Improving Care for Children with Bloody Diarrhea at Risk for Hemolytic Uremic Syndrome.

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.

Disorders of the Umbilical Cord.

The umbilical cord, a vital conduit between the placenta and the fetus, loses much of its significance after birth. However, newborns can often present with various abnormalities of the umbilicus, such as benign granulomas or more serious lesions due to persistent remnants, many of which can change the normal course of cord separation and may be associated with significant morbidities if left unrecognized and uncorrected. Although not uncommon, sanguineous drainage from the umbilical stump can be quite alarming to new parents. Parental counseling regarding normal umbilical cord changes, as well as abnormal findings, such as discharge and skin changes, are important for the recognition and timely treatment of potentially significant umbilical cord disorders.