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Improving Care for Children with Bloody Diarrhea at Risk for Hemolytic Uremic Syndrome
Carson S Burns1, Jason Rubin1, Tara Sardesai1
1Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Wash.
Insights
A new clinical pathway and rapid stool PCR testing for children with bloody diarrhea reduced hospitalizations and costs. This approach improved care without negatively impacting clinical outcomes for hemolytic uremic syndrome (HUS).
Area of Science:
- Pediatric Emergency Medicine
- Infectious Diseases
- Clinical Pathways
Background:
- Children with infectious bloody diarrhea face a higher risk of developing hemolytic uremic syndrome (HUS).
- Early detection and intervention are crucial for improving outcomes in at-risk pediatric patients.
- This study assessed a clinical pathway aimed at identifying HUS risk, guiding management, and supporting disposition decisions.
Purpose of the Study:
- To evaluate the impact of a clinical pathway and rapid stool PCR testing on the management of children with infectious bloody diarrhea.
- To determine if the implemented pathway influenced hospitalization rates, costs, and clinical outcomes related to HUS.
- To assess changes in diagnostic test utilization and patient disposition following pathway implementation.
Main Methods:
- A retrospective cohort study analyzed 305 children (4 months to 19 years) with bloody diarrhea or HUS risk factors presenting to the pediatric ED.
- A clinical pathway was implemented in January 2018, alongside the introduction of rapid stool PCR testing in May 2017.
- Statistical process control charts and Fisher's exact tests were used to analyze changes post-implementation.
Main Results:
- Stool PCR use increased from 78% to 91% post-implementation.
- Hospitalization rates decreased significantly from 49% to 30%.
- Mean total charges decreased, though ED discharge length of stay and associated charges increased. No adverse clinical outcomes were observed.
Conclusions:
- The introduction of a rapid stool PCR test and clinical pathway in the pediatric ED setting correlated with reduced hospitalizations and overall costs.
- This integrated approach demonstrated improved efficiency without compromising patient safety or leading to adverse clinical outcomes.
- The findings support the adoption of clinical pathways and rapid diagnostics for managing pediatric infectious diarrhea and preventing HUS.
Introduction:
Children with infectious bloody diarrhea are at an increased risk for developing hemolytic uremic syndrome (HUS). Early intervention may improve outcomes. This study evaluated the impact of a clinical pathway designed to identify those at risk for HUS, guide initial management, and provide decision support regarding patient disposition.
Methods:
We performed a retrospective cohort study of children 4 months to 19 years of age who presented with the acute onset of bloody diarrhea or other HUS risk factors to the pediatric emergency department (ED) from September 2015 through July 2020. A rapid stool polymerase chain reaction (PCR) test became available in May 2017. The clinical pathway was implemented in January 2018. We used Fisher's exact tests and statistical process control charts to analyze patient- and system-level changes following pathway implementation.
Results:
Three hundred five patients were included. Postimplementation, stool PCR use increased (78%-91%), hospitalization decreased (49%-30%), and mean total charges decreased ($7715-$6797). There were increases in length of stay (226-288 minutes) and charges ($2651-$3524) for patients discharged from the ED. All changes met rules for special cause variation. There was no change in early IV fluid administration, inpatient length of stay, ED return visits, hospital readmissions, or patients with Shiga toxin-producing Escherichia coli (STEC), acute kidney injury (AKI) or HUS.
Conclusions:
For children presenting to the ED with bloody diarrhea, introduction of a rapid stool PCR test and clinical pathway correlated with decreased hospitalizations and overall costs without adverse clinical outcomes.
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