Impact of a Standardized Clinical Pathway for Suspected and Confirmed Ileocolic Intussusception

Abstract

Introduction: Clinical pathways for specific diagnoses may improve patient outcomes, decrease resource utilization, and diminish costs. This study examines the impact of a clinical pathway for emergency department (ED) care of suspected and confirmed pediatric ileocolic intussusception. Methods: Our multidisciplinary team designed an intussusception clinical pathway and implemented it in a tertiary children’s hospital ED in October 2016. Process measures included the proportion of patients who underwent abdominal radiography, had laboratory studies, received antibiotics, or required admission following reduction of intussusception. The primary outcome measure was the cost per encounter. Balancing measures included unplanned ED visits within 72 hours of discharge. Data analyzed compared 24 months before and 21 months following pathway implementation. Results: After pathway implementation, the use of abdominal radiography in patients with suspected intussusception decreased from 50% to 12%. In patients with confirmed intussusception, laboratory studies decreased from 58% to 25%, antibiotic use decreased from 100% to 2%, and hospital admissions decreased from 100% to 12%. The average cost per encounter for confirmed intussusception decreased from $6,724 to $2,975. There was a small increase in unplanned returns to the ED within 72 hours but no increase in readmissions after pathway implementation. Conclusion: Implementation of a standardized ED pathway for the management of suspected and confirmed pediatric ileocolic intussusception is associated with a reduction in abdominal radiographs, improved antibiotic stewardship, reduction in laboratory studies, fewer inpatient admissions, and decreased cost, with no compromise in patient safety.

Improving Care for Children with Bloody Diarrhea at Risk for Hemolytic Uremic Syndrome

“…Likewise, pathways for intussusception and asthma led to similar decreases in hospital admission. 14,15 There was no change in ED returns, resulting in hospital admission within 72 hours, indicating that discharge from the ED was safe for patients. Only three had an STEC infection among the eight children who were initially discharged and subsequently admitted within 72 hours.…”

“…Likewise, pathways for intussusception and asthma led to similar decreases in hospital admission. 14,15…”

Intestinal intussusceptions in children population

“…Another common cause of pediatric intussusception is infectious etiology resulting in mesenteric lymphadenopathy [3]. A viral infection with accompanying hyperplasia of Peyer's patches and hypermobility has also been suggested as pathogenesis [10,11]. Approximately 30% of cases before intussusception had a viral disease [3].…”

“…Children with intussusception often present with nonspecific complaints, such as abdominal pain, fussiness, and emesis. These symptoms can make the diagnosis challenging [10]. The development of symptoms depends on the degree of strangulation and obstruction of the bowel [5].…”

“…Many studies have shown that conventional abdominal X-ray has a range of sensitivity and specificity much lower than that of ultrasound, which is very sensitive and specific with a high negative predictive value (99.0% -99.7%). [10,18,19,20]. Plain abdominal X-rays and computerised tomography are no longer commonly used to diagnose intussusception, and the exceptional use of contrast studies has been described [2].…”