provided by members of the expert panel who participated in the item generation, reduction, and pretesting phases of this study. Members of the panel included Drs. Kevin Chan, Bill Mounstephen, Suzan Schneeweiss, and Bruce Minnes.