TOP 23 - Sustaining Oral Rehydration Use in Pediatric Gastroenteritis Post-IV Fluid Shortage: A Quality Improvement Initiative

Publication Number: 3751.TOP 23

Hye-Yin Kim, Valley Children's Healthcare, Fresno, CA, United States; Sindhura Gandham, Valley Children's Healthcare, Madera, CA, United States; Michael Scahill, Valley Children's Healthcare, Madera, CA, United States

Background: Pediatric gastroenteritis with dehydration remains a significant health problem in the U.S. AAP guidelines recommend oral rehydration therapy (ORT) for the treatment of mild to moderate dehydration in gastroenteritis. This is supported by several studies showing that ORT is safe, cost-efficient, and as effective as IV rehydration. Despite this, ORT continues to be underutilized, with many providers preferring IV fluids. This practice was challenged by the national IV fluid shortage in September 2024, which necessitated a shift toward ORT. Sustaining these crisis-driven changes, however, has proven to be difficult, and further improvement is needed.

Objective: To decrease the percentage of IV rehydration in patients with acute gastroenteritis and mild to moderate dehydration evaluated in the ED at a large freestanding children's hospital by 10% from a baseline of 23% over 6 months.

Design/Methods: IRB exemption was obtained and a multidisciplinary team of key stakeholders (nursing leadership, ED and hospitalist physicians) was assembled. A Gemba walk was completed to develop a process map, informing our Ishikawa and key driver diagrams. We then used the IHI Model for Improvement to identify our interventions.

Baseline data was collected from 1/2024 to 6/2025 and demonstrated a significant drop in IV fluid use to 9% during the fluid shortage. Following deactivation of our institutional task force, IV fluid use rapidly returned to pre-crisis levels. Reviewing the interventions implemented during this time highlighted the challenges of sustaining crisis-driven practice changes. With this in mind, our first PDSA cycle focused on clarifying the language of an existing ED policy to increase PO challenge rates following ondansetron administration in triage. Our Gemba walk revealed that patients were kept NPO after receiving ondansetron until evaluated by a provider. Although current policy does not recommend this, actual practice differed due to cultural norms, and our intervention revealed the difficulty of shifting clinical culture in the absence of an external crisis. While this intervention is currently ongoing, future interventions will address the palatability of oral fluids as well as provider and family education.

Our primary outcome measure is the percentage of patients receiving IV rehydration. Process measures include ondansetron administration and ED throughput time. Balancing measures include ED return visits and missed surgical abdomens. Data will be analyzed using statistical process control charts to monitor trends and assess the impact of the interventions over time.

Percentage of Emergency Department Encounters with IV Fluids
ED encounters from 1/2024-8/2025. Internal Hospital Incident Command Structure (HICS) for IVF crisis activated 10/2/2024. HICS deactivated 12/23/24. Reactivated 1/27/25. Return to pre-crisis status 3/12/25.