Pediatric Hospital Adherence to the Standard of Care for Acute Gastroenteritis Joel S.

Tieder, Andrea Robertson and Michelle M. Garrison Pediatrics 2009;124;e1081-e1087; originally published online Nov 2, 2009; DOI: 10.1542/peds.2009-0473

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/124/6/e1081

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2009 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Pediatric Hospital Adherence to the Standard of Care for Acute Gastroenteritis

AUTHORS: Joel S. Tieder, MD, MPH,a,b Andrea Robertson, MPH,a,c and Michelle M. Garrison, PhDa,c
aDepartment of Pediatrics, University of Washington, Seattle, Washington; bDepartment of Pediatrics, Seattle Childrens, Seattle, Washington; and cCenter for Child Health, Behavior, and Development and Seattle Childrens Hospital Research Institute, Seattle, Washington

WHATS KNOWN ON THIS SUBJECT: There is a widely accepted standard of care for AGE that promotes ORT use and discourages routine laboratory testing. WHAT THIS STUDY ADDS: Guideline-adherent hospitals demonstrated 50% lower charges for ED or observation patients with uncomplicated AGE. Use of resources not routinely recommended by published AGE guidelines remains common in US pediatric hospitals.

KEY WORDS variability, gastroenteritis, acute gastroenteritis, dehydration, vomiting, diarrhea, quality improvement, adherence ABBREVIATIONS AGEacute gastroenteritis CBC complete blood count CDCCenters for Disease Control and Prevention ED emergency department ICD-9 International Classication of Diseases, Ninth Edition IQRinterquartile range LOSlength of stay ORT oral rehydration therapy PHISPediatric Health Information System www.pediatrics.org/cgi/doi/10.1542/peds.2009-0473 doi:10.1542/peds.2009-0473 Accepted for publication Jun 16, 2009 Address correspondence to Joel S. Tieder, MD, MPH, Seattle Childrens, M/S T-1201, PO Box 5371, Seattle, WA 98105. E-mail: joel.tieder@seattlechildrens.org PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright 2009 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no nancial relationships relevant to this article to disclose.

abstract
BACKGROUND: Adherence to published care guidelines for the management of acute gastroenteritis (AGE) is unknown. OBJECTIVES: To evaluate the association of AGE guideline adherence with outcomes and resource use at pediatric hospitals. DESIGN/METHODS: We studied children aged 6 months to 6 years with an International Classication of Diseases, Ninth Edition (ICD-9) discharge code indicative of AGE and without comorbid conditions in the emergency department, observation setting, or hospital. Laboratory studies, antiemetic use, and antibiotic use were evaluated, and the length of stay, mean adjusted total charges, and readmission proportion were documented. Multiple analysis of variance determined if the variance of adjusted charges, length of stay, and diagnostic studies were hospital-related. A regression analysis determined the association between guideline adherence and outcomes. RESULTS: There were a total of 188 873 patients; 174 594 (92.4%) were not admitted, and 14 279 (7.6%) were admitted. There was substantial variation in resource use among hospitals. The mean adjusted total charge for all patients was $863 (SD: 1336). The mean adjusted total charge for nonadmitted patients was $591 (SD: 636). Individual hospitals contributed to the variance of mean length of stay, total adjusted charges, and use of diagnostic studies after controlling for covariates (P .001). Guideline adherence was associated with a mean decrease in the average adjusted cost ($591) for nonadmitted patients of $296 (95% condence interval: 399 to 193). CONCLUSIONS: Guideline-adherent hospitals demonstrated 50% lower charges for emergency department or observation patients with uncomplicated AGE without adversely affecting outcomes. Use of resources not routinely recommended by published AGE guidelines remains common in pediatric hospitals. Pediatrics 2009;124: e1081e1087

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The US health care system is failing to deliver recommended ambulatory care most of the time.1,2 Recent studies have raised similar concerns about the quality of inpatient care in pediatric hospitals for common conditions such as bronchiolitis, urinary tract infection, and apparent life-threatening events.35 Care for common conditions that have a strong foundation of evidence-based management strategies should be consistent. Non evidence-based hospital care potentially exposes patients to unnecessary risk, increased costs, iatrogenic complications, and medical errors. Acute gastroenteritis (AGE) is 1 of the most common health problems affecting children in the United States, causing an estimated 1.5 million outpatient visits and 220 000 hospitalizations per year.6 Despite evidence that most hospital care for AGE is avoidable, especially after proper initiation of oral rehydration therapy (ORT), it remains 1 of the most common reasons for both pediatric emergency department (ED) visits and hospitalization.79 Since 1996, the American Academy of Pediatrics and the Centers for Disease Control and Prevention (CDC) have collaborated to promote evidence-based guidelines for the care of AGE that emphasize the importance of ORT and early nutritional support, and recommend against routine laboratory testing (electrolyte measurement, stool cultures, or rotavirus testing).6,1012 Despite a general acceptance of AGE guidelines and strong data supporting improved patient outcomes with adherence, such as a 45% decrease in hospitalization rates, the pediatric community has been slow to adopt the new practices.13 We sought to evaluate adherence to published AGE guidelines across pediatric hospitals and learn whether adherence was associated with hospital outcomes.
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METHODS
Data Source We used the Pediatric Health Information System (PHIS) database developed by the Child Health Corporation of America. The PHIS is an administrative database that includes hospital stay, demographic, and diagnostic data on freestanding childrens hospitals. The database uses clinical transaction codes to map hospital-specic charge codes to categorical variables that are consistent across hospitals in the system.14 The PHIS database represents 17 of the 20 major metropolitan areas and 70% of the freestanding childrens hospitals in the United States.4 The current analysis is from 27 hospitals and calendar quarters included in an expanded data set containing more comprehensive data, including ED, medication, and diagnostictest data. Additional data for designated observation units were collected and provided by the Child Health Corporation of America in a separate report, which was veried by the investigators independently through personal communication with the hospital administrators. Study Population We studied children aged 6 months to 6 years who were cared for in the ED, observation setting, or hospital over a 5.75-year period (January 2001 to September 2006). Criteria for inclusion were based on International Classication of Diseases, Ninth Revision (ICD-9) discharge codes indicative of AGE (dehydration, gastroenteritis, hypovolemia, vomiting, and diarrhea; see Appendix). These categories were not mutually exclusive, because patients could have multiple discharge diagnoses. Patients who met inclusion criteria were excluded for discharge ICD-9 codes not clinically consistent with AGE (pyloric stenosis, urinary tract infection, etc). They were also ex-

cluded if they had comorbid conditions not consistent with routine gastroenteritis in a previously healthy patient (eg, bronchiolitis, metabolic disorder, etc). If children had more than 1 qualifying encounter during the study period, only the rst was included in the primary analysis. Children 6 months of age, who are more susceptible to complications of dehydration, were excluded to improve specicity of the case denition. Outcome Measures The outcomes of interest were length of stay (LOS), hospital charges, and readmission. Charges were adjusted for regional variations in costs of care, and total hospital charges were documented, as well as pharmacy, imaging, and laboratory charges. Subsequent encounters were dened by using the same inclusion criteria as readmission if they occurred within 7 days of the index visit. Laboratory testing and treatment with antibiotics or antiemetics were evaluated. Their inclusion was based on the American Academy of Pediatrics endorsed 2003 CDC recommendation and report on managing acute gastroenteritis among children.6 Laboratory testing included electrolyte measurement, urine analysis or urine culture, a complete blood count (CBC), and stool studies (rotavirus, ova and parasite, Clostridium difcile, and stool culture). Intravenous and oral medications (antibiotics, ondansetron, and promethazine) were limited to those used in the hospital; data regarding medications prescribed at discharge for outpatient use were not available. Other recommendations from the CDC guidelines, such as intravenous uids and ORT, are not reliably coded and, therefore, were not included in this study. Diagnostic imaging was initially evaluated and found to be uncommon enough to preclude additional study.

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Covariates The following characteristics were used as covariates in the analyses: age, gender, Medicaid status, admission season, presence of observation unit, and patient volume. They were selected a priori because of their potential to affect clinical outcomes and contribute to interhospital variation. Age was modeled in the multiple analysis of variance both dichotomously and as a linear term in the regression models. Statistical Analysis In a descriptive analysis, we examined the distribution of covariates. To illustrate variation in hospitallevel resource utilization, medians and interquartile ranges were depicted graphically. Categorical and continuous variables were compared with 2 tests and t tests, respectively, across age groups ( 12 months or 12 months to 6 years) and inpatient status (LOS 24 hours). Multiple analysis of variance was used to determine if between-hospital variation signicantly contributed to variance in outcomes after controlling for covariates. To dene adherence, hospitals (n 27) were grouped into 2 categories on the basis of use of nonrecommended testing (rotavirus testing, stool studies, and electrolyte measurement). A variable for adherence was created that measured the proportion of patients at each hospital who received no rotavirus testing, electrolyte testing, or stool studies, because published guidelines state that these tests are unnecessary in uncomplicated AGE. The top third of hospitals with the highest percentages on this measure was coded as highly adherent hospitals in the analysis. A regression analysis of the hospitals in the top one third of guideline adherence (less testing) was performed to assess an association with total adjusted charges, LOS, and readmission
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TABLE 1 Characteristics of Study Population Aged 6 Months to 6 Years

Characteristic No. Male, % Mean age, y (SD) Medicaid, any, % Season First quarter Second quarter Third quarter Fourth quarter Hospital stay Mean LOS, d (SD) Adjusted total charges (SD), $ Readmission (within 7 d) proportion, % Resource utilization, % Medication Ondansetron Promethazine Intravenous antibiotics Oral antibiotics Lab studies CBC Electrolytes (NA, K, Cl, CO2, SUN, Cr, glucose) Urinalysis/urine culture Rotavirus Stool studies (culture, O and P, C difcile) Nonadmitted 174 594 52.3 1.7 (1.3) 55.5 38.4 23.1 18.4 20.2 1.0 (0.1) 591 (636) 4.7 Admitted 14 279 53.8 1.5 (1.2) 42.4 54.4 25.5 9.4 10.7 1.9 (1.0) 4188 (2590) 7.9 Overall 188 873 52.4 1.6 (1.3) 54.5 39.6 23.3 17.7 19.4 1.1 (0.4) 863 (1336) 5.0

8.9 2.4 2.3 0.7 12.4 22.1 12.4 4.1 4.5

12.2 2.7 13.9 5.4 51.2 85.0 36.9 53.8 24.6

9.1 2.4 3.2 1.1 15.3 26.8 14.2 7.9 6.0

NA indicates sodium; K, potassium; Cl, chloride; CO2, carbon dioxide; SUN, serum urea nitrogen; Cr, creatinine; O and P, ova and parasites.

after controlling for covariates. The study protocol was approved by the institutional review board of Seattle Childrens. To protect hospital anonymity, all results were analyzed and are presented without hospital identiers. All analyses were conducted by using Stata 9.0 (Stata Corp, College Station, TX).

were readmitted. The ED and observation patients were more likely to be insured by Medicaid (54.4%), whereas admitted patients were more likely to have non-Medicaid insurance (42.4%). The mean (SD) adjusted total charges for hospitals with (860 [1121]) and without (863 [1381]) designated observation units did not differ signicantly. Adherence to Guidelines (Patient Level and Hospital Level) Most patients (69%) received adherent care. Few patients received medications. The most commonly used medication was the antiemetic ondansetron (9.1%). Among admitted patients, antibiotic use was relatively common (intravenous: 13.9%; oral: 5.4%) compared with the observation and ED patients (intravenous: 2.3%; oral: 0.7%) (Table 1). Figure 1 shows the variation in resource utilization across hospitals. Nonrecommended laboratory testing (electrolyte and rotavirus testing, stool studies, and CBC) was common
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RESULTS
Description of Patient Population A total of 188 873 patients were included in the study; 174 594 (92%) were cared for in ED and observation settings, and 14 279 (8%) were admitted to the hospital (Table 1). The mean age was 1.6 (SD: 1.3) for the entire study population and 1.5 (SD: 1.2) years for patients admitted. The mean adjusted charges were $591 (SD: 636) for the ED and observation patients and $4188 (SD: 2590) for those admitted. Among ED and observation patients, 4.7% returned within 7 days; among hospitalized patients, 7.9%

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40%
p75 p25 median

Percentage of patients

30%

ling for the same covariates, adherence to guidelines in admitted patients was not associated with LOS or readmission (P .995).

DISCUSSION
20%

10%

0%

Resource
FIGURE 1
Variability of resource utilization across hospitals (total population).

To our knowledge, this is the rst large multiinstitutional study of AGE care at childrens hospitals. Through evaluation of resource utilization, this study demonstrates great variation in care of routine gastroenteritis in pediatric hospitals. The quality of pediatric ambulatory care for AGE is known to be variable, and this study suggests comparably variable care in hospitals.15,16 This variation persists after controlling for potential confounders and is attributed to the care practices of individual hospitals. The hospitals that were most adherent to recommended laboratory testing practices demonstrated 50% lower charges for ED or observation patients, without any discernable affect on measured outcomes. This is not surprising, because many admissions for AGE in the United States result from a failure to use ORT and a medical culture that is overly dependent on technology.7,8,13 For example, hospitals predisposed to ORT use may be less dependent on technology and tend to

C BC El ec tro ly te s

but most pronounced in the admitted population. The most commonly performed laboratory studies were serum electrolyte measurement and CBC. Among ED and observation patients, 22.1% had electrolytes measured, compared with 85% of those admitted. A CBC was performed in 12.4% of the ED and observation patients versus 51.2% of those admitted. Rotavirus and stool testing was common but highest in the admitted population (53.8% and 24.6%, respectively) and less common among ED and observation patients (4.1% and 4.5%, respectively). In the multiple analysis-ofvariance analyses, individual hospitals signicantly contributed to variance in total adjusted charges, CBCs, and electrolyte and rotavirus testing after controlling for covariates (P .001). Impact of Guideline Adherence on Outcomes For the ED and observation patients, charges were signicantly (t test; P .001) less in highly adherent hospitals ($412 vs $702), with a mean difference of $290 (95% condence interval: 284
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296). In the admitted population, charges in highly adherent hospitals were (t test; P .001) more than those in less adherent hospitals ($4404 vs $4127, respectively), with a mean difference of $277 (95% condence interval: 174 380). After controlling for covariates in an adjusted regression analysis, results were similar for ED and observation patients but were not signicant for admitted patients (Table 2). In a regression analysis control-

TABLE 2 Effect of Hospital on Combined (Nonrecommended) Resource-Utilization Rate on Gross

Adjusted Charges in Dollars
Hospital Characteristic Nonadmitted (ED and Observation) Coefcient Adherent to guidelines Has observation unit Patient volume (per 1000 patients) Patient and stay characteristics Medicaid Season First quarter Second quarter Third quarter Fourth quarter Age ( 1 y) Male
CI indicates condence interval.

nd an st er on Pr om et ha zin e An tib io tic s

Ur in e

s Ro ta vi ru

St oo ls

tu di es

Admitted Coefcient 271 360 134 266 Reference 86 176 89 120 40 95% CI 321 to 863 1081 to 360 230 to 38 58 to 474 Reference 105 to 278 64 to 417 380 to 202 42 to 283 20 to 99

95% CI 399 to 193 13 to 208 19 to 5 179 to 87

296 98 7 133 Reference 45 1.1 32 50 20

Reference 18 to 71 29 to 27 50 to 13 66 to 34 28 to 11

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draw blood for laboratory tests less frequently and to start fewer intravenous lines. In such facilities, where practice is standardized, provider anxiety and reliance on nonindicated laboratory test data are lessened.8,17,18 In fact, it is estimated that if AGE care were standardized and implemented according to guidelines, admission rates would decrease by 45%, resulting in more than $1 billion savings in direct medical costs. Despite this proven benet to the patient and the health care community, poor adherence to the standard of care persists.3,9,19,20 This study has limitations common to retrospective studies that use administrative data. Misclassication of cases was possible, because a case is dened by 1 of 5 ICD-9 discharge codes that may have been applied variably across institutions and may not be mutually exclusive to this condition. To limit misclassication, we narrowly dened the patient population and excluded comorbid conditions not consistent with routine gastroenteritis in a previously healthy patient. We did not attempt to validate case denitions by chart review across all hospitals; however, as part of a quality-improvement project at our institution, a chart review of 20% of the sample (n 144) over a 4.6-year period was performed and demonstrated 98% positive preREFERENCES
1. Mangione-Smith R, DeCristofaro AH, Setodji CM, et al. The quality of ambulatory care delivered to children in the United States. N Engl J Med. 2007;357(15):15151523 2. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003; 348(26):26352645 3. Conway PH, Edwards S, Stucky ER, Chiang VW, Ottolini MC, Landrigan CP. Variations in management of common inpatient pediatric illnesses: hospitalists and community pediatricians. Pediatrics. 2006;118(2): 441 447

dictive value for the case denition. In addition, the patient demographics and seasonality we observed were similar to the demographics and seasonal variation found in previous AGE studies.21 The reported variability in care might reect differences in patient populations, disease severity, or coding practice. However, in addition to controlling for covariates (Medicaid, age, season, gender, and hospital volume), our data represent a 5.75-year period, and we used a large population size and restricted the case denition narrowly (no comorbidities), which makes such an explanation highly unlikely. Because coding of observation status is not uniform across hospitals, we were unable to distinguish patients seen only in the ED from those in observation units who were observed for less than 24 hours; therefore, we analyzed the ED and observation patients together. Because the presence of an observation unit, especially those with dedicated resources for the short-stay patient, could decrease the disease severity among admitted patients and affect our outcome measures, we controlled for the presence of an observation unit in our regression analyses. After controlling for observation units, there was no signicant association with adherence. In a subanalysis, we evaluated the effect of designated

observation units on the study population and found no difference in mean charges for the admitted versus nonadmitted group. However, with this study design we were unable to measure LOS in the nonadmitted population in hours and were also unable to control for residual confounders such as how ED practice may affect admission rates and severity. Many state and national agencies have initiatives to promote accountability, improvement, and the delivery of quality care for AGE. Although disagreement remains over what measures to use, hospitals dedicated to delivering quality care can use these national resource-utilization data to identify decits and benchmark quality-improvement projects.

CONCLUSIONS
Adherence to published guideline recommendations for laboratory testing in patients with uncomplicated AGE is associated with less expensive care without adverse effects on patient outcomes. Hospitals striving to improve the quality of care for AGE may use these data to benchmark their quality improvement efforts.

ACKNOWLEDGMENT We thank Dr Edgar Marcuse for mentorship and review of this manuscript.

4. Christakis DA, Cowan CA, Garrison MM, Molteni R, Marcuse E, Zerr DM. Variation in inpatient diagnostic testing and management of bronchiolitis. Pediatrics. 2005;115(4): 878 884 5. Tieder JS, Cowan CA, Garrison MM, Christakis DA. Variation in inpatient resource utilization and management of apparent lifethreatening events. J Pediatr. 2008;152(5): 629 635, 635.e1 635.e2 6. King CK, Glass R, Bresee JS, Duggan C; Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral rehydration, maintenance,

and nutritional therapy. MMWR Recomm Rep. 2003;52(RR-16):116 7. Connell FA, Day RW, LoGerfo JP. Hospitalization of Medicaid children: analysis of small area variations in admission rates. Am J Public Health. 1981;71(6):606 613 8. Santosham M, Keenan EM, Tulloch J, Broun D, Glass R. Oral rehydration therapy for diarrhea: an example of reverse transfer of technology. Pediatrics. 1997;100(5). Available at: www.pediatrics.org/cgi/content/ full/100/5/e10 9. Snyder JD. Use and misuse of oral therapy for diarrhea: comparison of US practices

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with American Academy of Pediatrics recommendations. Pediatrics. 1991;87(1): 28 33 10. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Practice parameter: the management of acute gastroenteritis in young children. Pediatrics. 1996;97(3):424 435 11. Sandhu BK; European Society of Pediatric Gastroenterology, Hepatology and Nutrition Working Group on Acute Diarrhoea. Practical guidelines for the management of gastroenteritis in children. J Pediatr Gastroenterol Nutr. 2001;33(suppl 2):S36 S39 12. Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. Pediatrics. 2004; 114(2):507 13. Zolotor AJ, Randolph GD, Johnson JK, et al.

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Effectiveness of a practice-based, multimodal quality improvement intervention for gastroenteritis within a Medicaid managed care network. Pediatrics. 2007;120(3). Available at: www.pediatrics.org/cgi/content/ full/120/3/e644 Ponsky TA, Huang ZJ, Kittle K, et al. Hospitaland patient-level characteristics and the risk of appendiceal rupture and negative appendectomy in children. JAMA. 2004; 292(16):19771982 Rahman S, Aszkenasy OM. Management of childhood gastroenteritis in the community. Public Health. 2001;115(4):292294 Ozuah PO, Avner JR, Stein RE. Oral rehydration, emergency physicians, and practice parameters: a national survey. Pediatrics. 2002;109(2):259 261 Ober KP. Uncle Remus and the cascade effect in clinical medicine: Brer Rabbit kicks the Tar-Baby. Am J Med. 1987;82(5): 1009 1013

18. Mold JW, Stein HF. The cascade effect in the clinical care of patients. N Engl J Med. 1986; 314(8):512514 19. Chemaly RF, Yen-Lieberman B, Schindler SA, Goldfarb J, Hall GS, Procop GW. Rotaviral and bacterial gastroenteritis in children during winter: an evaluation of physician ordering patterns. J Clin Virol. 2003;28(1): 44 50 20. Uhlen S, Toursel F, Gottrand F; Association Francaise de Pediatrie Ambulatoire. Treatment of acute diarrhea: prescription patterns by private practice pediatricians [in French]. Arch Pediatr. 2004;11(8): 903907 21. Parashar UD, Chung MA, Holman RC, Ryder RW, Hadler JL, Glass RI. Use of state hospital discharge data to assess the morbidity from rotavirus diarrhea and to monitor the impact of a rotavirus immunization program: a pilot study in Connecticut. Pediatrics. 1999;104(3 pt 1):489 494

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APPENDIX Inclusion and Exclusion Criteria for the AGE Study Population
Diagnosis Group Inclusion criteria Dehydration Gastroenteritis ICD-9 Code 27651 0010, 0030, 0040, 0041, 0043, 0048, 0049, 0050, 0051, 0052, 00589, 0059, 0080000804, 00809, 0082, 0083, 0084100847, 00849, 0085, 0086100864, 00866, 00867, 00869, 0088 2765, 27652, 78701, 78702, 78703 78791 0061, 0070, 0072, 00810083, 00841, 00842, 01400, 01402, 1231, 1239, 1269, 5400, 5401, 5671, 5672, 5672156723, 56729, 56738, 5678, 56789, 5679, 5695, 00324, 0119004184, 04780549, 0701 0785, 07930796, 08611369 137139 140239 2002 2422429, 2432469, 260269, 270279 2502599 280289 282285.8, 286287.9 292294 290301.4, 301.6319 3203279, 330037214, 37263, 37274, 37313, 37430, 37446, 37530, 3760137992, 37999, 3833839, 386338639, 3893899, 3923929, 3943949, 3973979 4011, 40240299, 40340399, 40540599, 412, 4141 41499, 41641699, 4174178, 42142199, 423 42399, 42442499, 42642699, 42742799, 428 42899, 42942999, 431, 43243299, 43443499 None 520523, 525 527 540553 555557 562 564.2564.4 566568 570573.8 574577 580586 592, 594 600608 610611 614616, 617629 655 710729, 731739 All excluded

Hypovolemia Vomiting Diarrhea Exclusion criteria by system Infectious and parasitic disease

HIV (not in this sample), TB Neoplasms All tumors Endocrine, nutrition, metabolic, immune system All endocrine, DM, metabolic DO Blood No anemia or WBCs Mental disorder All except Munchhausen syndrome Nervous system

Circulatory system

Respiratory system Digestive Dental Salivary glands Appendix and hernia Colitis Diverticulitis Postsurgical complication Peritoneum Liver (does not include jaundice) Gallbladder and pancreas GU Glomerular nephritis and renal failure GU stones Male GU Breast Female GU Complication of pregnancy Known fetal malformation Musculoskeletal Not otherwise specied Congenital

DM, diabetes mellitus; DO, disorder; GU, genitourinary; TB, tuberculosis; WBCs, white blood cells.

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Pediatric Hospital Adherence to the Standard of Care for Acute Gastroenteritis Joel S. Tieder, Andrea Robertson and Michelle M. Garrison Pediatrics 2009;124;e1081-e1087; originally published online Nov 2, 2009; DOI: 10.1542/peds.2009-0473
Updated Information & Services References including high-resolution figures, can be found at: http://www.pediatrics.org/cgi/content/full/124/6/e1081 This article cites 19 articles, 9 of which you can access for free at: http://www.pediatrics.org/cgi/content/full/124/6/e1081#BIBL This article has been cited by 2 HighWire-hosted articles: http://www.pediatrics.org/cgi/content/full/124/6/e1081#otherarti cles This article, along with others on similar topics, appears in the following collection(s): Gastrointestinal Tract http://www.pediatrics.org/cgi/collection/gastrointestinal_tract Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.pediatrics.org/misc/Permissions.shtml Information about ordering reprints can be found online: http://www.pediatrics.org/misc/reprints.shtml

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