Gastroenteritis Care in children under five within the Paediatric ED setting

Name
Joanne Watson 

Role
Trainee Paediatric Advanced Nurse Practitioner 

Place of work
Paediatric Emergency Department, East Lancashire Hospitals NHS Trust  

Background  
Diarrhoea and/or vomiting is a common manifestation of acute gastroenteritis and is a leading cause of emergency attendances in children (Fedorowicz, Jagannath & Carter, 2011).
 
The primary focus in caring for those who attend paediatric ED/UCC is the early detection of dehydration. Tian, Dixon and Gao (2012) highlight that timely interventions will prevent deterioration and reduce admissions; dehydration and gastroenteritis account for 10.4% of emergency admissions.
 
Appropriate fluid challenge, in a timely manner, in order that dehydration or further deterioration of dehydration is prevented is ‘gold standard’. There are however, still variations in practice. An audit using the NICE (2009) five standards was performed over a three-month period to capture those attending ED/UCC under the age of five, with a primary diagnosis of gastroenteritis. The results showed limited, documented compliance with NICE (2009) guidelines; recording of weights, fluid challenges and dehydration scores were found to be particularly poor.
 
Aim  
To develop a care bundle for children attending the ED with gastroenteritis using NICE (2009) standards and introduce within the department to reduce variation and standardise care.
 
Method  
Kotter’s (2012) leading change theory was used to provide structure in adopting and instilling a more proficient way of managing gastroenteritis in the under-fives. Stakeholder involvement, acceptance and support were sought and a teaching package developed to ensure clinical staff compliance. Two “staff Champions” were selected to aid the change process.
 
Evaluation 
Donabedian’s (2005) structure, process and outcome framework was used in evaluating the effectiveness of the change in practice. A re-audit was undertaken on a four-weekly basis with measurement and evaluation of the baseline standards including staff compliance. Appropriateness and length of admissions was evaluated at the end of the pilot phase.
 
Conclusion  
Current practice required a shift towards a more proactive management of gastroenteritis care. The introduction of the bundle has ensured that evidence-based care is being instilled into everyday practice.
 
Three key learning points  
1. Early implementation of a fluid challenge in the ED will prevent further deterioration of the condition due to dehydration.
2. Staff resistance to change makes the implementation of the bundle difficult
3. Staff, parents/carers need to change their perception of the most appropriate fluid challenge required to manage the condition and therefore reduce admissions and facilitate safe discharge.