Recommended Citation
Mishra S, McKenzie S, Kravtchenko S, et al. Improving Integration of Intake and Output into Patient Care for Hospitalized Pediatric Patients. Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Abstract
Background/Significance:
Lack of a universally accepted definition of strict vs standard intake and output (Ia&nO) has led to variability in documentation and orders across the pediatric hospital medicine (PHM) team. A serious safety event (SE) occurred when severe dehydration in an infant was not recognized, resulting in hypovolemic shock. Chart review showed minimal output documentation and failure to recognize I&O imbalance.
Purpose:
We aimed to decrease the I&O SE rate by 10% over 2 years by improving the integration of I&O into the clinical care of general pediatric patients at two campuses of Advocate Children’s Hospital.
Methods:
A multidisciplinary team of physicians, nurses, and patient care technicians (PCTs) developed a key driver diagram, with primary drivers identified to be measurement, documentation, reconciliation, and discussion of I&O. Outcome measures were time between, and percentage of I&O SE. Process measures included appropriate flowsheet documentation, discussion of I&O on family-centered (FCR) and night rounds (NR) and correct I&O orders. Balance measures included nurse/PCT overtime and staff perceptions. Interventions included revising the IIntroduction O policy to define strict vs standard I&O and escalation criteria, standardizing nursing I&O report on rounds, adding order set and note hard stops, and placing visual reminders. Run and control charts were analyzed using standard rules.
Results:
The I&O SE rate is now less volatile, and the median time between events remained 18 days. Campus A documentation of intake improved from 91% to 98% and output sustained at 93%. Campus B documentation intake improved from 35% to 55% and output improved from 33% to 49%. Discussion of I&O went from 76% to 94% on FCR and 70% to 93% on NR. Percentage of I&O orders placed correctly improved from 50% to 79% with special cause variation achieved and sustained for the last 6 months of the project. Staff surveys show no perceived increase in time spent on documentation/rounds and there has been no change in overtime.
Conclusion:
This 2-year project improved I&O ordering, documentation, and discussion, meeting our aim of better integrating I&O into care and addressing SEs. Because the outcome measures rely on event reports, rates may decrease due to process improvement or increase due to staff awareness prompting increased reporting. Opportunity remains for improvement in documentation at Campus B. These interventions are generalizable to other inpatient pediatric settings.
Presentation Notes
Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Full Text of Presentation
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Document Type
Oral/Podium Presentation
Improving Integration of Intake and Output into Patient Care for Hospitalized Pediatric Patients
Background/Significance:
Lack of a universally accepted definition of strict vs standard intake and output (Ia&nO) has led to variability in documentation and orders across the pediatric hospital medicine (PHM) team. A serious safety event (SE) occurred when severe dehydration in an infant was not recognized, resulting in hypovolemic shock. Chart review showed minimal output documentation and failure to recognize I&O imbalance.
Purpose:
We aimed to decrease the I&O SE rate by 10% over 2 years by improving the integration of I&O into the clinical care of general pediatric patients at two campuses of Advocate Children’s Hospital.
Methods:
A multidisciplinary team of physicians, nurses, and patient care technicians (PCTs) developed a key driver diagram, with primary drivers identified to be measurement, documentation, reconciliation, and discussion of I&O. Outcome measures were time between, and percentage of I&O SE. Process measures included appropriate flowsheet documentation, discussion of I&O on family-centered (FCR) and night rounds (NR) and correct I&O orders. Balance measures included nurse/PCT overtime and staff perceptions. Interventions included revising the IIntroduction O policy to define strict vs standard I&O and escalation criteria, standardizing nursing I&O report on rounds, adding order set and note hard stops, and placing visual reminders. Run and control charts were analyzed using standard rules.
Results:
The I&O SE rate is now less volatile, and the median time between events remained 18 days. Campus A documentation of intake improved from 91% to 98% and output sustained at 93%. Campus B documentation intake improved from 35% to 55% and output improved from 33% to 49%. Discussion of I&O went from 76% to 94% on FCR and 70% to 93% on NR. Percentage of I&O orders placed correctly improved from 50% to 79% with special cause variation achieved and sustained for the last 6 months of the project. Staff surveys show no perceived increase in time spent on documentation/rounds and there has been no change in overtime.
Conclusion:
This 2-year project improved I&O ordering, documentation, and discussion, meeting our aim of better integrating I&O into care and addressing SEs. Because the outcome measures rely on event reports, rates may decrease due to process improvement or increase due to staff awareness prompting increased reporting. Opportunity remains for improvement in documentation at Campus B. These interventions are generalizable to other inpatient pediatric settings.
Affiliations
Advocate Children's Hospital