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Abstract

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References
  9. Supporting Information

ACADEMIC EMERGENCY MEDICINE 2011; 18:38–45 © 2011 by the Society for Academic Emergency Medicine

Abstract

Objectives:  Acute gastroenteritis is a very common emergency department (ED) diagnosis accounting for greater than 1.5 million outpatient visits and 200,000 hospitalizations annually among children in the United States. Although guidelines exist to assist clinicians, they do not clearly address topics for which evidence is new or limited, including the use of antiemetic agents, probiotics, and intravenous (IV) fluid rehydration regimens. This study sought to describe the ED treatments administered to children with acute gastroenteritis and to compare management between Canadian and U.S. physicians practicing pediatric emergency medicine (PEM).

Methods:  Members of PEM research networks located in Canada and the United States were invited to participate in a cross-sectional, Internet-based survey. Participants were included if they are attending physicians and provide care to patients < 18 years of age in an ED.

Results:  In total, 235 of 339 (73%) eligible individuals responded. A total of 103 of 136 Canadian physicians (76%) report initiating oral rehydration therapy (ORT) in children with moderate dehydration, compared with 44 of 94 (47%) of their U.S. colleagues (p < 0.001). The latter more often administer antiemetic agents to children with vomiting (67% vs. 45%; p = 0.001). American physicians administer larger IV fluid bolus volumes (p < 0.001) and over shorter time periods (p = 0.001) and repeat the fluid boluses more frequently (p < 0.001). Probiotics are routinely recommended by only 35 of 230 respondents (15%).

Conclusions:  The treatment of pediatric gastroenteritis varies by geographic location and differs significantly between Canadian and American PEM physicians. Oral rehydration continues to be underused, particularly in the United States. Probiotic use remains uncommon, while ondansetron administration has become routine. Children frequently receive IV rehydration, with the rate and volume administered being greater in the United States.

Acute gastroenteritis is a very common emergency department (ED) diagnosis, accounting for > 1.5 million outpatient visits, 200,000 hospitalizations, and approximately 300 deaths per year among children in the United States.1 While adherence to an evidence-based algorithm can improve outcomes in children with gastroenteritis,2 the available data suggest that there is significant variation in the management of this illness.3 Several guidelines addressing the management of this problem have recently been published; however, they do not clearly address some controversial topics for which evidence is new or limited, including the use of antiemetic agents, probiotics, and intravenous (IV) fluid rehydration regimens.1,4,5 When evidence is limited, background experiences, training, institutional culture, risk aversion,6 and parental wishes7 often influence practice patterns. As a result, therapeutic regimens employed may be highly variable between individual clinicians, institutions, and across national borders.8

As future research endeavors begin to clarify the roles of select therapeutic interventions, effective knowledge translation strategies will need to be devised, and these may need to be country-specific. However, an understanding of the current treatment practices in each country is an essential first step. Thus, the objective of this survey was to evaluate current gastroenteritis therapy delivered by pediatric emergency care providers and to compare practice patterns between Canadian and U.S. physicians. We also sought to better understand the current usage of antiemetics, probiotics, and IV rehydration. This information will allow experts to identify research priorities, areas of controversy, and where country-specific knowledge translation efforts should be focused.

Methods

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References
  9. Supporting Information

Study Design and Population

This cross-sectional, electronic survey of physicians practicing pediatric emergency medicine (PEM) was designed for distribution to current members of Pediatric Emergency Research Canada (PERC) and the Pediatric Emergency Medicine Collaborative Research Committee (PEM-CRC) of the (U.S.) American Academy of Pediatrics. These networks were selected to optimize generalizability and enhance survey response rate. Membership in the PEM-CRC and PERC is open to any health care provider interested in the delivery of emergency care to children. Individuals may work in either academic or community EDs. While PERC has recently completed a multicenter prospective observational study in pediatric gastroenteritis, to the best of our knowledge, PEM-CRC has not conducted any networkwide research studies in children with acute gastroenteritis. Contact information for members of these groups was provided by the organizations themselves following a review and approval of the research protocol.

Participants were included if they indicated that they were members of PERC or PEM-CRC and provide care to patients < 18 years of age in an ED setting. Participants who had inaccurate e-mail addresses, were not attending physicians, were not based in the United States or Canada, or were nonpracticing physicians were excluded. This study received approval from the Research Ethics Board of The Hospital for Sick Children, Toronto, and Children’s Memorial Hospital, Chicago.

Survey Content and Administration

The survey (Appendix 1, available as a Data Supplement S1 in the online version of this paper) was designed to examine practices, knowledge, and beliefs regarding the treatment of toddlers and young children with acute gastroenteritis in the ED. It was developed in accordance with a recently developed guide for the design and conduct of self-administered surveys for clinicians.9 After completing a literature review, a panel of experts was recruited to assist in item generation, reduction, and pretesting (see Acknowledgements for panel members and Appendix 2 [Data Supplement S2] for complete methodology details [Data Supplement S3]). As the majority of these individuals are members of either PERC or PEM-CRC, their responses were not included in the data analysis. The final 41-question survey included a variety of question formats, including dichotomous (yes/no) questions and frequency of endorsement with response options either being numeric (<5, 5–25, 26–50, 51–75, 76–95, and >95%) or Likert scale (strongly disagree, disagree, neither agree nor disagree, agree, strongly agree). The survey used an Internet-based survey tool (SurveyMonkey; http://www.surveymonkey.com). Completion time and incomplete responses were minimized by the use of multiple-item screens.10

All members of PERC and PEM-CRC were contacted by e-mail between June 4 and July 20, 2009. A modified Dillman technique,11 including advance mailing, the use of a small incentive, and reminder e-mails, was employed to optimize the response rate. Reminders were sent to nonresponders at predetermined 1- to 2-week intervals up to a maximum of four additional e-mails. To preserve anonymity while preventing multiple responses from a single individual, we enabled a tool (e-mail invitation collector) on SurveyMonkey, which prevented multiple entries from the same computer by encoding the recipient’s information in the link that is sent to him or her. Our survey was closed to new responses 2 weeks after the final reminder e-mail was sent. Consent was implied by survey completion, and data regarding nonresponders were provided by the umbrella organizations.

Data Analysis

Preliminary information from the two research groups indicated that their total membership would provide a sample size of 380 members. Based on previous surveys of these groups, we anticipated a response rate of 65%, which would provide 247 responses. Such a final sample size from a population of 2,000 (estimated size of PEM community that these research groups represent) produces a 95% confidence interval (CI) equal to the sample proportion for our responses, ±6% when the estimated proportion responding to a dichotomous question is 50% (worst-case scenario). Sample size calculations were conducted using PASS 2008, version 08.0.2 (NCSS, LLC, Kaysville, UT).

Once survey collection was complete, data were imported directly into Microsoft Excel (Microsoft Corp., Redmond, WA), and then into SPSS (version 16.0, SPSS, Inc., Chicago, IL). Responses were analyzed using standardized tabulations—descriptive statistics were used to describe demographic variables, and percentages were used to summarize categorical data. As has been done previously,12 for simplicity, we chose to present the data from the Likert scale (strongly agree AND agree; neither agree nor disagree; disagree AND strongly disagree) and frequency of endorsement questions (<5% AND 5%–25%; 26%–50% AND 51%–75%; 76%–95% AND >95%), grouped into three categories. This decision was driven by the distribution of the data and ease of interpretation. Comparison of Canadian and U.S. responses was completed using the chi-square test; Fisher’s exact test was used when appropriate. These analyses were conducted in order to highlight domains where the published literature was being interpreted differently or where training, institutional culture, risk aversion, and parental wishes had their greatest influence on clinical practice. Results were calculated based on the number of respondents to a particular question.

Because multiple comparisons increase the probability of having a statistically significant finding through chance alone, a Bonferroni correction was applied to the analyses presented in each table.13 The Bonferroni correction divides the type I (α) error (0.05) by the number of comparisons to yield a more conservative p-value that is then employed to assign statistical significance. For example, in Table 1, a p-value that is less than 0.05 divided by 5 (five comparisons) or 0.01 is considered statistically significant.

Table 1.    ORT Scenario
“You evaluate a 15-month-old with a history and physical examination consistent with moderate dehydration. The child has had seven episodes of nonbloody diarrhea today and five episodes of vomiting, with the last occurring 45 minutes ago. The presumed etiology is infectious gastroenteritis.” How often do you:PERC (n = 136)PEM-CRC (n = 94)p-value*
≤25%25%–75%>75%≤25%25%–75%>75%
  1. Data are reported as n (%).

  2. ORS = oral rehydration solution; ORT = oral rehydration therapy; PEM-CRC = Pediatric Emergency Medicine Collaborative Research Committee; PERC = Pediatric Emergency Research Canada.

  3. *p-values are a comparison between PERC and PEM-CRC responses calculated employing Pearson’s chi-square test. p-value of significance for this table is set at 0.01.

Initiate rehydration ORALLY as first-line therapy?13 (10)20 (15)103 (76)17 (18)33 (35)44 (47)<0.001
Believe the palatability of ORS results in fluid refusal?76 (57)47 (35)11 (8)49 (53)29 (31)15 (16)0.18
Administer liquids aside from ORS for oral rehydration?102 (75)26 (19)8 (6)58 (63)15 (16)20 (22)0.002
Alter the content of the ORS to improve palatability97 (73)27 (20)9 (7)71 (76)8 (9)15 (16)0.009
Instruct caregivers to administer ORS via a syringe?17 (13)37 (27)81 (60)22 (23)34 (36)38 (40)0.01

Results

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References
  9. Supporting Information

Of the 339 PEM-CRC and PERC members, 15 were excluded (11 did not have valid e-mail addresses, and four were not attending physicians working in North America). Of the 324 eligible participants, 235 (73%) responded (Canada 138/194, 71%; United States 97/130, 75%). Overall, 76% have been in practice at least 5 years, 88% worked in an ED at least 10 hours/week, and 88% did so in a university-based institution. The only difference between groups was that a greater number of PEM-CRC physicians completed a PEM fellowship (88% vs. 55%; p < 0.001). Thirteen surveys had fewer than 95% of the data fields completed.

For nonrespondents, there were no significant differences in years practicing PEM (p = 0.30) or clinical hours worked (p = 0.13), including for part-time employment (p = 0.86). However, they were more likely to work in a nonacademic setting (27% vs. 12%; p = 0.002) and were less likely to have completed a PEM fellowship (51% vs. 70%; p = 0.003).

Oral Rehydration

The oral rehydration therapy (ORT) scenario and responses (Table 1) demonstrate that PERC members reported initiating ORT more frequently than PEM-CRC members in children with moderate dehydration. Although overall use of oral rehydration solution (ORS) as the primary liquid for ORT was high (94%), alternative solutions offered differed between groups (Table 2). Canadian PEM physicians are less likely to offer an alternative solution (31% vs. 14%; p = 0.005) while PEM-CRC members often provide electrolyte sports drink or apple juice.

Table 2.    ORS Alternatives Provided by Survey Respondents Should a Child Refuse the Initial ORT Fluid Offered
 Total (N = 228)PERC (n = 137)PEM-CRC (n = 91)p-value*
  1. Data are reported as n (%).

  2. ORS = oral rehydration solution; ORT = oral rehydration therapy; PEM-CRC = Pediatric Emergency Medicine Collaborative Research Committee; PERC = Pediatric Emergency Research Canada.

  3. *p-values are a comparison between PERC and PEM-CRC responses calculated employing Pearson’s chi-square test. p-value of significance for this table is set at 0.005.

Electrolyte sports drinks69 (30)26 (19)43 (47)<0.001
None55 (24)42 (31)13 (14)0.005
ORS (Pedialyte, Enfalyte, Rehydralyte)50 (22)35 (26)15 (17)0.11
Apple juice45 (20)20 (15)25 (28)0.02
Popsicle34 (15)22 (16)12 (13)0.55
Water21 (9)16 (12)5 (6)0.11
Dilute ORS20 (9)15 (11)5 (6)0.15
Other7 (3)3 (2)4 (4)0.34
Juice6 (3)2 (2)4 (4)0.17
Milk6 (3)6 (4)0 (0)0.04

Overall, 201 of 228 physicians (88%) specify a rate for the administration of ORS, but this practice is more common in Canada (93% vs. 81%; p = 0.01). The median recommended rate was 5.0 mL per 5-minute ORT interval (interquartile range = 5.0–8.9 minutes). Respondents in both countries largely agreed on the importance of specific prerequisites for the discharge of children undergoing ORT (Table 3); however, a greater number of PEM-CRC members considered the availability of 24-hour primary care physician follow-up as important for discharge.

Table 3.    Discharge Criteria Identified as Prerequisite in a 15-Month-Old Undergoing ORT
 Total (N = 228)PERC (n = 137)PEM-CRC (n = 91)p-value*
  1. Data are reported as n (%).

  2. ORT = oral rehydration therapy; PEM-CRC = Pediatric Emergency Medicine Collaborative Research Committee; PERC = Pediatric Emergency Research Canada.

  3. *p-values are a comparison between PERC and PEM-CRC responses calculated employing Pearson’s chi-square test. p-value of significance for this table is set at 0.006.

Parents comfortable with discharge205 (90)125 (91)80 (88)0.41
Ability to tolerate ORT (absence of vomiting and consumption of adequate fluid)201 (88)123 (90)78 (86)0.35
Improved hydration status179 (79)105 (77)74 (81)0.40
Absence of vomiting for > 2 hours85 (37)50 (37)35 (39)0.76
Consumed sufficient volume of ORT solution (50–100 mL/kg over 2–4 hours)81 (36)47 (34)34 (37)0.64
Evidence of return to normal level of activity79 (35)44 (32)35 (39)0.32
Urination during ED stay68 (30)45 (33)23 (25)0.22
Absence of evidence of dehydration60 (26)36 (26)24 (26)0.99
24-hourr primary care follow-up available58 (25)17 (12)41 (45)< 0.001

Antiemetics

Respondents were asked several questions regarding their use of antiemetic agents in toddlers with mild to moderate dehydration and intractable vomiting (defined as persistent vomiting in the ED despite the use of appropriate ORS and ORT techniques). Given such a scenario, members of PEM-CRC indicated that they would routinely administer an antiemetic agent more often than PERC respondents (67% vs. 45%; p = 0.001). Ondansetron was the antiemetic agent most often administered; 100% (90/90) of PEM-CRC members selected it as their agent of choice compared to 107 of 136 (79%) among PERC members (p < 0.001). The route of administration also differed by country, with PEM-CRC members more likely to administer it orally (92% vs. 78%; p = 0.01). Reasons cited for not administering an antiemetic agent included the lack of evidence of clinical benefit (27/104, 26%) and the concern of side effects (19/104, 18%).

Probiotics

Only 35 of 230 PEM physicians (15%) reported that they administer a probiotic ≥ 25% of the time to toddlers with minimal dehydration, and 5 to 10 episodes of diarrhea/day secondary to infectious gastroenteritis. Eighty-two of 223 (37%) stated that the current evidence is sufficiently compelling to routinely recommend probiotics (Table 4). The majority indicated that knowledge of an effective, high-quality probiotic agent, available in North America, would increase the likelihood that they would recommend a probiotic agent. Endpoints of particular importance in making this decision were evidence that the probiotic agent reduces the frequency and duration of diarrhea (83/222, 37%) and the need for health care provider visits within the subsequent 2 weeks (73/222, 33%).

Table 4.    Opinions Regarding the Use of Probiotics
Respondents indicated how strongly they agree with each of the following statements:PERC (n = 134)PEM-CRC (n = 89)p-value*
DisagreeNeither Agree nor DisagreeAgreeDisagreeNeither Agree nor DisagreeAgree
  1. Data are reported as n (%).

  2. PEM-CRC = Pediatric Emergency Medicine Collaborative Research Committee; PERC = Pediatric Emergency Research Canada.

  3. *p-values are a comparison between PERC and PEM-CRC responses calculated employing Pearson’s chi-square test. p-value of significance for this table is set at 0.01.

Evidence that probiotic administration results in a reduction in diarrhea duration by 24 hours among children hospitalized with gastroenteritis is good reason to routinely recommend probiotics to children with gastroenteritis evaluated in the ED.27 (20)56 (42)51 (38)11 (12)47 (53)31 (35)0.18
Knowledge of a high-quality probiotic agent available in North America would increase the likelihood of my recommending the probiotic agent for use in children with gastroenteritis.14 (11)30 (23)89 (67)6 (7)24 (27)148 (67)0.53
Caregiver request for a probiotic agent strongly influences my decision to recommend probiotics.38 (29)53 (40)41 (31)19 (22)28 (32)41 (47)0.07
The absence of a clinical trial conducted in North America using a probiotic agent in children with acute gastroenteritis significantly influences my decision to recommend a probiotic agent.22 (16)45 (34)67 (50)12 (14)26 (29)51 (57)0.56

IV Rehydration

Respondents reported that IV hydration, when necessary, is most often administered as normal saline (0.9% NaCl) fluid bolus (200/216, 93%). Members of PERC reported administering smaller volumes of IV fluids during the initial bolus, over longer periods of time, which they repeat less frequently than PEM-CRC members (Table 5). When IV fluids are administered, PEM-CRC respondents measure electrolytes much less frequently than PERC members. Measuring serum electrolytes is also performed less often by those who administer larger volumes of fluids during the initial bolus (p = 0.03), those who administer fluid boluses more slowly (p < 0.001), and those who repeat the bolus less frequently (p = 0.01).

Table 5.    IV Rehydration Treatment Patterns as Reported by Respondents for a Child With Moderate Dehydration Requiring IV Rehydration
 TotalPERCPEM-CRCp-value*
  1. Data are reported as n (%).

  2. PEM-CRC = Pediatric Emergency Medicine Collaborative Research Committee; PERC = Pediatric Emergency Research Canada.

  3. *p-values are a comparison between PERC and PEM-CRC responses calculated employing Pearson’s chi-square test. p-value of significance for this table is set at 0.01.

Bolus volume (mL/kg), n = 215
 5–1514 (7)13 (10)1 (1)< 0.001
 16–25189 (88)116 (89)73 (86)
 >2512 (6)1 (1)11 (13)
Bolus time period (min), n = 214
 1519 (9)10 (8)9 (11)0.001
 3094 (44)45 (35)49 (58)
 459 (4)5 (4)4 (5)
 6092 (43)70 (54)22 (26)
Bolus repeated frequency (%), n = 214
 ≤25127 (59)102 (78)25 (30)<0.001
 25–7554 (25)20 (15)34 (41)
 >7533 (15)9 (7)24 (29)
Electrolyte frequency (%), n = 221
 ≤2547 (21)8 (6)39 (45)<0.001
 25–7538 (17)16 (12)22 (25)
 >75136 (62)110 (82)26 (30)

Disposition Medications

The majority of respondents indicated that they do not recommend the use of antimotility agents (100%, n = 219), antisecretory agents (100%, n = 219), or zinc (214/217, 99%) to toddlers with frequent nonbloody stools. The BRAT (banana, rice, applesauce, and toast) diet was reported as being recommended by 37% of PEM-CRC and 14% of PERC members (p < 0.001). Overall, 210 of 218 clinicians (96%) indicated that they recommend the empiric use of an antibiotic agent in toddlers with bloody diarrhea < 25% of the time. The provision of an antiemetic agent for use following discharge was reported by 45 of 220 (20%) of physicians, with similar proportions in the United States and Canada (28% vs. 16%, p = 0.07).

Discussion

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References
  9. Supporting Information

This study examined and compared the treatment of acute gastroenteritis as reported by PEM physicians in the United States and Canada in the summer of 2009. This survey is unique in that it evaluated previously unaddressed issues, including use of antiemetics, probiotics, and methods of IV rehydration. The survey data suggest that in keeping with the available evidence, antiemetic use has become routine, while probiotic use remains infrequent despite the publication of several positive meta-analyses and recent guidelines supporting their use.4,14–17 Across the domains evaluated we found that Canadian PEM physicians report practice patterns that are more in keeping with published recommendations1,18 and are less resource-intensive than those of their United States counterparts. Where sufficient evidence is lacking, physicians report broad practice variation. This was observed in the administration of IV rehydration; U.S.-based PEM physicians employ more aggressive regimens, including the administration of larger fluid boluses over shorter periods of time that are repeated more frequently.

Previous practice pattern surveys have focused on the use of ORT,19–22 as it has the greatest degree of supportive evidence.23,24 Nonetheless, in 2002, only 15% of respondents reported almost always or always using ORT in children with moderate dehydration.20 By 2007, this had increased to 39%.19 In the current survey, 47% of PEM-CRC and 76% of PERC respondents indicated that they would initiate oral rehydration as first-line therapy greater than 75% of the time in a similar scenario. Further progress may be difficult as, when provided with information regarding alternative treatment options, a majority of parents chose IV over oral rehydration.25 Evidence about the effectiveness of ondansetron was reported by parents to push them toward selecting ORT.25

During the past decade, six clinical trials supporting the effectiveness of ondansetron in acute gastroenteritis have been published along with a meta-analysis reporting that its use reduced the need for IV fluids (relative risk [RR] = 0.41, 95% CI = 0.27 to 0.95) and the risk of hospital admission (= 0.52, 95% CI = 0.27 to 0.95).26 Recent evidence27 and our survey demonstrate that antiemetic use in children with vomiting has become very common. Overall, the usage rate and the selection of ondansetron as the agent of choice were significantly greater in the United States. We speculate that usage will continue to increase because of evidence of clinical benefit,26 decreasing drug costs, and cost-effectiveness.28

The approach to IV rehydration appears to differ significantly between countries. PEM-CRC members tend to administer larger volumes of IV fluids during the initial bolus, over shorter periods of time, which is repeated more often. Unfortunately, there have been no studies that provide direct evidence to guide clinicians on the volume or duration over which IV rehydration should be performed.29 Lacking an evidence base, the reported practice variation likely represents training, clinical experience, and institutional culture.29

Our survey also found that PEM physicians in the United States report measuring serum electrolytes less frequently. Evidence for their usefulness in clinical decision-making among children with mild to moderate dehydration is limited.29 While the guidelines published by the Centers for Disease Control and Prevention in 2003 do not directly address this topic,1 the influential 1996 practice parameter endorsed by the American Academy of Pediatrics30 recommends measuring electrolyte levels in 1) moderately dehydrated children whose histories or examination features are not consistent with a simple episode of acute gastroenteritis, 2) all severely dehydrated children, and 3) children receiving IV therapy. Similarly, the National Institute for Health and Clinical Excellence recommends that electrolytes be measured in 1) all children requiring IV fluid therapy and 2) when there are symptoms and/or signs suggestive of hypernatremia.29 Guidelines published by the European Society for Paediatric Gastroenterology, Hepatology and Nutrition state that electrolytes should be measured in all children requiring IV rehydration therapy, as the serum sodium value will influence the rate at which rehydration fluids are given.4 While it is unclear as to why electrolytes are performed less often by PEM-CRC members, it may be that most children managed with IV hydration are mildly to moderately dehydrated, with history and physical examination features being consistent with a simple episode of acute gastroenteritis. Thus, their clinical suspicion for an abnormality is low. While not directly evaluated in the survey, the authors are aware that at some institutions, electrolytes are only measured if there is a failure to observe the anticipated clinical response in a short time period; thus, those requiring prolonged IV rehydration and larger fluid volumes are more likely to have electrolytes measured.

The use of probiotics in the outpatient management of pediatric gastroenteritis is uncommon. This appears in large part to be due to a lack of high-quality evidence, particularly when administered to outpatients. The choice of outcomes evaluated to date, duration, and frequency of diarrhea, while important to PEM physicians, does not fully capture the burden of disease, with many physicians indicating that studies evaluating future health care provider visits would be important. Others have reported that, similarly, pediatric health care providers have been reluctant to integrate the use of homeopathic antidiarrheal agents into their treatment regimen for children with gastroenteritis.31 The barriers identified in that survey were similar—the need for a stronger evidence base and efforts to increase awareness and experiential knowledge.

Practice variation between countries is not unique to gastroenteritis, yet it can be very difficult to ascertain the underlying causes. General emergency physicians treating adults have very different practice patterns;32 however, patient outcomes are similar. Differences have also been demonstrated in children, with U.S. patients receiving more of their “usual” problem asthma care in the ED than Canadian patients, highlighting the different roles that EDs play between countries.8 However, Canadian patients tend to spend more time in the ED receiving acute care and are hospitalized less often. The latter observation may reflect administrative differences between the health care systems, with the Canadian system having no financial rewards associated with admission. Alternatively, this finding may relate to inpatient bed shortages and ED overcrowding experiences in the two countries.

The aforementioned differences, and those reported in our survey, may reflect the fact that Canadian physicians are willing to persist longer with ED management in hopes of discharging patients home or that ongoing ED treatment is necessary because of a lack of inpatient hospital beds. Other explanations include conflicting or weak evidence upon which to base treatment decisions, such as the rate of IV rehydration. As it relates to PEM specifically, the subspecialty in Canada is rather in its infancy, with its first certification examination occurring in 2008, while the United States began developing the subspecialty in the 1970s.33,34 Thus, over time as PEM training and the workforce expands in Canada, practice patterns may become increasingly similar.

Limitations

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References
  9. Supporting Information

The main limitations of this work are the response rate, the sampling strategy employed, and the fact that the results only reflect practice patterns in infants and toddlers. While our response rate is superior to those of most published physician surveys (53% to 54%),35,36 the 27% nonresponse rate may have introduced self-selection bias. Nonrespondents were less likely to be fellowship trained and working in academic institutions. Our sampling strategy, which was chosen to optimize our response rate and enable the evaluation of two fairly comparable groups of physicians, may have resulted in sampling bias, as our cohort may not be representative of all emergency physicians, nor the care provided to children who present to general EDs. While the PERC database includes physicians from Canada’s 15 largest institutions where emergency care is provided to children, since certification in PEM is very recent, we do not know what percent of Canadian PEM physicians are members of PERC. The PEM-CRC includes members from over 40 institutions and represents approximately 18% of all members of the American Academy of Pediatrics Section of Emergency Medicine. Thus, PEM-CRC practice patterns may not be generalizable to the larger PEM community, nor to general community EDs where the majority of children are seen.37 We additionally did not restrict the number of respondents per site. This may have biased our responses to reflect practice patterns in institutions with large numbers of respondents. Additionally, as with all surveys, it is difficult to clearly determine what respondents actually do versus what they claim they do. Therefore, response bias may have occurred as some respondents may have answered questions in the way they think the survey wanted them to answer rather than according to their true beliefs and practices. Thus, future studies should include a more representative sample of physicians whose practice patterns are audited prospectively.

Conclusions

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References
  9. Supporting Information

We observed moderate variation in reported practices in the treatment of children with acute gastroenteritis by location of practice within North America. Pediatric emergency physicians frequently administer an antiemetic, most commonly ondansetron, in children with dehydration and intractable vomiting. Nonetheless, many children with moderate dehydration, particularly in the United States, are given IV rehydration. However, given that limited data exist to guide clinicians, the rate and volume of IV fluid administration differs significantly by country of practice. For a variety of reasons, the use of several other therapeutic interventions differs by country. Research evaluating the optimal use of these therapeutic interventions is needed to enable clinicians to make well-informed treatment decisions.

The authors are extremely 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. Samina Ali (Edmonton), Krishna Anchala (Hamilton), Marc Gorelick (Milwaukee), Steven Krug (Chicago), David McGillivray (Montreal), Alan Nager (Los Angeles), Amy Plint (Ottawa), Genie Roosevelt (Denver), David Schnadower (New York), Milton Tenenbein (Winnipeg), and Jennifer Thull-Freedman (Toronto).

References

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References
  9. Supporting Information
  • 1
    King CK, Glass R, Bresee JS, Duggan C. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003; 52:116.
  • 2
    Perlstein PH, Lichtenstein P, Cohen MB, et al. Implementing an evidence-based acute gastroenteritis guideline at a children’s hospital. Jt Comm J Qual Improv. 2002; 28:2030.
  • 3
    Powell EC, Hampers LC. Physician variation in test ordering in the management of gastroenteritis in children. Arch Pediatr Adolesc Med. 2003; 157:97883.
  • 4
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Supporting Information

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References
  9. Supporting Information

Data Supplement S1. Emergency physician gastroenteritis practice pattern survey.

Data Supplement S2. Complete methodology details.

Data Supplement S3. A survey of pediatric emergency physicians - gastroenteritis practice patterns.

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ACEM_960_sm_DataSupplement1.pdf1778KSupporting info item
ACEM_960_sm_DataSupplement2.doc61KSupporting info item
ACEM_960_sm_DataSupplement3.pdf111KSupporting info item

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