Implementation of Clinical Pathways for Pediatric Patients with

Acute Diarrhea and Their Therapy Management in a Hospital

Setting: A Systematic Literature Review

Norman Dyanto and Diana Laila Ramatillah

Faculty of Pharmacy, University of 17 Agustus 1945, Jakarta 14350, Indonesia

Keywords: Clinical Pathway, Acute Diarrhea, Gastroenteritis, Pediatric, Treatment.

Abstract: Clinical pathways, standardized care plans based on best clinical practices, aim to improve care quality and

consistency for specific patient groups, including those with diarrhea or Acute Gastroenteritis (AGE).

Pediatric emergency departments frequently encounter AGE cases, making it essential to streamline care. This

systematic literature review, following PRISMA guidelines, investigated the impact of clinical pathway

implementation on hospital stays and treatment outcomes for pediatric diarrhea patients. Out of 50 studies

retrieved from databases like Google Scholar and Scopus, seven met the criteria, primarily from the USA,

Egypt, and Indonesia. The analysis demonstrated a significant reduction in hospital stays (χ² = 55.79, P <

0.001), along with decreased intravenous fluid usage (15% to 9%) and reduced healthcare costs (USD 599 to

USD 410) post-implementation. In conclusion, clinical pathways not only shorten hospital stays but also

enhance diagnosis, treatment, and overall management of childhood diarrhea, emphasizing their crucial role

in pediatric care.

1 INTRODUCTION

A clinical pathway is an evidence-based

interdisciplinary care plan for a specific patient

population to reduce unnecessary waiting times in

treatment while simultaneously enhancing patient

satisfaction and clinical outcomes (Siswanto and

Chalidyanto, 2020). Clinical pathways have been

developed to improve the quality and standardization

of caring for specific diseases, including diarrhea.

In developing countries, diarrhea is a severe

public health issue, especially among the youth

population. Diarrhea continues to be the second

leading cause of death in children under the age of

five worldwide. Approximately two billion

individuals suffer from diarrhea annually, including

approximately one and a half million children under

the age of five. Children under five years of age are

more susceptible to diseases that compromise the

immune system's ability to combat pathogens and are

at a higher risk of contracting infections that cause

acute diarrhea, including some viruses and parasites

that do not induce diarrhea in healthier children

(Merry et al. 2019).

Many hospitals have clinical pathways, but they

have not been effectively implemented, rendering

clinical pathways seemingly ineffective for patient

therapy. This research aims to determine the

effectiveness of implementing clinical pathways in

pediatric patients with acute diarrhea in relation to

medication usage and length of hospital stay

(Siswanto and Chalidyanto, 2020). The clinical

pathway is used in hospitals and various healthcare

organizations across many parts of the world,

including Asia (Aniza et al., 2016). It is utilized as an

auditing and re-auditing tool and for quality assurance

purposes (Wetherill et al., 2016).

Implementing clinical pathways directly affects

the quality of healthcare services and patient safety

(Buchert and Butler, 2016). Healthcare service

quality can be enhanced by applying clinical

pathways (Mater and Ibrahim, 2014). Fewer

complications may occur in certain disease cases

when clinical pathways are implemented in hospitals

(Aniza et al., 2016).The implementation of clinical

pathways can reduce readmission rates and healthcare

costs (Buchert and Butler, 2016) and even improve

patient satisfaction (Cudre et al., 2016; Wetherill et

al., 2016).The patient feels satisfied and secure

Dyanto, N. and Ramatillah, D.

Implementation of Clinical Pathways for Pediatric Patients with Acute Diarrhea and Their Therapy Management in a Hospital Setting: A Systematic Literature Review.

DOI: 10.5220/0012585300003821

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 4th International Seminar and Call for Paper (ISCP UTA ’45 JAKARTA 2023), pages 175-181

ISBN: 978-989-758-691-0; ISSN: 2828-853X

175

because the doctor can elucidate the treatment

particulars provided to the patient as outlined in the

clinical pathway (Cudre et al., 2016). Patient safety

can also be enhanced by implementing the clinical

pathways (Asmirajanti et al., 2018).

2 METHOD

This research conducted a comprehensive literature

review, guided by the PRISMA (Preferred Reporting

Items for Systematic Review and Meta-Analyses)

methodology, to investigate the optimal

implementation of clinical pathways for emergency

care of pediatric patients with acute diarrhea in

hospital settings. The study commenced by

formulating specific research questions to guide the

inquiry. The search for relevant literature was

conducted within a defined timeframe, spanning from

May 2023 to July 2023, and encompassed a range of

reputable electronic databases, including Google

Scholar, Scopus, Springer, and Google.

In the first phase of the literature review, the

research team diligently scoured the selected

databases for articles published in both English and

Indonesian between 2017 and 2023. Their focus was

on identifying literature related to the management of

acute diarrhea in pediatric patients treated in hospital

environments, with a particular emphasis on the

implementation of therapeutic approaches.

Subsequently, in the second phase, the initial pool of

50 identified literary works underwent a rigorous

evaluation process, wherein articles were assessed for

their suitability based on predefined inclusion and

exclusion criteria. While the specific criteria were not

explicitly detailed in the provided text, standard

factors typically considered include relevance to the

research questions, research methodology quality,

and publication date.

Overall, this research methodically applied

PRISMA guidelines to meticulously select and

analyze pertinent literature, aiming to shed light on

the most effective strategies for implementing clinical

pathways in the emergency care of pediatric patients

experiencing acute diarrhea in a hospital setting. The

following criteria were used to determine what could

and could not be included in these articles:

Inclusion Criteria:

1. The selected article is one that discusses the

application of clinical pathways in pediatric

patients with acute diarrhea and its effectiveness.

2. The full-text version of the selected article has

been published in English and Indonesian.

3. The article was published between 2017 and

2023

Exclusion Criteria:

1. Articles are not focused on the clinical pathways

of acute diarrhea.

2. Articles discussing the clinical pathways of

diarrhea with complications related to cancer,

autoimmune diseases, and/or HIV/AIDS.

Figure 1: Scientific Article Selection Process.

Table 1: Pervious Research.

NO TITLE RESULTS

Effect of A

Clinical Pathway

Application on

Outcome of

Children Having

Diarrheal

Diseases

Children with diarrhea

following a clinical pathway

had fewer complications,

shorter hospital stays, and fewer

readmissions compared to those

receiving routine care.

Impact of Patient

Race/Ethnicity on

Emergency

Department

Management of

Pediatric

Gastroenteritis in

the Setting of a

Clinical Pathway

Among 30,849 ER visits for

AGE/dehydration, patients were

NH-White (18.0%), NH-Black

(57.2%), Hispanic (12.5%), and

NH-other (12.3%). Multi-

variable regre-ssion showed

other NH patients were more

likely to receive ondansetron.

Black, Hispanic, and other NH

patients were less likely to

receive IV fluids or be

hospitalized. NH-Black and

Hispanic patients had shorter

LOS without significant differ-

rences in return visits to ED.

Clinical Pathway

Produces

Sustained

Improvement in

Acute

Gastroenteritis

Care

Implementation of the clinical

pathway that emphasized oral

rehydration therapy and

Ondansentron. It reduced the use

of IV fluids and LOS in children

with Acute Gastroenteritis

(AGE) in pediatric ED.

The Effect of

Clinical Pathway

197 patients com

leted the

clinical pathway. 60.91% had

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NO TITLE RESULTS

Compliance on

Reducing Length

of Stay

diagnostic exams, and 88.32%

received therapy. No significant

correlation (p > 0.05) existed

between diagnostic or treatment

compliance and patient

hospitalization length.

Reduction in

Resources and

Cost for

Gastroenteritis

Through

Implementation

of Dehydration

Pathway

A total of 7,145 patients met the

inclusion criteria with a median

age of 17 months. IV fluid usage

decreased from an average of

15% to 9% after implementation.

The average cost of healthcare-

related treatment episodes

decreased from USD 599 to

USD 410. As a trade-off, there

was an increase in ED length of

stay, admission rate, and revisit

rate.

Evaluation of a

Nurse-Initiated

Acute

Gastroenteritis

Pathway in the

Pediatric

Emergency

Department

Among 643 patients, 392

received nurse-initiated care.

They had 10.2% less IV fluid use

(OR: 0.43; 95% CI: 0.27-0.68)

and 7.4% fewer laboratory tests

ordered (OR: 0.64; 95% CI:

0.43-0.94). Nurse-initiated care

led to a 46-minute faster

discharge after provider

examination (P < .001), reducing

overall length of stay (LOS) by

40 minutes (P < .001).

The Effectiveness

of Clinical

Pathway

Implementation

for Pediatric

Patients with

Acute

Gastroenteritis

(GEA) and

Dehydration

Treated Inpatient

at Permata Bekasi

Hospital

Before the clinical pathway,

more patients received

symptomatic

antipyretic/analgesic therapy

(43.3%), antiemetics (47.5%),

and zinc (48.9%). Afterward, the

percentages were 29.8%, 54.6%,

and 64.5%, respectively.

Hospitalization duration

decreased after the clinical

pathway (P < 0.000). Single

antibiotic use (44.7%) or no

antibiotics (53.2%) increased

post-pathway, compared to

before (35.5% and 17.7%).

Ceftriaxone usage was highest

both before (24.1%) and after

(33.3%) the pathway. Clinical

outcomes (discharge/recovery)

showed no significant difference

(P = 1.000). Overall, the clinical

pathway at Permata Bekasi

Hospital improved antibiotic

rationality, reduced antibiotic

use, and shortened hospital stays

without affecting clinical

outcomes for children with GEA

and dehydration.

3 RESULTS

The first step in conducting this systematic literature

review is searching for relevant articles published in

English and Indonesian between 2017 and 2022. The

provided data focuses on implementing clinical

pathways and outcomes in pediatric patients with

acute diarrhea. Subsequently, 50 publications are

evaluated using inclusion and exclusion criteria,

resulting in 7 selected articles of interest.

A study conducted in the Pediatric Department

affiliated with Beni Suef University Hospital and

General Beni Suef Hospital, Egypt, revealed that 90

pediatric patients suffering from diarrhea showed a

highly significant statistical difference between the

study group and the control group regarding hospital

stay, with x2 = 55.79 at a level of P < 0.001. There

was also a statistically significant difference between

the study and control groups regarding hospital

readmission after discharge, with x2 = 25.74 at P <

0.000003. Furthermore, there was a highly significant

statistical difference between the study group and the

control group regarding diarrhea complications in

pediatric patients with diarrhea following the

implementation of a clinical pathway at a level of P <

0.001. Lastly, there was a highly significant statistical

difference between the group studied before and after

the clinical pathway implementation concerning the

physical examination of diarrhea in pediatric patients

suffering from diarrhea, with a level of P < 0.001

(Merry et al. 2019).

A study conducted at the Children’s Hospital of

Philadelphia involving 30,849 Emergency

Department (ED) patients meeting inclusion criteria

for visits by children aged six months to 18 years with

ESI levels 3 to 5 indicated cases of AGE/dehydration.

Out of the 30,849 ED visits, there were 25,784 unique

patients. The racial/ethnic composition of children

included 5,545 (18.0%) NH-White, 17,650 (57.2%)

NH-Black, 3,867 (12.5%) Hispanic, and 3,787

(12.3%) NH-others. NH-Black, Hispanic, and NH-

other patients had shorter ED LOS compared to NH-

White patients (adjusted coefficients [95% CI] = -

21.35 [-25.90 to -16.79], -11.38 [-17.22 to -5.55], and

-6.19 [-11.91 to -0.47], respectively). When

compared to NH-White patients, NH-Black,

Hispanic, and NH-other patients were less likely to be

hospitalized (aOR [95% CI] = 0.54 [0.45 to 0.64],

0.62 [0.49 to 0.78], 0.76 [0.61 to 0.94]). There was no

significant racial/ethnic difference in 72-hour return

visits. The mixed-effects multivariable general linear

regression, which controlled for age, gender, triage

acuity, payer, and language, revealed that, compared

to NH-White patients, NH-Other patients were more

Implementation of Clinical Pathways for Pediatric Patients with Acute Diarrhea and Their Therapy Management in a Hospital Setting: A

Systematic Literature Review

177

likely to have received ondansetron (adjusted odds

ratio [95% CI] = 1.30 [1.17 to 1.43]). NH-Black,

Hispanic, and NH-Other patients were significantly

less likely to have received IVF (0.59 [0.53 to 0.65];

0.74 [0.64 to 0.84]; 0.74 [0.65 to 0.85]) or to have

been hospitalized (0.54 [0.45 to 0.64]; 0.62 [0.49 to

0.78]; 0.76 [0.61 to 0.94] (Congdon et al., 2021).

A study conducted in the Division of Pediatric

Emergency Medicine at Seattle Children's Hospital

revealed 30,519 patients who met the specified

criteria. There was no significant difference between

the groups before and after the clinical pathway

implementation regarding age, gender, or

race/ethnicity. The group with the implementation of

the clinical pathway showed a reduction in the length

of stay in the emergency department, and the

immediate provision of oral rehydration

demonstrated significant data. There were challenges

in implementing the clinical pathway, including

opinions and practices that favored IV fluid

administration over oral rehydration therapy (Rutman

et al., 2017).

In a study conducted at a private hospital in

Surabaya, Indonesia, there were 197 patients whose

clinical pathways had been fully completed. In total,

60.91% of cases were collected for diagnostic

examinations and 88.32% for therapy. The clinical

journey and duration of patient hospitalization

(combined = p > 0.05) did not correlate with patient

compliance with diagnostic examinations (p > 0.05)

or treatment (p > 0.05). The severity of the patient's

illness is just one of several variables contributing to

the patient's length of stay. Compliance with the

clinical pathway did not contribute to a shorter

hospitalization period in this study (Siswanto and

Chalidyanto, 2020).

A study conducted on 7,145 patients at Boston

Children's Hospital found that the use of IV fluids

decreased from an average of 15% to 9% following

implementation. The average episode cost of

healthcare related to treatment decreased from $599

to $410. As a trade-off, there was an increase in ED

length of stay, admission rates, and revisit rates. The

implementation of Evidence-Based Guidelines

(EBG) for patients with gastroenteritis resulted in a

reduction in the frequency of IV administration,

shorter inpatient stays, and lower healthcare costs

(Creedon et al., 2020).

A study conducted at Children's National Medical

Center, Washington, USA, out of 643 patients, 392

received nurse-initiated care. The proportion of

intravenous fluids used was 10.2% lower (odds ratio

[OR], 0.43; 95% confidence interval [CI], 0.27-0.68)

and laboratory test orders were 7.4% lower (OR, 0.64;

95% CI, 0.43-0.94) in patients receiving nurse-

initiated care. Discharge time after provider check-up

was 46 minutes less in the nurse-initiated care group

(P < 0.001), resulting in an overall reduction in LOS

of 40 minutes (P < 0.0019) (Carson et al., 2017).

In a research conducted at Permata Hospital,

Bekasi, Indonesia, there were 282 pediatric patients

with Gastroenteritis (GEA) and dehydration (141

patients before the clinical pathway and 141 after the

clinical pathway). The gender distribution of patients

before (52.5%) and after (66.7%) the clinical pathway

showed the highest prevalence of male patients, with

the highest age range being 1-4 years before the

clinical pathway (59.6%) and after the clinical

pathway (50.4%). The most common comorbidity

with GEA was typhoid fever before the clinical

pathway (48.2%) and after the clinical pathway

(36.2%), with the highest degree of dehydration being

moderate dehydration before the clinical pathway

(51.8%) and after the clinical pathway (63.1%). There

was a difference in the number of patients who

received symptomatic antipyretic/analgesic therapy

before the clinical pathway (43.3%) and after the

clinical pathway (29.8%), antiemetics before the

clinical pathway (47.5%) and after the clinical

pathway (54.6%), as well as zinc before the clinical

pathway (48.9%) and after the clinical pathway

(64.5%). The length of hospital stays for patients after

the clinical pathway decreased compared to before

the implementation of the clinical pathway (P-value

0.000). After the implementation of the clinical

pathway, the use of a single antibiotic increased

(44.7%), or no antibiotics were given (53.2%)

compared to before the clinical pathway (35.5% and

17.7%), with ceftriaxone being the most common

antibiotic before (24.1%) and after (33.3%) the

clinical pathway. The clinical outcomes of patients

before and after the clinical pathway allowed for

discharge/recovery (P-value 1.000). The

implementation of the clinical pathway at Permata

Bekasi Hospital for pediatric patients with

gastroenteritis and dehydration improved antibiotic

rationalization, reduced antibiotic utilization, and

decreased the length of hospital stay without affecting

clinical outcomes (Adiwisastra et al., 2019).

4 DISCUSSION

The results of a systematic literature review of 7

selected articles reveal a significant correlation

between the implementation of clinical pathways and

the length of hospital stay for patients visiting the

Emergency Department (ED) or admitted to inpatient

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units. Several studies conducted in the ED on children

with acute diarrhea indicate that implementing

clinical pathways yields better outcomes in terms of

length of hospital stay and patient outcomes upon

discharge. Some studies even report that the

implementation shortens the ED stay and reduces the

treatment costs for patients treated using clinical

pathways.

This systematic literature review is conducted by

comparing the length of hospital stays before and

after the implementation of a clinical pathway. The

results obtained from each study conducted in various

countries indicate that using standardized clinical

pathways reduces the duration of treatment and yields

better outcomes by preventing patient deterioration

and excessive cost utilization.

Diarrhea still ranks as the second leading cause of

death among children under the age of five

worldwide. Approximately two billion people are

afflicted with diarrhea each year, with 1.9 million of

them being children under the age of 5 (Merry et al.,

2019). The term "diarrhea" originates from the Greek

language, meaning "to flow," a term used to describe

this condition. Symptoms of diarrhea include an

increased frequency of bowel movements or changes

in stool consistency, both of which may be attributed

to disruptions in digestion, absorption, and secretion

(Hockenberry et al., 2017; Sharma, 2013). In

children, diarrhea can be either acute or chronic, with

varying degrees of severity, ranging from mild to

moderate to severe. Mild diarrhea typically resolves

independently without treatment within 1 or 2 days.

In cases of severe diarrhea, a child may have

persistent watery stools, exhibit symptoms of fluid

and electrolyte imbalance, experience cramps,

become highly irritable, and be difficult to comfort.

Viruses in developed countries are the primary cause

of most diarrhea cases, resulting in over 1.5 million

outpatient visits and 200,000 hospitalizations yearly

(Fleisher, 2014; Hockenberry and Wilson, 2015). The

prevalence of diarrhea in Indonesia, especially acute

diarrhea, remains relatively high (Kemenkes, 2017).

The primary goal in managing acute diarrhea

includes assessing fluid and electrolyte imbalances.

Oral Rehydration Solution (ORS) is one of the

primary treatments for diarrhea worldwide because it

is more effective, safer, less painful, and less

expensive than intravenous rehydration (IV). Infants

and children treated for acute diarrhea and initial

dehydration are first administered Oral Rehydration

Solution (ORS), followed by maintenance fluid

therapy and appropriate dietary measures. Diarrhea

treatment involves fluid replacement, resuming

feeding, and monitoring infants and children closely.

Therefore, it is crucial to develop a clinical pathway

for delivering healthcare services (El Baz, 2017).

The Clinical Pathway has been collaboratively

developed by nurses, doctors, physical and

occupational therapists, technicians, pharmacists, and

other staff members involved in patient care

(Chungyang, 2011). A Clinical pathway is a tool for

a multidisciplinary care plan that outlines the

essential steps required to treat patients with specific

diagnoses, depicting patient care (Chungyang, 2011;

Hollak et al., 2013). It is based on clinical pathway

guidelines that optimize clinical outcomes while

maximizing clinical efficiency. The use of clinical

pathways has been shown to reduce patient length of

stay, enhance interdisciplinary communication, and

improve patient knowledge and self-awareness

(Adiong, 2014; Hinkle et al., 2014). Clinical

pathways represent a new approach to patient care,

meeting many demands of clinical practice, and their

enhancement allows for continuous evaluation and

helps in stimulating research (Leigh and Resnick,

2014; Pirog et al., 2015). The implementation of

clinical pathways in healthcare services has been

proven to enhance patient outcomes, including

hospitalization duration, treatment continuity, and

service quality. Implementing clinical pathways for

long-term hospitalizations will reduce patient risk,

disability, and unnecessary costs (Merry et al., 2019;

Piazza, 2015).

The primary objective of a clinical pathway is to

enhance the quality of healthcare services by

improving patient treatment outcomes, ensuring

patient safety, increasing patient satisfaction,

optimizing resource utilization, facilitating effective

communication among healthcare service team

members and with patients and their families, and

minimizing unwarranted variations in patient care

and length of stay. Prolonged hospitalization

(Carman, 2016; Huiskes et al., 2012). The treatment

process can be coordinated through role coordination

and the sequence of activities within a

multidisciplinary care team, providing

documentation to patients and their relatives,

monitoring and evaluating variations and outcomes,

and identifying appropriate resources (Lux, 2012).

In Jakarta Teaching Hospital, diarrhea in

children ranks fourth out of 10 major diseases that

require inpatient care in both the Emergency

Department (ED) and inpatient units. In this study,

the authors conducted interviews with the clinical

pathway team leader, pediatric specialist doctor, ED

coordinator, and nursing coordinator. The interview

with the clinical pathway team leader explained that

the clinical pathway implemented in this hospital was

Implementation of Clinical Pathways for Pediatric Patients with Acute Diarrhea and Their Therapy Management in a Hospital Setting: A

Systematic Literature Review

179

developed based on pediatric clinical practice

guidelines and had been discussed in meetings

involving the medical committee, nursing committee,

pharmacists, and nutrition experts to establish

integrated care services. The evaluation of the clinical

pathway implementation revealed that patients

treated using the clinical pathway had a significantly

shorter length of stay compared to those who did not

use the clinical pathway. An interview with a

pediatric specialist reveals that clinical pathways are

used to provide care for toddlers and children

suffering from diarrhea. However, in some cases, this

cannot be applied, such as when patients with the

same diagnosis undergo drastic changes in their

condition. In these instances, the clinical pathway is

not employed in delivering care. An interview with

the emergency department coordinator reveals that

clinical pathways can be implemented and utilized in

the initial management when patients arrive at the

emergency unit. This facilitates the determination of

therapy and reporting to the pediatric specialist if the

patient continues to be hospitalized. The nursing

coordinator states that the implementation of a

clinical pathway facilitates other healthcare

professionals in providing patient orientation, shift

handovers, querying the sequence of doctor therapies,

and evaluating the performance of staff in delivering

patient care, thus ensuring that patients treated for

acute diarrhea receive the best possible nursing care

as outlined in the clinical pathway. Therefore, based

on interviews with the relevant unit, it can be

concluded that the implementation of the clinical

pathway has a significant impact on patient care,

reducing the length of hospital stays through standard

treatment that yields better outcomes for infants and

children with diarrhea.

5 CONCLUSION

The implementation of clinical pathways in various

health conditions has resulted in a reduction in the

length of hospital stays and therapy costs. These

findings suggest that implementing clinical pathways

offers better therapy than those without clinical

pathways by enhancing the value of care through a

reduction in hospital stay duration, costs, treatment,

and resource utilization for patient therapy. It is

crucial for future research to consider policies that

advocate for the utilization of clinical pathways by

clinicians and healthcare professionals in the

treatment of children with diarrhea or other cases,

aiming to provide better outcomes for patients. The

results of a systematic literature review of seven

selected articles reveal the impact of implementing

clinical pathways on the length of hospital stays for

children with acute diarrhea.

ACKNOWLEDGEMENTS

The researcher extends appreciation to the authors,

researchers, mentors, and healthcare professionals

whose collective efforts have contributed to the

creation of this systematic literature review.

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