A framework of pediatric hospital discharge care informed by legislation, research, and practice

Pediatrician perspectives on barriers and facilitators to discharge instruction comprehension and adherence for parents of children with medical complexity

BACKGROUND

High rates of posthospitalization errors are observed in children with medical complexity (CMC). Poor parent comprehension of and adherence to complex discharge instructions can contribute to errors. Pediatrician views on common barriers and facilitators to parent comprehension and adherence are understudied.

OBJECTIVE

To examine pediatrician perspectives on barriers and facilitators experienced by parents in comprehension of and adherence to inpatient discharge instructions for CMC.

DESIGN, SETTINGS, AND PARTICIPANTS

We conducted a qualitative, descriptive study of attending pediatricians (n = 20) caring for CMC in inpatient settings (United States and Canada) and belonging to listservs for pediatric hospitalists/complex care providers. We used purposive/maximum variation sampling to ensure heterogeneity (e.g., hospital, region).

MAIN OUTCOME AND MEASURES

A multidisciplinary team designed and piloted a semistructured interview guide with pediatricians who care for CMC. Team members conducted semistructured interviews via phone or video call. Interviews were audiorecorded and transcribed. We analyzed transcripts using content analysis; codes were derived a priori from a conceptual framework (based on the Pediatric Self-Management Model) and a preliminary transcript analysis. We applied codes and identified emerging themes.

RESULTS

Pediatricians identified three themes as barriers and facilitators to discharge instruction comprehension and adherence: (1) regimen complexity, (2) access to the healthcare team (e.g., inpatient team, outpatient pediatrician, home nursing) and resources (e.g., medications, medical equipment), and (3) need for a family centered and health literacy-informed approach to discharge planning and education. Next steps include the assessment of parent perspectives on barriers and facilitators to discharge instruction comprehension and adherence for prents of CMC and the development of intervention strategies.

Discharge Time of Day and 30-day Hospital Reutilization at an Academic Children's Hospital

BACKGROUND

Pediatric hospital discharge is a complex process. Although morning discharges are operationally preferred, little is known about the association between discharge time of day and discharge outcomes. We assessed whether children discharged from the hospital in the evening have a higher 30-day hospital reutilization rate than those discharged in the morning or afternoon.

METHODS

We conducted a retrospective cohort study on discharges from a children's hospital between July 2016 and December 2019. The cohort was divided into morning, afternoon, and evening discharges. Multivariable modified least-squares regression was used to compare 30-day all-cause hospital reutilization rates between morning, afternoon, and evening discharges while adjusting for demographic and clinical characteristics.

RESULTS

Among 24 994 hospital discharges, 6103 (24.4%) were in the morning, 13 786 (55.2%) were in the afternoon, and 5105 (20.4%) were in the evening. The unadjusted 30-day hospital reutilization rates were 14.1% in children discharged in the morning, 18.2% in children discharged in the afternoon, and 19.3% in children discharged in the evening. The adjusted 30-day hospital reutilization rate was lowest in the morning (6.1%, 95% confidence interval [CI] 4.1%-8.2%), followed by afternoon (9.0%, 95% CI 7.0%-11.0%) and evening discharges (10.1%, 95% CI 8.0%-12.3%). Morning discharge had a significantly lower adjusted 30-day all-cause hospital reutilization rate compared with evening discharge (P < .001), whereas afternoon and evening discharges were not significantly different (P = .06).

CONCLUSIONS

The adjusted 30-day all-cause hospital reutilization rate was higher for evening discharges compared with morning discharges, whereas the rate was not significantly different between afternoon and evening discharges.

Essential elements nurses have to address to promote a safe discharge in paediatrics: A systematic review and narrative synthesis

AIM

The aim of the study was to synthesize the evidence on the essential elements, nurses must address when they perform therapeutic education to patients and their caregivers to promote a safe paediatric hospital-to-home discharge.

DESIGN

A systematic review and narrative synthesis.

METHODS

The search strategy identifies studies published between 2016 and 2023. The quality of the included studies was assessed using the Critical Appraisal Skills Programme checklists. The protocol of this review was not registered. A search of three electronic databases (PubMed, CINAHL and Web of Science) and a search in the reference lists of the included studies was conducted in February 2021 and June 2023.

RESULTS

Fifteen studies met the inclusion criteria. The essential elements identified are grouped into the following topics: emergency management, physiological needs, medical device and medications management, long-term management and short-term management. Nurses have a critical role in ensuring patient safety and quality of care, and the nurses' competence makes the difference in the discharge's related outcomes. Our results can help the nursing profession implement comprehensive discharge projects. Our results support the improvement of nurse-led paediatric discharge programmes. Nurse managers can identify the grey areas of therapeutic education provided in their units and work for their improvement. Following the implementation of therapeutic education on these topics, measuring the discharge's related outcomes could be interesting. This study addresses the problem of managing a safe and efficient nurse-led discharge in a paediatric setting. It presents evidence on the essential elements to promote a safe paediatric discharge at home. These could impact nursing practice by using them to implement project and discharge pathways. We have adhered to relevant EQUATOR guidelines-PRISMA guidelines for reporting systematic review. No patients, service users, caregivers or public members were involved in this study due to its nature (systematic review).

Exploring Telehealth to Improve Discharge Outcomes in Children

OBJECTIVES

The inpatient to outpatient transition is critical for patient safety but suffers from lack of standardization and communication. Expanding telehealth use allows unique opportunities to leverage secure video conferencing to streamline communication between families and hospital-based providers (HBPs) after hospital discharge. We conducted a qualitative study to evaluate HBP and caregiver beliefs regarding a proposed telehealth follow-up visit after hospital discharge (THDF).

METHODS

Interviews were conducted with pediatric hospitalists, senior pediatric residents, and caregivers of patients recently hospitalized on the study hospital's pediatric hospitalist service. Authors developed consensus regarding major themes to inform THDF design. These were organized into a conceptual model.

RESULTS

We conducted 23 interviews with 6 hospitalists, 6 senior residents, and 11 caregivers. Three primary themes were identified: (1) Caregivers and HBPs agree THDF would be beneficial for patients and families; however, evidence is not robust enough to solidify provider buy-in. (2) Telehealth should supplement and enhance current discharge practices; it should not serve as a bandage for a broken system. Although a key aspect of THDF is to have the hospitalist provide follow-up care, this should be provided in addition to primary care provider follow-up. (3) HBPs expressed concerns about challenging workflows, competing demands, and inadequate resources, which are potential barriers to widespread adoption.

CONCLUSIONS

THDF leverages expanding telehealth use to provide hospital-based follow-up. While HBPs shared workflow challenges in conducting telehealth, HBPs and caregivers believed potential benefits of THDF outweighed the challenges. This qualitative study will guide implementation of THDF in future studies.

Management of Discharge Instructions for Children With Medical Complexity: A Systematic Review

CONTEXT

Children with medical complexity (CMC) are at risk for adverse outcomes after discharge. Difficulties with comprehension of and adherence to discharge instructions contribute to these errors. Comprehensive reviews of patient-, caregiver-, provider-, and system-level characteristics and interventions associated with discharge instruction comprehension and adherence for CMC are lacking.

OBJECTIVE

To systematically review the literature related to factors associated with comprehension of and adherence to discharge instructions for CMC.

DATA SOURCES

PubMed/Medline, Embase, Cochrane Central Register of Controlled Trials, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, Web of Science (database initiation until March 2023), and OAIster (gray literature) were searched.

STUDY SELECTION

Original studies examining caregiver comprehension of and adherence to discharge instructions for CMC (Patient Medical Complexity Algorithm) were evaluated.

DATA EXTRACTION

Two authors independently screened titles/abstracts and reviewed full-text articles. Two authors extracted data related to study characteristics, methodology, subjects, and results.

RESULTS

Fifty-one studies were included. More than half were qualitative or mixed methods studies. Few interventional studies examined objective outcomes. More than half of studies examined instructions for equipment (eg, tracheostomies). Common issues related to access, care coordination, and stress/anxiety. Facilitators included accounting for family context and using health literacy-informed strategies.

LIMITATIONS

No randomized trials met inclusion criteria. Several groups (eg, oncologic diagnoses, NICU patients) were not examined in this review.

CONCLUSIONS

Multiple factors affect comprehension of and adherence to discharge instructions for CMC. Several areas (eg, appointments, feeding tubes) were understudied. Future work should focus on design of interventions to optimize transitions.

Pediatric Resident Communication of Hospital Discharge Instructions

OBJECTIVE

Suboptimal provider-parent communication contributes to poor parent comprehension of pediatric discharge instructions, which can lead to adverse outcomes. Residency is a critical window to acquire and learn to utilize key communication skills, potentially supported by formal training programs or visual reminders. Few studies have examined resident counseling practices or predictors of counseling quality. Our objectives were to (1) examine pediatric resident counseling practices and (2) determine how formal training and presence of discharge templates with domain-specific prompts are associated with counseling.

METHODS

We conducted a cross-sectional survey of a convenience sample of residents in the American Academy of Pediatrics Section on Pediatric Trainees. Outcomes included resident self-report of frequency of (1) counseling in domains of care and (2) use of health literacy-informed counseling strategies (pictures, demonstration, Teach Back, Show Back) (6-point scales; frequent = often/usually/always). Predictor variables were (1) formal discharge-related training (e.g., lectures) and (2) hospital discharge instruction template with space for individual domains. Logistic regression analyses, utilizing generalized estimating equations when appropriate to account for multiple domains (adjusting for resident gender, postgraduate year), were performed.

KEY RESULTS

Few residents (N = 317) (13.9%) reported formal training. Over 25% of residents infrequently counsel on side effects, diagnosis, and restrictions. Resident reported use of communication strategies was infrequent: drawing pictures (24.1%), demonstration (15.8%), Teach Back (36.8%), Show Back (11.4%). Designated spaces in instruction templates for individual domains were associated with frequent domain-specific counseling (adjusted odds ratio [aOR] 4.1 [95% confidence interval: 3.5-4.8]). Formal training was associated with frequent Teach Back (aOR 2.6 [1.4-5.1]) and Show Back (aOR 2.7 [1.2-6.2]).

CONCLUSIONS

Lack of formal training and designated space for domain-specific instructions are associated with suboptimal counseling at discharge by pediatric residents. Future research should focus on determining the best mechanisms for teaching trainees communication skills and optimizing written instruction templates to support verbal counseling. [HLRP: Health Literacy Research and Practice. 2023;7(4):e178-e186.].

Reduced Postdischarge Incidents After Implementation of a Hospital-to-Home Transition Intervention for Children With Medical Complexity

OBJECTIVES

Prior research suggests that errors occur frequently for patients with medical complexity during the hospital-to-home transition. Less is known about effective postdischarge communication strategies for this population. We aimed to assess rates of 30-day (1) postdischarge incidents and (2) readmissions and emergency department (ED) visits before and after implementing a hospital-to-home intervention.

METHODS

We conducted a prospective intervention study of children with medical complexity discharged at a children's hospital from April 2018 to March 2020. A multistakeholder team developed a bundled intervention incorporating the I-PASS handoff framework including a postdischarge telephone call, restructured discharge summary, and handoff communication to outpatient providers. The primary outcome measure was rate of postdischarge incidents collected via electronic medical record review and family surveys. Secondary outcomes were 30-day readmissions and ED visits.

RESULTS

There were 199 total incidents and the most common were medication related (60%), equipment issues (15%), and delays in scheduling/provision of services (11%). The I-PASS intervention was associated with a 36.4% decrease in the rate of incidents per discharge (1.51 versus 0.95, P = 0.003). There were fewer nonharmful errors and quality issues after intervention (1.27 versus 0.85 per discharge, P = 0.02). The 30-day ED visit rate was significantly lower after intervention (12.6% versus 3.4%, per 100 discharges, P = 0.05). Thirty-day readmissions were 15.8% versus 10.2% postintervention (P = 0.32).

CONCLUSIONS

A postdischarge communication intervention for patients with medical complexity was associated with fewer postdischarge incidents and reduced 30-day ED visits. Standardized postdischarge communication may play an important role in improving quality and safety in the transition from hospital-to-home for vulnerable populations.

Pharmacist-Led Discharge Transitions of Care Interventions for Pediatric Patients: A Narrative Review

Transitions of care (TOC) before, during, and after hospital discharge are an opportune setting to optimize medication management. The quality standards for pediatric care transitions, however, are lacking, leading to reduced health outcomes in children. This narrative review characterizes the pediatric populations that would benefit from focused, TOC interventions. Different types of medication-focused TOC interventions during hospital discharge are described, including medication reconciliation, education, access, and adherence tools. Various TOC intervention delivery models following hospital discharge are also reviewed. The goal of this narrative review is to help pediatric pharmacists and pharmacy leaders better understand TOC interventions and integrate them into the hospital discharge process for children and their caregivers.

Child Opportunity Index and Hospital Utilization in Children With Traumatic Brain Injury Admitted to the PICU

The need to understand how Community-based disparities impact morbidity and mortality in pediatric critical illness, such as traumatic brain injury. Test the hypothesis that ZIP code-based disparities in hospital utilization, including length of stay (LOS) and hospital costs, exist in a cohort of children with traumatic brain injury (TBI) admitted to a PICU using the Child Opportunity Index (COI).

DESIGN

Multicenter retrospective cohort study.

SETTING

Pediatric Health Information System (PHIS) database.

PATIENTS

Children 0-18 years old admitted to a PHIS hospital with a diagnosis of TBI from January 2016 to December 2020 requiring PICU care. To identify the most severely injured children, a study-specific definition of "Complicated TBI" was created based on radiology, pharmacy, and procedure codes.

INTERVENTIONS

None.

Main Outcomes and Measures

Using nationally normed ZIP code-level COI data, patients were categorized into COI quintiles. A low COI ZIP code has low childhood opportunity based on weighted indicators within educational, health and environmental, and social and economic domains. Population-averaged generalized estimating equation (GEE) models, adjusted for patient and clinical characteristics examined the association between COI and study outcomes, including hospital LOS and accrued hospital costs. The median age of this cohort of 8,055 children was 58 months (interquartile range [IQR], 8-145 mo). There were differences in patient demographics and rates of Complicated TBI between COI levels. The median hospital LOS was 3.0 days (IQR, 2.0-6.0 d) and in population-averaged GEE models, children living in very low COI ZIP codes were expected to have a hospital LOS 10.2% (95% CI, 4.1-16.8%; p = 0.0142) longer than children living in very high COI ZIP codes. For the 11% of children with a Complicated TBI, the relationship between COI and LOS was lost in multivariable models. COI level was not predictive of accrued hospital costs in this study.

CONCLUSIONS

Children with TBI requiring PICU care living in low-opportunity ZIP codes have higher injury severity and longer hospital LOS compared with children living in higher-opportunity ZIP codes. Additional studies are needed to understand why these differences exist.

Parental caregivers' perception of their transition from hospital to home in children with cerebral palsy who have undergone orthopedic surgery

PURPOSE

Evaluate parental perception of the quality of discharge teaching, readiness for discharge, and the impact of these on post discharge coping difficulty and resource utilization in children with cerebral palsy (CP) following surgery.

DESIGN AND METHODS

Prospective cohort study conducted from September 2017-March 2021 at a pediatric academic medical center. Demographics were collected pre-operatively. Parents completed the Readiness for Hospital Discharge Scale (RHDS) and Quality of Discharge Teaching Scale (QDTS) within four hours of discharge. Four weeks post-discharge, parents completed the Post-discharge Coping Difficulty Scale (PDCDS). Utilization of healthcare resources were extracted from the electronic health record for 90 days post-operatively. Associations among demographics, RHDS, QDTS, PDCDS and resource utilization were assessed using general linear models; PDCDS's open-ended questions were analyzed using directed content analysis.

RESULTS

114 parental caregivers participated. Post discharge coping was significantly associated with additional resource utilization: length of stay (p = 0.046), readmissions (p = 0.001), emergency department visits (p = 0.001), clinic calls (p = 0.001) and unplanned clinic visits (p = 0.006). PDCDS was negatively correlated with the QDTS Quality of Teaching Delivered subscale (r = -0.32; p = 0.004) and three of five RHDS subscales: 1) Child's Personal Status (r = -0.24; p = 0.02); 2) Knowledge (r = -0.30; p = 0.005); and 3) Coping Ability (r = -0.39; p < 0.001). Four themes explicated parental coping difficulties.

CONCLUSION

Parents experiencing coping difficulties were more likely to have difficulty managing their child's care needs at home and required additional health care resources.

PRACTICE IMPLICATIONS

Recognizing that parents' readiness for discharge may not reflect their coping abilities post-discharge requiring nurses to coordinate pre- and post-discharge education and support services.

Delays in Hospital Discharge for Children in Foster Care: Reasons and Recommendations From a Multisite Study

OBJECTIVE

To elucidate challenges to timely hospital discharge of children in foster care (CFC).

METHODS

Inpatient providers with prior experience caring for CFC were recruited from 6 mid-Atlantic hospitals. Semi-structured interviews were conducted to explore provider experience discharging CFC. Conventional content analysis was applied to interview transcripts with Dedoose software.

RESULTS

Interviews were completed with 15 MDs/NPs, 11 RNs, 10 social workers, and 2 case managers. Participants explained that delayed discharge is the norm for CFC, especially for those entering new foster care placements. Participants detailed challenges to efficiently discharging CFC, which were categorized into 3 themes: 1) Waiting for discharge disposition: Providers' ability to proceed with discharge planning is contingent on procedural steps (eg, court decisions) needed to determine disposition (eg, entering new foster care placement); 2) Medically cleared, but no place to go: Participants report placement searches are often not initiated by child welfare until the child is medically cleared. Lack of available, appropriate foster care placements delays discharge, particularly for children with complex medical or behavioral diagnoses; 3) Coordinating for a safe discharge: Establishing a safe discharge for CFC involves meticulous discharge planning, foster parent training, and multidisciplinary team communication/coordination.

CONCLUSION

Delayed discharge for CFC is multifactorial, yet often predictable. There are modifiable factors identified that can be addressed to promote timely hospital discharge and prevent medically unnecessary hospital days, benefitting patients in foster care and the hospital system.

Drug-related risk of hospital readmission in children with chronic diseases, a systematic review

BACKGROUND

Drug-related problems (DRPs) are one of the leading causes of hospital readmissions. Children with chronic diseases are more likely to experience DRPs than adults. The burden and characteristics of drug-related readmissions at and after hospital discharge in children remain unclear.

OBJECTIVE

We aimed to summarize the impact of DRPs at and after hospital discharge on the risk of readmissions in children with chronic diseases.

METHODS

We conducted a systematic review searching PubMed from inception until January 2022. Study selection criteria were studies assessing the impact of different factors at discharge and after discharge on the risk of hospital readmissions in children with chronic diseases, reporting an assessment of DRPs. DRP could be the only risk factor assessed or one among others. Included studies were assessed with the Risk of Bias in Non-Randomized Studies - of Exposure (ROBINS-E) tool. We summarized the qualitative impact of the reported DRPs on hospital readmission as conclusive (significant association) or inconclusive.

RESULTS

Of the 4734 studies initially identified, 13 met inclusion criteria. Eleven studies were retrospective, using electronic health records. The studies assessed the impact of DRPs at or after discharge according to the type of medication (in 6 studies), number of medication (in 5 studies) and medication nonadherence (in 2 studies). From the 44 reported associations between DRPs and the risk of readmission 26 (59% [95% CI, 43%-73%]) were conclusive, of which 81% increased the risk and 19% decreased the risk, and 17 (39% [95% CI, 24%-55%]) were inconclusive.

CONCLUSION

The impact of DRPs on hospital readmissions in children with chronic diseases displayed conflicting results, estimated associations having potentially a serious risk of bias. We need more evidence with a lower risk of bias.

One Size Does Not Fit All: Discharge Teaching and Child Challenging Behaviors

This study compares quality of discharge teaching and care coordination for parents of children with challenging behaviors participating in a nursing implementation project, which used an interactive iPad application, to usual discharge care. Unlike parents in the larger quasi-experimental longitudinal project, parents of children with challenging behaviors receiving the discharge teaching application (n = 14) reported lower mean scores on the quality of discharge teaching scale-delivery subscale (M = 8.2, SD = 3.1) than parents receiving usual care (n = 11) (M = 9.6, SD = 4.7) and lower scores on the Care Transition Measure (M = 2.44, SD = 1.09) than parents receiving usual care (M = 3.02, SD = 0.37), with moderate to large effects (0.554-0.775). The discharge teaching approach was less effective with this subset, suggesting other approaches might be considered for this group of parents. Further study with a larger sample specific to parents of children with challenging behaviors is needed to assess their unique needs and to optimize their discharge experience.

Risk factors for hospital readmission among infants with prolonged neonatal intensive care stays

OBJECTIVE

To assess risk factors associated with 30-day hospital readmission after a prolonged neonatal intensive care stay.

STUDY DESIGN

Retrospective analysis of 57,035 infants discharged >14 days from the NICU between 2013 and 2016. Primary outcome was 30-day, all-cause hospital readmission. Adjusted likelihood of readmission accounting for demographic and clinical characteristics, including chronic conditions was also estimated.

RESULTS

The 30-day readmission rate was 10.7%. Respiratory problems accounted for most (31.0%) readmissions. In multivariable analysis, shunted hydrocephalus [OR 2.2 (95%CI 1.8-2.7)], gastrostomy tube [OR 2.0 (95%CI 1.8-2.3)], tracheostomy [OR 1.5 (95%CI 1.2-1.8)], and use of public insurance [OR 1.3 (95%CI 1.2-1.4)] had the highest likelihood of readmission. Adjusted hospital readmission rates varied significantly (p < 0.001) across hospitals.

CONCLUSIONS

The likelihood of hospital readmission was highest for infants with indwelling medical devices and public insurance. These findings will inform future initiatives to reduce readmission for high risk infants with medical and social complexity.

Direct Discharge to Home From the Pediatric Cardiovascular ICU

OBJECTIVES

To describe direct discharge to home from the cardiovascular ICU.

DESIGN

Mixed-methods including retrospective Pediatric Cardiac Critical Care Consortium and Pediatric Acute Care Cardiology Collaborative data and survey.

SETTING

Tertiary pediatric heart center.

PATIENTS

Patients less than 25 years old, with a cardiovascular ICU stay of greater than 24 hours and direct discharge to home from January 1, 2016, to December 8, 2020, were included. Select data describing patients discharged from acute care internally and nationally from Pediatric Acute Care Cardiology Collaborative sites were compared with the direct discharge to home cohort.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Encounter- and patient-specific characteristics. Seven-day and 30-day readmission and 30-day mortality served as surrogate safety markers. A survey of cardiovascular ICU frontline providers assessed comfort and skills related to direct discharge to home.There were 364 direct discharge to home encounters that met inclusion criteria. The majority of direct discharge to home encounters were associated with a surgery or procedure (305; 84%). There were 27 encounters (7.4%) for medical technology-dependent patients requiring direct discharge to home. Unplanned 7-day readmissions among direct discharge to home patients was 1.9% compared with 4.6% (p = 0.04) of patients discharged from acute care internally. Readmission among those discharged from acute care internally did not differ from those at Pediatric Acute Care Cardiology Collaborative sites nationally. Frontline cardiovascular ICU providers had mixed levels of confidence in technical aspects and low levels of confidence in logistics of direct discharge to home.

CONCLUSIONS

Cardiovascular ICU direct discharge to home was not associated with increased unplanned readmissions compared with patients discharged from acute care and may be safe in select patients. Frontline cardiovascular ICU providers feel time constraints challenge direct discharge to home. Further research is needed to identify patient characteristics associated with safe direct discharge to home and systems needed to support this practice.Summary statistics are described using proportions or medians with interquartile ranges (IQRs) and were performed using Microsoft Excel (Microsoft, Redmond, WA). Two-sample tests of proportions were used to compare readmission frequency of the DDH cohort compared with internal and national PAC3 data using STATA Version 15 (StataCorp, College Station, TX).

Multi-Disciplinary Discharge Coordination Team to Overcome Discharge Barriers and Address the Risk of Delayed Discharges

Background

Methods

Results

Conclusion

NICU discharge preparation and transition planning: guidelines and recommendations

In this section, we present Interdisciplinary Guidelines and Recommendations for Neonatal Intensive Care Unit (NICU) Discharge Preparation and Transition Planning. The foundation for these guidelines and recommendations is based on existing literature, practice, available policy statements, and expert opinions. These guidelines and recommendations are divided into the following sections: Basic Information, Anticipatory Guidance, Family and Home Needs Assessment, Transfer and Coordination of Care, and Other Important Considerations. Each section includes brief introductory comments, followed by the text of the guidelines and recommendations in table format. After each table, there may be further details or descriptions that support a guideline or recommendation. Our goal was to create recommendations that are both general and adaptable while also being specific and actionable. Each NICU's implementation of this guidance will be dependent on the unique makeup and skills of their team, as well as the availability of local programs and resources. The recommendations based only on expert opinion could be topics for future research.

Assessing Parental Discharge Readiness by Using the Ticket to Home Survey Tool

OBJECTIVES

Ticket to Home (TTH), a survey tool designed to assess parental comprehension of their child's hospitalization and postdischarge care needs, allows providers to address knowledge gaps before discharge. Our goal was to evaluate the impact of TTH on parents' retention of discharge teaching.

METHODS

In this pilot study, we enrolled a convenience sample of families admitted to pediatric hospital medicine and randomly assigned families on the basis of team assignment. The intervention group received TTH before discharge. The control group received usual care (without TTH survey tool). Both groups were sent a survey 24 to 72 hours postdischarge to assess parental understanding of discharge teaching. A senior-level provider also completed a survey; responses were compared with evaluate parent level of understanding. Descriptive statistics and logistic regression were used for analysis.

RESULTS

Although 495 parents consented to participate, only 100 completed the necessary surveys (41 intervention and 59 control). Both groups showed high parent-provider concordance regarding reason for admission (92.7% intervention versus 86.4% control; P = .33). The intervention group had significantly higher concordance for return precautions (90.2% vs 58.2%; P < .001), which remained significant when controlling for covariates (odds ratio 6.24, 95% confidence interval 1.78-21.93). Most parents in the intervention group felt sharing TTH responses with their medical team was beneficial (95.0%).

CONCLUSIONS

Parents who received TTH before discharge were more likely to accurately recall return precautions and valued sharing TTH results with the team. Given that response bias may have affected pilot results, additional studies in which researchers use larger samples with more diverse patient populations is required.

Improving Discharge Instructions for Hospitalized Children With Limited English Proficiency

BACKGROUND AND OBJECTIVES

Patients with limited English proficiency (LEP) have increased risk of adverse events after hospitalization. At our institution, LEP families did not routinely receive translated discharge instructions in their preferred language. Our objective for this study was to increase the percentage of patients with LEP on the hospital medicine (HM) service receiving translated discharge instructions from 12% to 80%.

METHODS

Following the Model for Improvement, we convened an interdisciplinary team that included HM providers, pediatric residents, language access services staff, and nurses to design and test interventions aimed at key drivers through multiple plan-do-study-act cycles. Interventions addressed the translation request process, care team education, standardizing discharge instructions for common conditions, and identification and mitigation of failures. We used established rules for analyzing statistical process control charts to evaluate the percentage of patients with translated discharge instructions for all languages and for Spanish.

RESULTS

During the study period, 540 patients with LEP were discharged from the HM service. Spanish was the preferred language for 66% of patients with LEP. The percentage of patients with LEP who received translated discharge instructions increased from 12% to 50% in 3 months and to 77% in 18 months. For patients whose preferred language was Spanish, the percentage increased from 16% to 69% in 4 months and to 96% in 18 months.

CONCLUSIONS

Interventions targeting knowledge of the translation process and standardized Spanish discharge instructions were associated with an increased percentage of families receiving translated discharge instructions. Future work will be used to assess the impact of these interventions on postdischarge disparities, including emergency department revisits and readmissions.

Factorial Analysis Quantifies the Effects of Pediatric Discharge Bundle on Hospital Readmission

BACKGROUND AND OBJECTIVES

Factorial design of a natural experiment was used to quantify the benefit of individual and combined bundle elements from a 4-element discharge transition bundle (checklist, teach-back, handoff to outpatient providers, and postdischarge phone call) on 30-day readmission rates (RRs).

METHODS

A 2⁴ factorial design matrix of 4 bundle element combinations was developed by using patient data (N = 7725) collected from January 2014 to December 2017 from 4 hospitals. Patients were classified into 3 clinical risk groups (CRGs): no chronic disease (CRG1), single chronic condition (CRG2), and complex chronic condition (CRG3). Estimated main effects of each bundle element and their interactions were evaluated by using Study-It software. Because of variation in subgroup size, important effects from the factorial analysis were determined by using weighted effect estimates.

RESULTS

RR in CRG1 was 3.5% (n = 4003), 4.1% in CRG2 (n = 1936), and 17.6% in CRG3 (n = 1786). Across the 3 CRGs, the number of subjects in the factorial groupings ranged from 16 to 674. The single most effective element in reducing RR was the checklist in CRG1 and CRG2 (reducing RR by 1.3% and 3.0%) and teach-back in CRG3 (by 4.7%) The combination of teach-back plus a checklist had the greatest effect on reducing RR in CRG3 by 5.3%.

CONCLUSIONS

The effect of bundle elements varied across risk groups, indicating that transition needs may vary on the basis of population. The combined use of teach-back plus a checklist had the greatest impact on reducing RR for medically complex patients.

Changes in Assessment of and Satisfaction With Discharge Preparation From the Neonatal Intensive Care Unit

BACKGROUND

A successful transition from the neonatal intensive care unit (NICU) to home is aided by a comprehensive discharge planning program that keeps families involved and engaged with the discharge preparation process.

PURPOSE

To compare the assessment of parental NICU discharge preparedness with parental satisfaction with the NICU discharge preparation.

METHODS

Families were surveyed 4 to 6 weeks after NICU discharge, and those selecting "very prepared" were considered "satisfied" with their discharge preparation. On discharge day, families were considered "prepared" for discharge based on their overall level of preparedness and their nurse's rating of them on a discharge readiness assessment tool.

RESULTS

In total, 1104 families (60%) reported being both "satisfied" and "prepared"; 293 families (16%) were "satisfied" but not "prepared"; 297 families (16%) were not "satisfied" but were "prepared"; and 134 families (7%) were neither "satisfied" nor "prepared." Compared with families that were both "satisfied" and "prepared," families that were neither "satisfied" nor "prepared" were more likely to be raising the infant alone, of Black race, and to have sicker infants.

IMPLICATIONS FOR PRACTICE

Some families are at a higher risk and merit more consideration during NICU discharge planning. Assess the discharge readiness of all families prior to discharge. Those at an increased risk may benefit from more discharge education and training, specifically for single mothers, those with limited resources, or others considered at high risk.

Challenges in pediatric post-sepsis care in resource limited settings: a narrative review

OBJECTIVE

The objective of this narrative review is to outline the current epidemiology and interventional research within the context of sepsis recovery, and to provide a summary of key priorities for future work in this area.

BACKGROUND

Morbidity and mortality secondary to sepsis disproportionately affects children, especially those in low- and middle-income countries (LMICs), where over 85% of global cases and deaths occur. These regions are plagued by poorly resilient health systems, widespread socio-economic deprivation and unique vulnerabilities such as malnutrition. Reducing the overall burden of sepsis will require a multi-pronged strategy that addresses all three important periods along the sepsis care continuum - pre-facility, facility and post-facility. Of these aspects, post-facility issues have been largely neglected in research, practice and policy, and are thus the focus of this review.

METHODS

Relevant data for this review was identified through a literature search using PubMed, through a review of the citations of select systematic reviews and from the personal repositories of articles collected by the authors. Data is presented within three sections. The first two sections on the short and long-term outcomes among sepsis survivors each outline the epidemiology as well as review relevant interventional research done. Where clear gaps exist, these are stated. The third section focuses on priorities for future research. This section highlights the importance of data (and data systems) and of innovative interventional approaches, as key areas to improve research of post-sepsis outcomes in children.

CONCLUSIONS

During the initial post-facility period, mortality is high with as many children dying during this period as during the acute period of hospitalization, mostly due to recurrent illness (including infections) which are associated with malnutrition and severe acute disease. Long-term outcomes, often labelled as post-sepsis syndrome (PSS), are characterized by a lag in developmental milestones and suboptimal quality of life (QoL). While long-term outcomes have not been well characterized in resource limited settings, they are well described in high-income countries (HICs), and likely are important contributors to long-term morbidity in resource limited settings. The paucity of interventional research to improve post-discharge outcomes (short- or long-term) is a clear gap in addressing its burden. A focus on the development of improved data systems for collecting routine data, standardized definitions and terminology and a health-systems approach in research need to be prioritized during any efforts to improve outcomes during the post-sepsis phase.

Parent Perceptions and Experiences Regarding Medication Education at Time of Hospital Discharge for Children With Medical Complexity

BACKGROUND

Children with medical complexity (CMC) often require complex medication regimens. Medication education on hospital discharge should provide a critical safety check before medication management transitions from hospital to family. Current discharge processes may not meet the needs of CMC and their families. The objective of this study is to describe parent perspectives and priorities regarding discharge medication education for CMC.

METHODS

We performed a qualitative, focus-group-based study, using ethnography. Parents of hospitalized CMC were recruited to participate in 1 of 4 focus groups; 2 were in Spanish. Focus groups were recorded, transcribed, and then coded and organized into themes by using thematic analysis.

RESULTS

Twenty-four parents participated in focus groups, including 12 native English speakers and 12 native Spanish speakers. Parents reported a range of 0 to 18 medications taken by their children (median 4). Multiple themes emerged regarding parental ideals for discharge medication education: (1) information quality, including desire for complete, consistent information, in preferred language; (2) information delivery, including education timing, and delivery by experts; (3) personalization of information, including accounting for literacy of parents and level of information desired; and (4) self-efficacy, or education resulting in parents' confidence to conduct medical plans at home.

CONCLUSIONS

Parents of CMC have a range of needs and preferences regarding discharge medication education. They share a desire for high-quality education provided by experts, enabling them to leave the hospital confident in their ability to care for their children once home. These perspectives could inform initiatives to improve discharge medication education for all patients, including CMC.

Discharge planning considerations for the neonatal intensive care unit

Neonatal intensive care unit (NICU) discharge readiness is the primary caregivers' masterful attainment of technical care skills and knowledge, emotional comfort and confidence with infant care by the time of discharge. NICU discharge preparation is the process of facilitating discharge readiness. Discharge preparation is the process with discharge readiness as the goal. Our previous work described the importance of NICU discharge readiness and strategies for discharge preparation from an American medical system perspective. NICU discharge planning is, however, of international relevance as challenges in relation to hospital discharge are a recurring global theme. In this manuscript, we conceptualise NICU discharge preparation with international perspective.

One Call Away: Addressing a Safety Gap for Urgent Issues Post Discharge

OBJECTIVES

The transition period from hospitalization to outpatient care can be high risk for pediatric patients. Our aim was to profile the use of a "safety net" for families through provision of specific inpatient provider contact information for urgent issues post discharge.

METHODS

In this prospective study, we implemented an updated after-visit summary that directed families to call the hospital operator and specifically ask for the pediatric hospital medicine attending on call if they were unable to reach their primary care provider (PCP) with an urgent postdischarge concern. Education for nursing staff, operators, and pediatric hospital medicine providers was completed, and contact information was automatically populated into the after-visit summary. Information collected included the number of calls, the topic, time spent, whether the family contacted the PCP first, and the time of day. Descriptive statistics and Fisher's exact test were used to summarize findings.

RESULTS

Over a 13-month period, of 5145 discharges, there were 47 postdischarge phone calls, which averaged to 3.6 calls per month. The average length of time spent on a call was 21 minutes. For 30% of calls, families had tried contacting their PCPs first, and 55% of calls occurred at night. Topics of calls included requesting advice about symptoms, time line for reevaluation, and assistance with medications.

CONCLUSIONS

This safety net provided families with real-time problem-solving for an urgent need post discharge, which included triaging patient symptoms at home, counseling on medication questions, information about the time line of illness recovery, and provision of additional resources.

Posthospitalization follow-up recommendations after pediatric critical illness due to respiratory failure

OBJECTIVES

To characterize the recommended posthospitalization follow-up by provider type and location after a pediatric critical illness due to respiratory failure.

WORKING HYPOTHESIS

After pediatric critical illness due to respiratory failure, patients will not have a standard follow-up pattern with regard to provider type or follow-up location.

STUDY DESIGN

A retrospective cohort study.

SUBJECT SELECTION

Children, 18 years or younger, admitted to a quaternary care pediatric intensive care unit with respiratory failure between January 1, 2013 and December 31, 2014.

METHODOLOGY

For eligible patients, recommendations for posthospitalization follow-up including provider type (primary care and specialty care) and location (community care center vs. tertiary care center) were characterized from medical chart review. Recommendations were examined for all patients and two patient subgroups (patients who received extracorporeal membrane oxygenation and patients with tracheostomy).

RESULTS

Of 155 patients alive at hospital discharge, the median age was 2.1 (interquartile range, 0.7-10.6) years. Eighty percent of patients were instructed to follow-up with a primary care provider but only 52.9% with a pulmonologist. We found 10 unique follow-up patterns between provider location (community care center, tertiary care center, or both) and global provider type (primary care versus specialty care). Primary care follow-up was recommended more often at community locations (74.2%), whereas specialty care was more often recommended at tertiary care centers (68.6%).

CONCLUSIONS

Our study findings demonstrate significant variability in the recommendations for follow-up by provider type and location after hospitalization for acute respiratory failure and highlight areas for improvement in follow-up care after pediatric critical illness.

Safe transitions from the hospital to home: A review of the pediatric hospitalist's discharge workflow

For children to have safe transitions from the hospital to home, inpatient physicians, nurse practitioners, and physician assistants, should use a standardized discharge process that focuses on thorough discharge planning, multidisciplinary teamwork, communication, and effective hand-offs of care.  Using quality improvement science will help physicians analyze and improve their discharge process and ensure safe discharges.

Children with medical complexity: A concept analysis

AIM

The aim of this paper is to conduct a concept analysis on the term, "children with medical complexity."

BACKGROUND

Children with medical complexity (CMC) describes pediatric patients with chronic, sustained acuity; however, there is a lack of consensus in the literature regarding its exact meaning, characteristics, and implications.

DESIGN

This analysis relied upon the framework described by Walker and Avant.

DATA SOURCE

The CINAHL, MEDLINE, and PubMed databases were queried from April 2020 to December 2020 with an initial search of the literature for the keyword, "children with medical complexity" and other associated terms, such as "pediatric medical complexity" and "nursing care of children with medical complexity."

REVIEW METHODS

This analysis will explore the concept of CMC and its significance, attributes, antecedents, and consequences.

RESULTS

This investigation revealed that CMC are a growing population of pediatric patients who have one or more complex chronic conditions that affect multiple body systems, experience functional limitations, require extensive care coordination from multiple providers, and are dependent upon life-sustaining medical technology.

CONCLUSIONS

The findings can serve as a foundation for future work advancing the understanding of the topic of CMC.

Disparity in Nurse Discharge Communication for Hospitalized Families Based on English Proficiency

OBJECTIVES

Effective communication is critical for safely discharging hospitalized children, including those with limited English proficiency (LEP), who are at high risk of reuse. Our objective was to describe and compare the safety and family centeredness of nurse communication at hospital discharge for English-proficient (EP) and LEP families.

METHODS

In this single-center, cross-sectional study, we used direct observation of hospital discharges for EP and LEP children. Observers recorded quantitative and qualitative details of nurse-family communication, focusing on 3 domains: safe discharge, family centeredness, and family engagement. Patient characteristics and percentages of encounters in which all components were discussed within each domain were compared between EP and LEP encounters by using Fisher's exact tests. We used field notes to supplement quantitative findings.

RESULTS

We observed 140 discharge encounters; 49% were with LEP families. Nurses discussed all safe discharge components in 31% of all encounters, most frequently omitting emergency department return precautions. Nurses used all family-centered communication components in 11% and family-engagement components in 89% of all encounters. Nurses were more likely to discuss all components of safe discharge in EP encounters when compared with LEP encounters (53% vs 9%; P < .001; odds ratio: 11.5 [95% confidence interval 4.4-30.1]). There were no differences in family centeredness or family engagement between LEP and EP encounters.

CONCLUSIONS

Discharge encounters of LEP patients were less likely to include all safe discharge communication components, compared with EP encounters. Opportunities to improve nurse-family discharge communication include providing written discharge instructions in families' primary language, ensuring discussion of return precautions, and using teach-back to optimize family engagement and understanding.

Implementation of a Standardized Approach to Improve the Pediatric Discharge Medication Process

BACKGROUND AND OBJECTIVES

The pediatric inpatient discharge medication process is complicated, and caregivers have difficulty managing instructions. Authors of few studies evaluate systematic processes for ensuring quality in these care transitions. We aimed to improve caregiver medication management and understanding of discharge medications by standardizing the discharge medication process.

METHODS

An interprofessional team at an urban, tertiary care children's hospital trialed interventions to improve caregiver medication management and understanding. These included mnemonics to aid in complete medication counseling, electronic medical record enhancements to standardize medication documentation and simplify dose rounding, and housestaff education. The primary outcome measure was the proportion of discharge medication-related failures in each 4-week period. Failure was defined as an incorrect response on ≥1 survey questions. Statistical process control was used to analyze improvement over time. Process measures related to medication documentation and dose rounding were compared by using the χ² test and process control.

RESULTS

Special cause variation occurred in the mean discharge medication-related failure rate, which decreased from 70.1% to 36.1% and was sustained. There were significantly more complete after-visit summaries (21.0% vs 85.1%; P < .001) and more patients with simplified dosing (75.2% vs 95.6%; P < .001) in the intervention period. Special cause variation also occurred for these measures.

CONCLUSIONS

A systematic approach to standardizing the discharge medication process led to improved caregiver medication management and understanding after pediatric inpatient discharge. These changes could be adapted by other hospitals to enhance the quality of this care transition.

Development and Implementation of a Complex Health System Intervention Targeting Transitions of Care from Hospital to Post-acute Care

BACKGROUND

Failure of effective transitions of care following hospitalization can lead to excess days in the hospital, readmissions, and adverse events. Evidence identifies both patient and system factors that influence poor care transitions, yet health systems struggle to translate evidence into complex interventions that have a meaningful impact on care transitions.

OBJECTIVE

We report on our experience developing, pilot testing, and evaluating a complex intervention (Addressing Complex Transitions program, or ACT program) that aims to improve care transitions for complex patients.

DESIGN

Following the Medical Research Council (MRC) framework, we engaged in iterative, stakeholder-driven work to develop a complex care intervention, assess feasibility and pilot methods, evaluate the intervention in practice, and facilitate ongoing implementation monitoring and dissemination.

PARTICIPANTS

Patients receiving care from UW Medicine's health system including 4 hospitals and 20-site Post-Acute Care network.

INTERVENTION

Literature review and prospective data collection activities informed ACT program design. ACT program components include a tailored risk calculator that provides real-time scoring of transitions of care risk factors, a multidisciplinary team with the capacity to address complex barriers to safe transitions, and enhanced discharge workflows to improve care transitions for complex patients.

KEY MEASURES

Program evaluation metrics included estimated hospital days saved and program acceptance by care team members.

KEY RESULTS

During the 6-month pilot, 565 patients were screened and 97 enrolled in the ACT program. An estimated 664 hospital days were saved for the index admission of ACT program participants. Analysis of pre/post-hospital utilization for ACT program participants showed an estimated 3227 fewer hospital days after ACT program enrollment.

CONCLUSIONS

Health systems need to address increasingly difficult challenges in care delivery. The use of evidence-based frameworks, such as the MRC framework, can guide systems to design complex interventions that respond to their local context and stakeholder needs.

Video discharge instructions for pediatric gastroenteritis in an emergency department: a randomized, controlled trial

The aim was to evaluate if the addition of video discharge instructions (VDIs) to usual verbal information improved the comprehension of information provided to caregivers of patients who consult for acute gastroenteritis (AGE). We conducted an open-label, parallel, randomized trial, enrolling patients who consulted for AGE at a tertiary hospital. First, caregivers answered a written test concerning AGE characteristics and management. They were randomly allocated to a control group, which received the usual verbal instructions, or to an intervention group, which additionally received VDI. After discharge, caregivers were contacted by telephone and answered the same test, satisfaction questions, and follow-up information. From September 2019 to March 2020, 139 patients were randomized, 118 completed follow-up. The mean score was 3.13 (SD 1.07) over 5 points in the initial test and 3.96 (SD 0.96) in the follow-up test. Patients in the intervention group had a greater improvement (1.17 points, SD 1.11) than those in the control group (0.47 points, SD 0.94, p < 0.001). In the follow-up test, 49.1% in the intervention group and 18.6% in the control group answered all questions correctly (p < 0.001). There were no significant differences in return visits. Caregivers gave high satisfaction scores regardless of the allocation group.Conclusion: Video instructions improve caregivers' understanding of discharge information.Trial registration: [NCT04463355, retrospectively registered July 9, 2020]. What is Known: • Poor comprehension of discharge instructions leads to incorrect treatment after discharge, increased readmissions and a reduction of caregivers' satisfaction. • Video discharge instructions are useful providing concise information independently of the patients' health literacy level or communication skills of the health care provider What is New: • The addition of video discharge instructions to verbal instructions improves caregivers' knowledge about AGE improved with respect to those who only receive verbal instructions • Video instructions do not add extra time to the emergency department visits.

A systematic concept analysis of 'technology dependent': challenging the terminology

There are an increasing number of children who are dependent on medical technology to sustain their lives. Although significant research on this issue is taking place, the terminology used is variable and the concept of technology dependence is ill-defined. A systematic concept analysis was conducted examining the attributes, antecedents, and consequences of the concept of technology dependent, as portrayed in the literature. We found that this concept refers to a wide range of clinical technology to support biological functioning across a dependency continuum, for a range of clinical conditions. It is commonly initiated within a complex biopsychosocial context and has wide ranging sequelae for the child and family, and health and social care delivery.Conclusion: The term technology dependent is increasingly redundant. It objectifies a heterogenous group of children who are assisted by a myriad of technology and who adapt to, and function with, this assistance in numerous ways. What is Known: • There are an increasing number of children who require medical technology to sustain their life, commonly referred to as technology dependent. This concept analysis critically analyses the relevance of the term technology dependent which is in use for over 30 years. What is New: • Technology dependency refers to a wide range of clinical technology to support biological functioning across a dependency continuum, for a range of clinical conditions. It is commonly initiated within a complex biopsychosocial context and has wide-ranging sequelae for the child and family, and health and social care delivery. • The paper shows that the term technology dependent is generally portrayed in the literature in a problem-focused manner. • This term is increasingly redundant and does not serve the heterogenous group of children who are assisted by a myriad of technology and who adapt to, and function with, this assistance in numerous ways. More appropriate child-centred terminology will be determined within the TechChild project.

Parent Perspectives on Short-Term Recovery After Spinal Fusion Surgery in Children With Neuromuscular Scoliosis

Family perspectives on short-term recovery after spinal fusion for neuromuscular scoliosis are essential for improving patient outcomes. Semistructured interviews were conducted with 18 families of children within 3 months after spinal fusion performed August 2017 to January 2019 at a children's hospital. Interviews were recorded, transcribed, and coded line-by-line by 2 independent reviewers using grounded theory to identify themes. Five themes emerged among families when reflecting back on the postoperative recovery: (1) communicating and making shared decisions regarding postoperative care in a patient- and family-centered manner, (2) setting hospital discharge goals and being ready for discharge, (3) planning for transportation from hospital to home, (4) acquiring supports for caregiving at home after discharge, and (5) anticipating a long recovery at home. Important family perceptions were elicited about the recovery of children from spinal fusion for neuromuscular scoliosis that will inform better perioperative planning for clinicians, future patients, and their families.

Nudging Discharge Readiness With a Poster: A Sequential, Exploratory Mixed Methods Pilot Study of Patient Caregivers

Many hospitals face a common challenge: limited space for a high number of patients. This has led to quick patient throughput, which can impact patient perception of discharge readiness. This study examined whether a poster highlighting tasks to complete as part of the discharge process improved caregiver perception of readiness to transition home. Using a sequential, exploratory mixed methods design, focus groups were convened to explore clinical staff perspective on the discharge process on 3 pediatric inpatient units at a large, urban, pediatric academic medical center in the United States. Analysis of this content informed the design of a poster intervention to “nudge” caregivers (eg, parents, legal guardians) toward readiness and self-efficacy that was then tested in a randomized, controlled experiment. The poster focused on practical knowledge for specific areas of transition adjustment, such as medication and care recipient recovery behaviors, barriers, and enablers. Caregivers (n = 135) completed surveys at discharge indicating their perceived readiness to transition home with their child. Analysis of covariance was used to test the effect of the poster condition (poster vs no poster) on caregiver readiness, preparedness, and confidence for discharge while controlling for previous admission history. Significant effects for poster presence were found on caregivers’ perceived readiness for discharge, F_1,125 = 7.75, P = .006, Cohen’s d = 0.44; and caregivers’ perceived preparedness for the transition home, F_1,121 =7.24, P = .008, Cohen’s d = 0.44. Only a marginal effect was found for poster condition on caregivers’ confidence ratings, F_1,125 = 2.93, P = .090, Cohen’s d = 0.29. The results suggest that simple nudges in the patient care environment may yield measurable improvements in caregiver outcomes.

Engaging Parents in Education for Discharge (ePED): Evaluating the Reach, Adoption & Implementation of an Innovative Discharge Teaching Method

PURPOSE

This paper describes the evaluation of the implementation of an innovative teaching method, the "Engaging Parents in Education for Discharge" (ePED) iPad application (app), at a pediatric hospital.

DESIGN AND METHODS

The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to guide the evaluation. Three of the five RE-AIM elements are addressed in this study: Reach, Adoption, and Implementation.

RESULTS

The Reach of the ePED was 245 of 1015 (24.2%) patient discharges. The Adoption rate was 211 of 245 (86%) patients discharged in the five months' study period. High levels of fidelity (89.3%) to Implementation of the ePED were attained: the Signs and Symptoms domain had the highest (93%) and Thinking Forward about Family Adjustment screen had the lowest fidelity (83.3%). Nurse themes explained implementation fidelity: "It takes longer", and "Forgot to do it."

CONCLUSIONS

The ePED app operationalized how to have an engaging structured discharge conversation with parents. While the Reach of the ePED app was low under the study conditions, the adoption rate was positive. Nurses were able to integrate a theory-driven practice change into their daily routine when using the ePED app.

IMPLICATIONS FOR PRACTICE

The rates of adoption and implementation fidelity support the feasibility of future hospital wide implementation to improve patient and family healthcare experience. Attention to training of new content and the interactive conversation approach will be needed to fully leverage the value of the ePED app. Future studies are needed to evaluate the maintenance of the ePED app.

Factors associated with discharge delay and direct discharge home from paediatric intensive care

AIM

To examine the patient and hospital admission characteristics associated with direct discharge home from paediatric intensive care.

METHODS

This was a single-centre retrospective analysis of all admissions to a tertiary metropolitan general paediatric intensive care unit (ICU) surviving to discharge over a 10-year period between 1 January 2007 and 31 December 2016, divided into two epochs defined by changes in health service structure. Patient and admission characteristics were compared between groups discharged direct to home and discharged to ward across these two epochs.

RESULTS

There was a marked increase in the annual rate of direct discharge to home from ICU between the two epochs (3.7-9.5%, P < 0.0001). There was an inverse relationship between monthly ICU activity and rates of direct discharge to home. Patients discharged directly home were significantly more likely to experience delay to discharge (46.4 vs. 30.7%, P < 0.0001), for that delay to exceed 24 h and comprise a greater proportion of total ICU length of stay. Bronchiolitis accounted for an increasing proportion of admissions between epochs (7.0-15.1%) and was over-represented among patients discharged direct to home (up to 18.2%).

CONCLUSIONS

The high observed rate of direct discharge home is likely to have resulted from increased delays to discharge and changes to patient admission characteristics, attributable to organisational restructuring and possibly changing approaches to clinical management of bronchiolitis. It is imperative to now consider how we ensure that our systems support the proper use of intensive care resources.

Using the Engaging Parents in Education for Discharge (ePED) iPad Application to Improve Parent Discharge Experience

PURPOSE

The purpose of this study was to evaluate the use of the Engaging Parents in Education for Discharge (ePED) iPad application on parent experiences of hospital discharge teaching and care coordination. Hypotheses were: parents exposed to discharge teaching using ePED will have 1) higher quality of discharge teaching and 2) better care coordination than parents exposed to usual discharge teaching. The secondary purpose examined group differences in the discharge teaching, care coordination, and 30-day readmissions for parents of children with and without a chronic condition.

DESIGN/METHODS

Using a quasi-experimental design, ePED was implemented on one inpatient unit (n = 211) and comparison group (n = 184) from a separate unit at a pediatric academic medical center. Patient experience outcome measures collected on day of discharge included Quality of Discharge Teaching Scale-Delivery (QDTS-D) and care coordination measured by Care Transition Measure (CTM). Thirty-day readmission was abstracted from records.

RESULTS

Parents taught using ePED reported higher QDTS-D scores than parents without ePED (p = .002). No differences in CTM were found between groups. Correlations between QDTS-D and CTM were small for ePED (r = 0.14, p 0.03) and non-ePED (r = 0.29, p < .001) parent groups. CTM was weakly associated with 30-day readmissions in the ePED group.

CONCLUSION

The use of ePED by the discharging nurse enhances parent-reported quality of discharge teaching.

PRACTICE IMPLICATIONS

The ePED app is a theory-based structured conversation guide to engage parents in discharge preparation. Nursing implementation of ePED contributes to optimizing the patient/family healthcare experience.

Factors Associated With Return Visits at 7 Days After Hospital Discharge

OBJECTIVE

To identify variables associated with return visits to the hospital within 7 days after discharge.

METHODS

We performed a retrospective study of 7-day revisits and readmissions between October 2012 and September 2015 using the Pediatric Health Information System database supplemented by electronic medical record data from a tertiary-care children's hospital. We examined factors associated with revisits among the top 10 most frequent indications for hospitalization using generalized estimating equations.

RESULTS

There were 736 (4.2%) revisits and 416 (2.3%) readmissions within 7 days. Predictors of 7-day revisits and readmissions included age, length of hospital stay, and presence of a chronic medical condition. In addition, insurance status was associated with risk of revisits and race was associated with risk of readmissions in the bivariate analysis.

CONCLUSIONS

In this study, we identified patient characteristics that may be associated with a higher risk of early return to the emergency department and/or readmissions. Early identification of this at-risk group of patients may provide opportunities for intervention and enhanced care coordination at discharge.

Identifying and Communicating Postdischarge Goals for Hospitalized Children With Medical Complexity: A Process Improvement Pilot in a Specialty Pediatric Setting

INTRODUCTION

Family-centered communication at transitions of care can decrease readmissions and costs for children with medical complexity (CMC). The purpose of this quality improvement project was to improve the communication of postdischarge goals for CMC in a pediatric specialty setting.

METHODS

We used process improvement strategies to implement a Post-Hospitalization Action Grid (PHAG) and a standardized discharge handoff process. Families of hospitalized CMC at high risk for readmission received the pilot intervention over 3 months. Indicators of successful implementation included rates of use of the PHAG, perceptions of integrated care, and usability of the tool.

RESULTS

The PHAG was implemented with 11 of 40 eligible CMC families. Most staff agreed that the new process could improve the communication of postdischarge goals; however, perceptions of integrated care in the organization changed only minimally.

DISCUSSION

The PHAG facilitates family engagement in discharge transitions but requires organizational investment of resources to implement.

A Quality Improvement Intervention Bundle to Reduce 30-Day Pediatric Readmissions

Supplemental Digital Content is available in the text.

Introduction:

Pediatric hospital readmissions can represent gaps in care quality between discharge and follow-up, including social factors not typically addressed by hospitals. This study aimed to reduce the 30-day pediatric readmission rate on 2 general pediatric services through an intervention to enhance care spanning the hospital stay, discharge, and follow-up process.

Methods:

A multidisciplinary team developed an intervention bundle based on a needs assessment and evidence-based models of transitional care. The intervention included pre-discharge planning with a transition coordinator, screening and intervention for adverse social determinants of health (SDH), medication reconciliation after discharge, communication with the primary care provider, access to a hospital-based transition clinic, and access to a 24-hour direct telephone line staffed by hospital attending pediatricians. These were implemented sequentially from October 2013 to February 2017. The primary outcome was the readmission rate within 30 days of index discharge. The length of stay was a balancing measure.

Results:

During the intervention, the included services discharged 4,853 children. The pre-implementation readmission rate of 10.3% declined to 7.4% and remained stable during a 4-month post-intervention observation period. Among 1,394 families screened for adverse SDH, 48% reported and received assistance with ≥ 1 concern. The length of stay increased from 4.10 days in 2013 to 4.30 days in 2017.

Conclusions:

An intervention bundle, including SDH, was associated with a sustained reduction in readmission rates to 2 general pediatric services. Transitional care that addresses multiple domains of family need during a child’s health crisis can help reduce pediatric readmissions.

Implementation of a multidisciplinary discharge videoconference for children with medical complexity: a pilot study

Background

The hospital to home transition for children with medical complexity (CMC) poses many challenges, including suboptimal communication between the hospital and medical home. Our objective was to evaluate the implementation of a discharge videoconference incorporating the patient, caregiver, primary care provider (PCP), hospitalist physician, and case manager.

Methods

We evaluated implementation of this pilot intervention at a freestanding tertiary care children's hospital using mixed methods. A discharge videoconference was conducted for hospitalized children (< 18 years old) meeting complex chronic disease (C-CD) criteria. We collected field notes and conducted surveys and semi-structured interviews. Outcomes included adoption, cost, acceptability, feasibility, and appropriateness. Adoption, cost, and acceptability were analyzed using descriptive statistics. Acceptability, feasibility, and appropriateness were summarized using thematic content analysis.

Results

Adoption: A total of 4 CMC (9% of the 44 eligible children) had discharge videoconferences conducted. Cost (in provider time): On average, videoconferences took 5 min to schedule and lasted 21.5 min. Acceptability: All hospitalists involved (n = 4) were very likely to participate again. Interviews with caregivers (n = 4) and PCPs (n = 5) demonstrated that for those participating, videoconferences were acceptable and appropriate due to benefits including development of a shared understanding, remote physical assessment by the PCP, transparency, and humanization of the care handoff, and increased PCP comfort with care of CMC. Feasibility: Barriers included internet connection quality and scheduling constraints.

Conclusions

This novel, visual approach to discharge communication for CMC had low adoption, possibly related to recruitment strategy. The videoconference posed low time burdens, and participating physicians and caregivers found them acceptable due to a variety of benefits. We identified several feasibility barriers that could be targeted in future implementation efforts.

Validation of a Parent-Reported Hospital-to-Home Transition Experience Measure

OBJECTIVES

The Pediatric Transition Experience Measure (P-TEM) is an 8-item, parent-reported measure that globally assesses hospital-to-home transition quality from discharge through follow-up. Our goal was to examine the convergent validity of the P-TEM with existing, validated process and outcome measures of pediatric hospital-to-home transitions.

METHODS

This was a prospective, cohort study of English-speaking parents and legal guardians who completed the P-TEM after their children's discharge from a tertiary children's hospital between January 2016 and October 2016. By using data from 3 surveys, we assessed convergent validity by examining associations between total and domain-specific P-TEM scores (0-100 scale) and 4 pediatric hospital-to-home transition validation measures: (1) Child Hospital Consumer Assessment of Healthcare Providers and Systems Discharge Composite, (2) Center of Excellence on Quality of Care Measures for Children With Complex Needs parent-reported transition measures, (3) change in health-related quality of life from admission to postdischarge, and (4) 30-day emergency department revisits or readmissions.

RESULTS

P-TEM total scores were 7.5 points (95% confidence interval: 4.6 to 10.4) higher for participants with top-box responses on the Child Hospital Consumer Assessment of Healthcare Providers and Systems Discharge Composite compared with those of participants with lower Discharge Composite scores. Participants with highet P-TEM scores (ie, top-box responses) had 6.3-points-greater improvement (95% confidence interval: 2.8 to 9.8) in health-related quality of life compared with participants who reported lower P-TEM scores. P-TEM scores were not significantly associated with 7- or 30-day reuse.

CONCLUSIONS

The P-TEM demonstrated convergent validity with existing hospital-to-home process and outcome validation measures in a population of hospitalized children.

Parent Readiness for Hospital Discharge Scale: Psychometrics and Association With Postdischarge Outcomes

INTRODUCTION

The purpose of this study is to validate the Readiness for Hospital Discharge Scale (RHDS) for use with parents of hospitalized children. PedRHDS is a structured tool for a discharge readiness assessment before pediatric discharge.

METHODS

Using combined data from four studies with 417 parents, psychometric testing and item reduction proceeded with principal component analysis for factor structure delineation, Cronbach's alpha for reliability estimation, and regression analysis for predictive validity.

RESULTS

A 23-item PedRHDS retained the a priori factor structure. Reliability ranged from 0.73 to 0.85 for the 23-item and 10- and 8-item short scales. PedRHDS (all forms) was associated with postdischarge coping difficulty (explaining 12%-16% of variance) and readmission (odds ratio = 0.71-0.80).

DISCUSSION

The PedRHDS and both short forms (PedRHDS-SF10 and PedRHDS-SF8) are reliable and valid measures of parental discharge readiness that can be used as outcome metrics of hospital care and risk indicators for postdischarge coping difficulty and readmission.

Caregiver Medication Management and Understanding After Pediatric Hospital Discharge

OBJECTIVES

Caregivers frequently make mistakes when following instructions on discharge medications, and these instructions often contain discrepancies. Minimal literature reflects inpatient discharges. Our objective was to describe failures in caregiver management and understanding of inpatient discharge medications and to test the association of documentation discrepancies and sociodemographic factors with medication-related failures after an inpatient hospitalization.

METHODS

This study took place in an urban tertiary care children's hospital that serves a low-income, minority population. English-speaking caregivers of children discharged on an oral prescription medication were surveyed about discharge medication knowledge 48 to 96 hours after discharge. The primary outcome was the proportion of caregivers who failed questions on a 10-item questionnaire (analyzed as individual question responses and as a composite outcome of any discharge medication-related failure). Bivariate tests were used to compare documentation errors, complex dosing, and sociodemographic factors to having any discharge medication-related failure.

RESULTS

Of 157 caregivers surveyed, 70% had a discharge medication-related failure, most commonly because of lack of knowledge about side effects (52%), wrong duration (17%), and wrong start time (16%). Additionally, 80% of discharge instructions provided to caregivers lacked integral medication information, such as duration or when the next dose after discharge was due. Twenty five percent of prescriptions contained numerically complex doses. In bivariate testing, only race and/or ethnicity was significantly associated with having any failure (P = .03).

CONCLUSIONS

The majority of caregivers had a medication-related failure after discharge, and most discharge instructions lacked key medication information. Future work to optimize the discharge process to support caregiver management and understanding of medications is needed.

Discharge Instruction Comprehension and Adherence Errors: Interrelationship Between Plan Complexity and Parent Health Literacy

OBJECTIVE

To examine associations between parent health literacy, discharge plan complexity, and parent comprehension of and adherence to inpatient discharge instructions.

STUDY DESIGN

This was a prospective cohort study of English/Spanish-speaking parents (n = 165) of children ≤12 years discharged on ≥1 daily medication from an urban, public hospital. Outcome variables were parent comprehension (survey) of and adherence (survey, in-person dosing assessment, chart review) to discharge instructions. Predictor variables included low parent health literacy (Newest Vital Sign score 0-3) and plan complexity. Generalized estimating equations were used to account for the assessment of multiple types of comprehension and adherence errors for each subject, adjusting for ethnicity, language, child age, length of stay, and chronic disease status. Similar analyses were performed to assess for mediation and moderation.

RESULTS

Error rates were highest for comprehension of medication side effects (50%), adherence to medication dose (34%), and return precaution (78%) instructions. Comprehension errors were associated with adherence errors (aOR, 8.7; 95% CI, 5.9-12.9). Discharge plan complexity was associated with comprehension (aOR, 7.0; 95% CI, 5.4-9.1) and adherence (aOR, 5.5; 95% CI, 4.0-7.6) errors. Low health literacy was indirectly associated with adherence errors through comprehension errors. The association between plan complexity and comprehension errors was greater in parents with low (aOR, 8.3; 95% CI, 6.2-11.2) compared with adequate (aOR, 3.8; 95% CI, 2.2-6.5) health literacy (interaction term P = .004).

CONCLUSIONS

Parent health literacy and discharge plan complexity play key roles in comprehension and adherence errors. Future work will focus on the development of health literacy-informed interventions to promote discharge plan comprehension.

Clinician Perceptions of the Importance of Hospital Discharge Components for Children

BACKGROUND

Discharging hospitalized children involves several different components, but their relative value is unknown. We assessed which discharge components are perceived as most and least important by clinicians.

METHODS

March and June of 2014, we conducted an online discrete choice experiment (DCE) among national societies representing 704 nursing, physician, case management, and social work professionals from 46 states. The DCE consisted of 14 discharge care components randomly presented two at a time for a total of 28 choice tasks. Best-worst scaling of participants' choices generated mean relative importance (RI) scores for each component, which allowed for ranking from least to most important.

RESULTS

Participants, regardless of field or practice setting, perceived "Discharge Education/Teach-Back" (RI 11.1 [95% confidence interval, CI: 11.0-11.3]) and "Involve the Child's Care Team" (RI 10.6 [95% CI: 10.4-10.8]) as the most important discharge components, and "Information Reconciliation" (RI 4.1 [95% CI: 3.9-4.4]) and "Assigning Roles/Responsibilities of Discharge Care" (RI 2.8 [95% CI: 2.6-3.0]) as least important.

CONCLUSIONS

A diverse group of pediatric clinicians value certain components of the pediatric discharge care process much more than others. Efforts to optimize the quality of hospital discharge for children should consider these findings.