Allison Bahm1, Stephen B Freedman2, Jun Guan3, Astrid Guttmann1,3,4. 1. Hospital for Sick Children and the Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada. 2. Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada. 3. Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. 4. Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
Abstract
OBJECTIVE: Acute gastroenteritis (AGE) is a leading cause of pediatric emergency department (ED) visits. Despite evidence-based guidelines, variation in adherence exists. Clinical decision tools can enhance evidence-based care, but little is known about their use and effectiveness in pediatric AGE. This study sought to determine if the following tools-1) pathways/order sets, 2) medical directives for oral rehydration therapy (ORT) or ondansetron, and 3) printed discharge instructions-are associated with AGE admission and ED revisits. METHODS: This was a retrospective population-based cohort study of all children 3 months-18 years with an AGE ED visit in Ontario, Canada, from 2008 to 2010, using linked survey and health administrative databases. Logistic regression models associating clinical decision tools (CDTs) with hospitalizations and revisits controlling for hospital and patient characteristics were employed. RESULTS: Of the 57,921 patient visits during the study period, there were 2,401 hospitalizations (4.2%). A total of 55,520 patients were discharged from the ED, with 2,378 (4.3%) experiencing a 72-hour return visit. In adjusted models, none of the tools were significantly associated with admission. Medical directive for ORT was associated with lower return visit rates (adjusted odds ratio [aOR] = 0.86, 95% confidence interval [CI] = 0.79-0.94] and printed discharge instructions with higher return visits (aOR = 1.33, 95% CI = 1.08-1.65); pathways/order sets and medical directives for ondansetron had no association. CONCLUSIONS: Admissions in children with AGE are not associated with the presence of CDTs. While ORT medical directives are associated with lower ED revisits, printed discharge instructions have the opposite effect. The simple presence/absence of decision support tools does not guarantee improved clinical outcomes.
OBJECTIVE: Acute gastroenteritis (AGE) is a leading cause of pediatric emergency department (ED) visits. Despite evidence-based guidelines, variation in adherence exists. Clinical decision tools can enhance evidence-based care, but little is known about their use and effectiveness in pediatric AGE. This study sought to determine if the following tools-1) pathways/order sets, 2) medical directives for oral rehydration therapy (ORT) or ondansetron, and 3) printed discharge instructions-are associated with AGE admission and ED revisits. METHODS: This was a retrospective population-based cohort study of all children 3 months-18 years with an AGE ED visit in Ontario, Canada, from 2008 to 2010, using linked survey and health administrative databases. Logistic regression models associating clinical decision tools (CDTs) with hospitalizations and revisits controlling for hospital and patient characteristics were employed. RESULTS: Of the 57,921 patient visits during the study period, there were 2,401 hospitalizations (4.2%). A total of 55,520 patients were discharged from the ED, with 2,378 (4.3%) experiencing a 72-hour return visit. In adjusted models, none of the tools were significantly associated with admission. Medical directive for ORT was associated with lower return visit rates (adjusted odds ratio [aOR] = 0.86, 95% confidence interval [CI] = 0.79-0.94] and printed discharge instructions with higher return visits (aOR = 1.33, 95% CI = 1.08-1.65); pathways/order sets and medical directives for ondansetron had no association. CONCLUSIONS: Admissions in children with AGE are not associated with the presence of CDTs. While ORT medical directives are associated with lower ED revisits, printed discharge instructions have the opposite effect. The simple presence/absence of decision support tools does not guarantee improved clinical outcomes.
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Authors: Stephen B Freedman; Cindy G Roskind; Suzanne Schuh; John M VanBuren; Jesse G Norris; Phillip I Tarr; Katrina Hurley; Adam C Levine; Alexander Rogers; Seema Bhatt; Serge Gouin; Prashant Mahajan; Cheryl Vance; Elizabeth C Powell; Ken J Farion; Robert Sapien; Karen O'Connell; Naveen Poonai; David Schnadower Journal: Pediatrics Date: 2021-05-20 Impact factor: 9.703
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Authors: Naveen Poonai; Elizabeth C Powell; David Schnadower; T Charles Casper; Cindy G Roskind; Cody S Olsen; Phillip I Tarr; Prashant Mahajan; Alexander J Rogers; Suzanne Schuh; Katrina F Hurley; Serge Gouin; Cheryl Vance; Ken J Farion; Robert E Sapien; Karen J O'Connell; Adam C Levine; Seema Bhatt; Stephen B Freedman Journal: JAMA Netw Open Date: 2021-04-01