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
Proceedings Copyright © 2024 by SCITEPRESS Science and Technology Publications, Lda.
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
1
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.
2
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.
3
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.
4
The Effect of
Clinical Pathway
197 patients com
p
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.
5
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.
6
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).
7
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.
REFERENCES
Siswanto, M. and Chalidyanto, D., 2020. The Effect of
Clinical Pathway Compliance on Reducing Length of
Stay. Jurnal Administrasi Kesehatan Indonesia, 8 (1),
hal.79-90.
Merry, B.F., Ibrahim, I., and Morsy, M.A., 2019. Effect of
A Clinical Pathway Application on Outcome of
Children Having Diarrheal Diseases. International
Journal of Novel Research in Healthcare and Nursing,
6 (1), pp.589-600.
Aniza, I. et al., 2016. Implementation of Clinical Pathways
in Malaysia: Can Clinical Pathways Improve the
Quality of Care? International Medical Journal, 23(1),
pp. 47-50.
Wetherill, C. V. et al., 2016. Implementation of A Care
Pathway for Infantile Hypertrophic Pyloric Stenosis
Reduces Length of Stay and Increases Parent
Satisfaction. International Journal of Care
Coordination, 18(4), pp. 78–84.
Buchert, A. R. and Butler, G. A., 2016. Clinical Pathways:
Driving High Reliability and High-Value Care.
Pediatric Clinics, 63(2), pp. 317–328. doi:
http://dx.doi.org/10.1016/j.pcl.2015.12.005.
Mater, W. and Ibrahim, R., 2014. Delivering Quality
Healthcare Services Using Clinical Pathways.
International Journal of Computer Applications, 95 (1),
pp. 5–8.
Cudre, L. et al., 2016. Implementation of A Visceral
Surgery Clinical Pathway: Evaluating Patient
Satisfaction with Information, Safety and Involvement
in Care. International Journal of Care Coordination,
18(4), pp. 93–99.
Asmirajanti, M. et al., 2018. Clinical Care Pathway
Strenghens Interprofessional Collaboration and Quality
of Health Service: A Literature Review. Enfermería
Clínica, 28 (Supplement 1), pp. 240–244.
Congdon, M., Schnell, S.A., Gentile, T.L., Faerber, J.A.,
Bonafide, C.P., Blackstone, M.M. and Johnson, T.J.,
2021. Impact of Patient Race/Ethnicity on Emergency
Department Management of Pediatric Gastroenteritis in
the Setting of A Clinical Pathway. Acad Emerg Med,
28, pp. 1035–1042.
ISCP UTA ’45 JAKARTA 2023 - THE INTERNATIONAL SEMINAR AND CALL FOR PAPER (ISCP) UTA ’45 JAKARTA
180
Rutman, L., Klein, E.J. and Brown, J.C. 2017. Clinical
Pathway Produces Sustained Improvement in Acute
Gastroenteritis Care. Pediatrics, 140 (4): e20164310.
Creedon, J.K., Eisenberg, M., Monuteaux, M.C.,
Samnaliev, M. and Levy, J. 2020. Reduction in
Resources and Cost for Gastroenteritis Through
Implementation of Dehydration Pathway. Pediatrics,
146 (1): e20191553.
Carson, R.A., Mudd, S.S. and Madati, P.J. 2017. Evaluation
of a Nurse-Initiated Acute Gastroenteritis Pathway in
the Pediatric Emergency Department. Journal of
Emergency Nursing, 43 (5), pp. 406-412.
Adiwisastra, N.G., Arozal, W. dan Utami, H. 2019.
Efektivitas Implementasi Clinical Pathway pada Pasien
Anak Gastroenteritis Akut (GEA) dengan Dehidrasi
yang Dirawat Inap di Rumah Sakit Permata Bekasi.
Jurnal Medical Profession (MedPro), 3 (3), hal.264-
276.
Kemenkes RI. 2017. Data dan Informasi
Kesehatan Profil Kesehatan Indonesia 2016.
Chungyang, N. 2011. The role of clinical pathways in
improving patient outcomes, American Academy of
physical medicine and rehabilitation, 4(2): 67-77.
Hollak, C., Demirdas, S., Kessel, I., Korndewal, M.,
Meutgeert, H., Klaren, A., Spronsen, F. & Bosch, A.
2013. Clinical pathways for inborn errors of metabolism:
warranted and feasible. US National Library of Medicine
National Institutes of Health. 8(4): 37.
Adiong, M. 2014. Nursing Services Administration Practice
Tools to Manage and Evaluation Care: Clinical Pathway
& Clinical Practice Guidelines; 12 (4): 112-116.
Hinkle, J.; Bare, B. & Smeltzer, S. 2014. Brunner &
Suddarth's textbook of medical-surgical nursing.
Understanding clinical pathways. pp. 2240-2246.
Leigh, A. & Resnick, M. 2014. Paving Clinical Pathways.
ASQ’s Healthcare; 6 (4): 114-116.
Pirog, F.; Kleiner, H.; Marcheva, B.; Jagun, D.; Sweetnam,
N. & Frieder, M. (2015): Clinical Pathways: Overview
of Current Practices and Potential Implications for
Patients, Payers, and Providers; 27(7): 1233-1239.
Piazza, A. 2015. Clinical Pathway Guideline; 25(8): 1355-
1362.
El Baz, N. 2017. Chapter 2 Are the outcomes of clinical
pathways evidence-based? A critical appraisal of
clinical pathway evaluation research. Journal of
Evaluation in Clinical Practice December; 13(6): 920
– 929.
Hockenberry, M.; Wilson, D. & Rodgers, C. 2017. The
child with gastrointestinal disorder. Wong's essentials
of pediatric nursing, 11th ed., Canada: Elsevier, pp:
699-702.
Sharma, R. 2013. Essentials of Pediatric Nursing, 1st ed.,
London, Jaypee Brothers Medical Publishers, p. 341.
Fleisher, G. 2014. Evaluation of diarrhea in children. 12(6):
40-45.
Hockenberry, M. & Wilson, D. 2015. The child with
gastrointestinal dysfunction. Wong's nursing care of
infants and children,10th ed., Canada: Mosby, pp: 1058-
1062.
Carman, S. 2016. Essentials of pediatric nursing, 3rd ed.,
Canada: Wolters Kluwer Co., pp:720-725.
Huiskes, N.; Schrijvers, G. & Hoorn, A. 2012. The care
pathway: concepts and theories: an introduction. 12(5):
22-28.
Lux, T. 2012. Hospital Engineering. In M. Szomszor & P.
Kostkova, Electronic Healthcare, 69(22): 229–234.
Berlin, Heidelberg: Springer. doi:10.1007/978-3-642-
23635-8 26(9): 1358-1368.
Aarnoutse, M. 2015. The effectiveness of clinical pathway
management software. Master thesis. 14 (9): 45-49.
Implementation of Clinical Pathways for Pediatric Patients with Acute Diarrhea and Their Therapy Management in a Hospital Setting: A
Systematic Literature Review
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