Professional Documents
Culture Documents
C
ritical pathways (CPs) are one of the many initia-
Donna Ojanen Thomas, RN, MSN
tives introduced in the past 2 decades to improve
patient care and clinical effectiveness and reduce
Louise P. Martin is Emergency Clinical Educator, Emergency variation by standardizing care for a given patient condi-
Department, Childrens Hospital of Eastern Ontario, Ottawa, Ontario, tion. A CP explicitly states a problem and lists exactly what
Canada.
activities must occur during a specified period for certain
For reprints, write: Louise P. Martin, RN, BN, 401 Smyth, Ottawa,
Ontario, Canada K1H 8L1; E-mail: martin_l@cheo.on.ca. patient outcomes.1 We present here our implementation of
J Emerg Nurs 2001;27:597-601. a CP for diarrhea and vomiting in a pediatric emergency
Copyright 2001 by the Emergency Nurses Association. department, including the 4 phases of the process, the ben-
0099-1767/2001 $35.00 + 0 18/9/119988 efits, and what can be learned from the process itself.
doi:10.1067/men.2001.119988
The goals of our CP were not only to standardize and
improve care, but also to improve documentation with a
written treatment form that would be used to assess, plan,
deliver, monitor, and evaluate care.
We implemented this CP at a 156-bed tertiary pedi-
atric facility in Ontario, Canada, which serves a broad geo-
graphic area and is a designated regional trauma center. The
emergency department has a 3-bed resuscitation room and
23 examination rooms staffed by 66 nurses. More than
50,000 children and youth are seen each year in the emer-
gency department.
FIGURE 1
Diarrhea and vomiting CP. (This portion of the CP is preceded by a page with the patients information stamp, presenting problem,
physicians signature, date, and time, and inclusion criteria [brief duration of illness, alert and oriented, history shows vomiting and
diarrhea/or diarrhea only, mild to moderate dehydration] and exclusion criteria [chronic conditions, bloody emesis, bilious emesis,
bloody diarrhea, head injury, abdominal pain, resuscitation cases, severe dehydration]. It is followed by a vertical flow sheet noting the
date, time, and serial notations including aspect of care, vital signs and oxygen saturation, and comments.)
The literature revealed strong evidence to support the consuming clear fluids such as diluted apple juice. Some
use of oral rehydration therapy (ORT) to treat mild to patients received up to 36 hours of intravenous therapy in
moderate dehydration resulting from gastroenteritis.2 the ED observation unit and then were discharged home, if
A review of hospital records identified sources of variation they were not vomiting, with instructions to consume clear
in treatment, such as physicians preferences and experi- fluids and to follow a diet consisting of bananas, rice,
ence. For example, some patients were told to take noth- applesauce, and tea or toast (the BRAT diet).
ing by mouth until the vomiting stopped and then to start
FIGURE 1
Diarrhea and vomiting CP (continued).
The CP was developed by a multidisciplinary team of The CP clearly outlines the processes, expected out-
nurses, physicians, a dietitian, and the manager from quali- comes, and time frame for care of children with diarrhea
ty utilization. Monthly meetings were held for 3 months to and vomiting with mild to moderate dehydration. It out-
develop the content of the CP. We included an intervention lines inclusion and exclusion criteria that triage nurses use
in our CP if evidence existed that it would achieve the best to decide when to initiate the CP. Children with diarrhea
discharge outcomes. Having members of the CP team with or diarrhea and vomiting are started on ORT at triage.
varied expertise and experience meant that our standards The CP flow sheet includes 9 key aspects of care, list-
would be followed by all disciplines. We incorporated the ed vertically (eg, assessment, medication, and hydration).
Canadian Pediatric Society statement for ORT3 (Table 1). The timing of care activities is indicated on horizontal
FIGURE 2
Inpatients admitted through the emergency department with gastroenteritis.