PEDIATRIC UPDATE
Implementing a Critical Pathway
for Oral Rehydration of Mild to Moderate
Dehydration of Children
Author: Louise P. Martin, RN, BN, Ottawa, Ontario, Canada
Section Editors: Deborah Parkman Henderson, RN, PhD, and
Donna Ojanen Thomas, RN, MSN
Louise P. Martin is Emergency Clinical Educator, Emergency
Department, Childrens Hospital of Eastern Ontario, Ottawa, Ontario,
Canada.
For reprints, write: Louise P. Martin, RN, BN, 401 Smyth, Ottawa,
Ontario, Canada K1H 8L1; E-mail: martin_l@cheo.on.ca.
J Emerg Nurs 2001;27:597-601.
Copyright 2001 by the Emergency Nurses Association.
0099-1767/2001 $35.00 + 0 18/9/119988
doi:10.1067/men.2001.119988
December 2001 27:6
C
ritical pathways (CPs) are one of the many initia-
tives introduced in the past 2 decades to improve
patient care and clinical effectiveness and reduce
variation by standardizing care for a given patient condi-
tion. A CP explicitly states a problem and lists exactly what
activities must occur during a specified period for certain
patient outcomes.1 We present here our implementation of
a CP for diarrhea and vomiting in a pediatric emergency
department, including the 4 phases of the process, the ben-
efits, and what can be learned from the process itself.
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.
Phase 1: assessing and planning
We selected diarrhea and vomiting to be the topic of a CP
because gastroenteritis was a top diagnosis in the emer-
gency department, representing high-volume health care
and social costs for families. We expected that by quickly
initiating care for children with symptoms of gastroenteri-
tis, the need for intravenous therapy would be reduced, the
children would be discharged from the emergency depart-
ment earlier, and hospital admission would be avoided.
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 PEDIATRIC UPDATE/Martin

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
use of oral rehydration therapy (ORT) to treat mild to
moderate dehydration resulting from gastroenteritis.2
A review of hospital records identified sources of variation
in treatment, such as physicians preferences and experi-
ence. For example, some patients were told to take noth-
ing by mouth until the vomiting stopped and then to start
consuming clear fluids such as diluted apple juice. Some
patients received up to 36 hours of intravenous therapy in
the ED observation unit and then were discharged home, if
they were not vomiting, with instructions to consume clear
fluids and to follow a diet consisting of bananas, rice,
applesauce, and tea or toast (the BRAT diet).

598 JOURNAL OF EMERGENCY NURSING 27:6 December 2001


FIGURE 1
Diarrhea and vomiting CP (continued).
The CP was developed by a multidisciplinary team of
nurses, physicians, a dietitian, and the manager from quali-
ty utilization. Monthly meetings were held for 3 months to
develop the content of the CP. We included an intervention
in our CP if evidence existed that it would achieve the best
discharge outcomes. Having members of the CP team with
varied expertise and experience meant that our standards
would be followed by all disciplines. We incorporated the
Canadian Pediatric Society statement for ORT3 (Table 1).
December 2001 27:6
PEDIATRIC UPDATE/Martin
The CP clearly outlines the processes, expected out-
comes, and time frame for care of children with diarrhea
and vomiting with mild to moderate dehydration. It out-
lines inclusion and exclusion criteria that triage nurses use
to decide when to initiate the CP. Children with diarrhea
or diarrhea and vomiting are started on ORT at triage.
The CP flow sheet includes 9 key aspects of care, list-
ed vertically (eg, assessment, medication, and hydration).
The timing of care activities is indicated on horizontal
JOURNAL OF EMERGENCY NURSING 599

TABLE 1
Use of maintenance therapy (Lytren or Pedialyte) in
the emergency department
Rate of rehydration
Mild dehydration: 10 mL/kg/h
Moderate dehydration: 15-20 mL/kg/h
columns. We incorporated charting by exception to elimi-
nate repetitive documentation, giving nurses more time to
educate and care for patients and families.4 Nurses use a
symbol and their initials on the flow sheet to indicate when
an activity is completed () and when there is additional
documentation (*). The flow sheet is shown in Figure 1.
Phase 2: piloting the program
In 1998, the CP was piloted and monitored for 3 months.
The pathway was started by the triage nurse and then con-
tinued by the examination nurse for every child who came
to the emergency department with diarrhea and vomiting
and was mildly or moderately dehydrated. The family
recorded the amount of oral rehydration solution taken by
their child. Nurses provided support and education to the
patient and family.
The literature revealed strong evidence
to support the use of oral rehydration
therapy to treat mild to moderate dehy-
dration resulting from gastroenteritis.
We set up a time line with target start dates and
planned for training in and production of the CP. The clin-
ical educator coached 3 resource nurses for the pilot train-
ing and education, and they in turn taught each of their
nurse colleagues for at least 1 hour. In the end, these flexi-
ble, committed, and motivated resource nurses were key in
getting the nursing staff involved in the change. All nursing,
medical, and allied health professionals were trained in 1
month. The medical director secured physician cooperation.
600
PEDIATRIC UPDATE/Martin
Phase 3: monitoring, reporting, and evaluating
As a result of the CP, ORT instead of intravenous therapy
was initiated for children with mild or moderate dehydra-
tion, as in the following example.
CASE VIGNETTE
A 1-year-old boy who presented at triage with moderate
dehydration was listless, with sunken eyes and decreased
urinary output. The triage nurse started oral hydration
according to the CP, and carefully monitored the patients
intake and output, but remained convinced that the child
would need intravenous therapy. The childs mother con-
tinued giving him the oral rehydration solution, as instruct-
ed. Within an hour, the childs color improved and he
became more active and playful. He voided and drank well
and was discharged after 2 hours with dietary instructions.
His parents were pleased with the result and expressed their
relief that he did not need intravenous therapy.
Quality indicators gave us data showing that care had
improved, and we presented these data to nurses during the
pilot phase to help motivate change.
Our goal was to have the best format for documenta-
tion. The CP form was revised twice in 1 year, incorporat-
ing ideas and concerns from nurses and physicians.
Phase 4: implementing the critical pathway
On April 1, 1999, the diarrhea and vomiting CP was
implemented and became a permanent part of the chart.
Concerns and problems were addressed through feedback
by E-mail, a communications book, and staff meetings.
Compliance with the CP was monitored, and it was
reported that some physicians continued to order the
BRAT diet, even though this diet was no longer recom-
mended by our protocol. We revised a family teaching sheet
on diarrhea and vomiting to describe the expected diet and
feeding schedule with oral rehydration solution. Educating
parents meant that reluctant physicians had less choice
about deviating from the evidence-based practice. Monthly
pizza draws to encourage nurses to start the CP at triage
have proved to be an effective way to remind staff to use the
CP with more patients.
JOURNAL OF EMERGENCY NURSING 27:6 December 2001

FIGURE 2
Inpatients admitted through the emergency department with gastroenteritis.
Benefits of implementing the critical pathway
The CP helped our emergency department improve quali-
ty of care. It provided a means of standardizing patient care
for assessment, diet, treatment, and discharge teaching.
Children received better care and were discharged home
more quickly. Fewer children were admitted to the hospital
with gastroenteritis (Figure 2).
Nurses responded positively: Patient care for gas-
troenteritis is easy to follow on the CP. It is impossible to
forget any care that needs to be provided. It can provide
safe and quality care. It is a good visual tool. They
believed that it provided concise, clear documentation.
Our physicians have identified specific problems for
which more CPs are needed. The CP has given nurses and
physicians another reason to communicate and exchange
information at shift changes and when patients are admit-
ted to inpatient units.
Implementing the diarrhea and vomiting CP has been
a very positive experience both for staff of the emergency
department of the Childrens Hospital of Eastern Ontario
and (especially) for our patients, many of whom now expe-
rience a less intrusive medical intervention. We will no
doubt use this model on a regular basis.
December 2001 27:6
PEDIATRIC UPDATE/Martin
Acknowledgment
We give special thanks to Ms Diane Stephenson, chief nursing
officer, for her support throughout this change process; Dr Lynn
McCleary, clinical scientist, for her encouragement and support;
and Dr Genevive Moineau, emergentologist, for championing
the cause.
REFERENCES
1. Sturch C, Weinstein J. Hospital-to home paths: a tool to ensure
quality, continuity, and cost-effectiveness of care. Presented at
Pathways 2000; 2000 June 26; Toronto, Canada.
2. Ho MS, Glass P, Pinsky PF, Anderson LJ. Rotovirus as a cause of
diarrheal morbidity and mortality in the United States. J Infect
Dis 1988;158:1112-6.
3. Canadian Paediatric Society. Oral rehydration therapy and early
refeeding in the management of childhood gastroenteritis. (CPS
statement). Can J Paediatr 1994;1(5):160-4.
4. Short M. Charting by exception on a clinical pathway. Nurs
Manage 1997;28:45-6.
5. Zander K. Use of variance from clinical paths: coming of age.
Clin Perform Qual Health Care. 1997;5:20-30.
Submissions to this column are welcomed and encouraged.
Contributions can be sent to one of the following:
Deborah Parkman Henderson, RN, PhD
1255 Linda Ridge Rd, Pasadena, CA 91103
310 328-0720 dhendersn@aol.com
Donna Ojanen Thomas, RN, MSN
2822 E Canyon View Dr, Salt Lake City, UT 84109
801 588-2240 pcdthoma@ihc.com.
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