Background: Failure to thrive and malnutrition continues to be a common diagnosis in pediatrics contributing to a significant number of hospital admissions (1-5). There is no national practice guideline or consensus recommendation for diagnosis and treatment for patients hospitalized with failure to thrive, contributing to significant clinical practice variation. Unnecessary variability in practice has been shown to affect clinical outcomes with concerns for decreased quality and increased cost (6,7). Readmission rates have been reported at 14% at 30 days and at 3 years. In one study, 56% of readmissions were found to be potentially preventable readmissions at a cost of 6.9 million dollars (2,4). Multidisciplinary care has been shown to reduce readmissions and improve outcomes (8-11).
Methods: Our institution recognized care variation in our failure to thrive (FTT) patients. A multidisciplinary pathway development team, in partnership with Texas Children’s Hospital and Pediatric Initiative for Clinical Standards (PICS), developed a clinical pathway with an aim to improve quality of care and resource utilization. One such recommendation was orders to appropriate multidisciplinary team members. The pathway included FTT patients 24 months or younger admitted to our academic pediatric institution. It excluded patients with a known chronic disease impacting nutrition status. In addition to a pathway algorithm, an order set and history and physical (H&P) template were developed. Eighteen months after development we noted increased utilization of a multidisciplinary team (occupational therapists, Speech therapists, Registered dietitians, Nutrition, Lactation consultants, and Social workers) However, we saw no change in length of stay (LOS) and order set utilization plateaued. We utilized quality improvement (QI) methods to increase order set utilization with the aim to decrease LOS. QI interventions included electronic health record optimization, communication and education, visual cues, and defined health care team roles.
Results: Eighteen months after pathway implementation we observed an increased utilization of a multidisciplinary care team including occupational therapists, speech therapists, registered dietitians, lactation consultants, and social workers. Length of stay (LOS) remained unchanged and order set utilization had plateaued at 78%. After QI interventions, we reached a 94% utilization of our order set (Figure 1), reduced LOS from 5 to 3.5 days (Figure 2), and reduced 90-day readmissions from 11% to 6%. We have seen a charge savings of $600 per hospitalization and $500,000 in total charge savings.
Conclusions: An evidence-based practice clinical pathway, followed by quality improvement interventions to improve order set utilization, reduced FTT LOS, patient charges and 90-day readmission rate. Pathway implementation led to increased utilization of a multidisciplinary team to improve quality of care. Next steps for this team are development of an ambulatory portion of the pathway with a goal of improved multidisciplinary care and resource utilization.