Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting and diarrhea
Treatment: Inpatient admission 

The Inpatient admission was not medically necessary.

The patient is a female child that presented to the ED with five-day history of vomiting and one episode of diarrhea. She was not able to keep down fluids, vomiting with every attempt at drinking. She was seen by the pediatrician two days prior, and the family was instructed to keep the child hydrated. She continued to vomit, with increasing fatigue and decreased urine output. She had no fevers or respiratory symptoms. 

The patient's vital signs included temperature 37.6, heart rate 115, and respiratory rate 20. Her examination was significant for facial pallor, sunken eyes, tachycardia, dry mucous membranes, and normal capillary refill. Her laboratory evaluation was significant for metabolic acidosis (CO2 [carbon dioxide] 14), hypoglycemia (glucose 43), elevated alkaline phosphatase (203), and mildly elevated transaminase (AST [aspartate aminotransferase] 56). 

The patient was treated with Zofran, 50 mL of D25 (dextrose 25%) IV push, and two IV fluid boluses. After the glucose and Zofran, the facial pallor improved and the child was sitting up and drinking juice. She had no episodes of emesis in the ED, and was tolerating food and drink. However, because of the degree of dehydration, she was admitted for continued IV fluids and monitoring. Admission orders included maintenance IV fluids with 5% correction, repeat metabolic studies, and regular diet as tolerated. 

After admission, the patient had one episode of vomiting and one episode of watery diarrhea overnight, but was able to resume eating and drinking thereafter. Repeat lab studies revealed resolution of the metabolic acidosis with CO2 21. IV fluids were decreased to maintenance and then stopped overnight. The following day, her appetite had improved and she appeared well hydrated. She was deemed stable for discharge to follow-up with her pediatrician in one to two days.  

Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of five years. Most cases are caused by viruses, are self-limited, and require supportive treatment. According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Vomiting limits the success of oral rehydration, prompting use of anti-emetic medications.

This young female child presented to the ED following a five-day illness with persistent vomiting and one episode of diarrhea. She was significantly dehydrated upon arrival, with sunken eyes and dry mucous membranes on exam and metabolic acidosis on laboratory evaluation. She received fluid resuscitation in the ED along with antiemetic medication and thereafter was able to drink and take some food. Because of the severity of her dehydration and the need to slowly replenish fluids, she was admitted to the pediatric floor. She had a single episode of vomiting and diarrhea the night after admission, after which she was stable and able to tolerate her diet. While it was important to rehydrate this child in a safe manner, she was overall stable, with no evidence of sepsis, and no significant ongoing fluid losses. She did not require acute inpatient admission. The patient could have been safely and appropriately managed at a lower level of care, such as observation.