The impact of presenting problem based guidelines for children with medical problems in an accident and emergency department

Aims: To evaluate the impact of presenting problem based guidelines in managing children with either diarrhoea ( with or without vomiting) or seizure ( with or without fever). Methods: This prospective observational study with an intervention was based on a paediatric accident and emergency (A&E) department in Nottingham. All patients ( either GP or self referred) were acute attenders aged 0 - 15 years, with a medical presenting problem during 4 months in the spring of 1997 and 1999. Five hundred and thirty-one diarrhoea attendances ( 292 before guideline implementation and 239 after) and 411 seizure attendances ( 212 before guideline implementation and 199 after) were recorded. Evidence based and consensus ratified guidelines developed for the study were implemented using care pathway documentation. Process ( documentation, time in the department, investigations, treatment) and outcome ( admission to hospital, returns to A&E) data were collected from case notes. Results: The percentage of children investigated with blood tests fell significantly ( haematology requests in diarrhoea presentations from 11% to 4%, biochemistry in seizure presentations from 29% to 17%). Intravenous infusions in diarrhoea presenters fell ( 9% to 1%), and more appropriate oral fluids were used. Management time in A&E was reduced ( diarrhoea presenters: median of 55 - 40 minutes, seizure presenters: 80 - 55 minutes, but remained static for other presenting problems). Marked improvements in documentation were seen. Admission rates for diarrhoea attenders increased (27% to 34%) but remained the same for seizure (69% v 73%) Conclusions: The implementation of a presenting problem based guideline as a care pathway was associated with improvements in the quality of care by: improved documentation; reduced invasive investigations; more appropriate treatment, and reduced time spent in AE.