Effects of a 1-Time Nurse-Led Telephone Call After Pediatric Discharge: The H2O II Randomized Clinical Trial

The Telehealth Education for Asthma Connecting Hospital and Home (TEACHH) pilot study

OBJECTIVE

To evaluate the feasibility of a novel intervention of health literacy-informed, telemedicine-enhanced asthma education and home management support for hospitalized children and caregivers, and assess caregiver perspectives of the intervention.

METHODS

We conducted a pilot randomized trial of the Telehealth Education for Asthma Connecting Hospital and Home (TEACHH) intervention vs. standardized care (SC) for children (5-13 yrs) hospitalized with asthma. Participants in TEACHH received health literacy-informed teaching prior to discharge, including pictorial materials (e.g. flipchart, action plan), color- and shape-coded medication labels, and medication demonstration. Two Zoom-based follow-up teaching visits were completed within 1-month of discharge. Feasibility was assessed by tracking visit completion, and we measured preliminary outcomes using health records (i.e. total asthma-related acute healthcare visits) and blinded surveys of caregivers 2-, 4-, and 6-months post-discharge (i.e. symptom-free days, quality of life). We interviewed caregivers about their perceptions of TEACHH. Transcripts were coded inductively.

RESULTS

We enrolled 26 children and interviewed 14 caregivers (9 TEACHH, 5 SC). All inpatient sessions were completed, as were 77% of virtual visits. Both groups experienced improved symptoms and quality of life over time. Caregivers valued the teaching, involvement of children, visual tools, and color-coded information of TEACHH. They described child-specific benefits, greater support after discharge, and improved asthma-related communication, and indicated that other families would benefit from similar teaching.

CONCLUSIONS

A novel program of patient-centered asthma education was feasible in both hospital and home settings and well received by caregivers. A larger study is needed to assess the impact of TEACHH on childhood asthma morbidity.

CLINICALTRIALS.GOV IDENTIFIER

NCT04995692 (Registration date 8/9/2021).

Validation of 30-Day Pediatric Hospital Readmission Risk Prediction Models

Importance

Accurate identification of hospital readmission risk during a current hospitalization may enhance decision-making, facilitate targeted systems-level interventions, and avoid preventable readmissions.

Objective

To temporally and externally validate a suite of readmission risk prediction models across 48 children's hospitals to assess their generalizability and feasibility for future clinical implementation.

Design, Setting, and Participants

This prognostic study analyzed data from the Pediatric Health Information System (PHIS) database, which contains billing and resource use data from 48 US children's hospitals, including the derivation hospital (DH) and 47 hospitals participating in the PHIS database (hereafter other PHIS hospitals). Children aged 18 years or younger discharged from these hospitals between January 1, 2016, to December 31, 2019, were included. This cohort was divided as specified into the 3 prediction models at the DH: 6 months or older with no recent hospitalizations (new admission model [NAM]), 6 months or older with 1 or more prior hospitalizations within the last 6 months (recent admission model [RAM]), and 6 months or younger (young infant model [YIM]). Data were analyzed from August 9 to December 1, 2023.

Main Outcomes and Measures

The primary validation outcome was hospital-level discrimination measured with area under the receiver operating characteristic curve (AUROC). Predictors included demographic, clinical, and utilization variables. All-cause 30-day readmission was modeled for each hospital using logistic regression and parameter estimates from the DH. Calibration plots examined observed vs predicted outcome frequencies for each hospital.

Results

In external validation, a total of 851 499 children were discharged from 48 hospitals (16 330 DH discharges and 835 169 other PHIS hospital discharges). The largest group of children was aged 5 to 14 years (281 193 [33.0%]). In temporal validation, the DH PHIS 2016-2018 cohort included 45 682 discharges. All-cause 30-day readmission rates were 7.2% for NAM, 35.5% for RAM, and 11.7% for YIM. The 2019 DH PHIS cohort included 16 330 discharges. All cause 30-day readmision rates were 7.2% for NAM, 35.1% for RAM, and 11.1% for YIM. Temporal validation demonstrated reduced discrimination across all 3 models (median AUROC, 0.65 [95% CI 0.62-0.67] for the NAM; 0.73 [95% CI 0.72-0.75) for RAM; 0.67 [95% CI 0.63-0.70) for the YIM compared with the original estimates (median AUROC 0.76 [95% CI 0.85-0.78] for the NAM; 0.84 [95% CI 0.83-0.84] for the RAM; 0.79 [95% CI 0.77-0.80] for the YIM). Overall readmission rates were 5.9% for NAM, 30.1% for RAM, and 7.6% for YIM. External validation yielded similiar findings as the temporal validation, although with demonstrable variation in performance across hospitals (median [range] AUROC, 0.64 [0.60-0.68] for the NAM; 0.73 [0.64-0.80] for the RAM; 0.65 [0.53-0.74] for the YIM). Most hospitals were poorly calibrated, with both significant overestimation and underestimation of observed risk. Of 47 other PHIS hospitals, only 3 for the RAM (6.4%) and 9 for both the NAM and YIM (19.1%) were adequately calibrated.

Conclusions and Relevance

This prognostic study found that the readmission risk prediction models had reduced predictive accuracy across time and variability in hospital-level performance. These findings stress the importance of local validation prior to clinical implementation and suggest opportunities to improve generalizability, including multicenter derivation and expansion of candidate predictors.

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).

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.].

Garnering effective telehealth to help optimize multidisciplinary team engagement (GET2HOME) for children with medical complexity: Protocol for a pragmatic randomized control trial

BACKGROUND

Children and young adults with medical complexity (CMC) experience high rates of healthcare reutilization following hospital discharge. Prior studies have identified common hospital-to-home transition failures that may increase the risk for reutilization, including medication, technology and equipment issues, financial concerns, and confusion about which providers can help with posthospitalization needs. Few interventions have been developed and evaluated for CMC during this transition period.

OBJECTIVE

We will compare the effectiveness of the garnering effective telehealth 2 help optimize multidisciplinary team engagement (GET2HOME) transition bundle intervention to the standard hospital-based care coordination discharge process by assessing healthcare reutilization and patient- and family-centered outcomes.

DESIGNS, SETTINGS, AND PARTICIPANTS

We will conduct a pragmatic 2-arm randomized controlled trial (RCT) comparing the GET2HOME bundle intervention to the standard hospital-based care discharge process on CMC hospitalized and discharged from hospital medicine at two sites of our pediatric medical center between November 2022 and February 2025. CMC of any age will be identified as having complex chronic disease using the Pediatric Medical Complexity Algorithm tool. We will exclude CMC who live independently, live in skilled nursing facilities, are in custody of the county, or are hospitalized for suicidal ideation or end-of-life care.

INTERVENTION

We will randomize participants to the bundle intervention or standard hospital-based care coordination discharge process. The bundle intervention includes (1) predischarge telehealth huddle with inpatient providers, outpatient providers, patients, and their families; (2) care management discharge task tracker; and (3) postdischarge telehealth huddle with similar participants within 7 days of discharge. As part of the pragmatic design, families will choose if they want to complete the postdischarge huddle. The standard hospital-based discharge process includes a pharmacist, social worker, and care management support when consulted by the inpatient team but does not include huddles between providers and families.

MAIN OUTCOME AND MEASURES

Primary outcome will be 30-day urgent healthcare reutilization (unplanned readmission, emergency department, and urgent care visits). Secondary outcomes include 7-day urgent healthcare reutilization, patient- and family-reported transition quality, quality of life, and time to return to baseline using electronic health record and surveys at 7, 30, 60, and 90 days following discharge. We will also evaluate heterogeneity of treatment effect for the intervention across levels of financial strain and for CMC with high-intensity neurologic impairment. The primary analysis will follow the intention-to-treat principle with logistic regression used to study reutilization outcomes and generalized linear mixed modeling to study repeated measures of patient- and family-reported outcomes over time.

RESULTS

This pragmatic RCT is designed to evaluate the effectiveness of enhanced discharge transition support, including telehealth huddles and a care management discharge tool, for CMC and their families. Enrollment began in November 2022 and is projected to complete in February 2025. Primary analysis completion is anticipated in July 2025 with reporting of results following.

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.

Development of a post discharge telecare program for premature infants in Covid 19 era: Protocol for a mixed methods study

BACKGROUND

Post-discharge care of premature infants is an important goal that can provide a safe transition for these infants from the hospital to the home setting, especially who has undergone significant changes during Covid19. Most premature infants experience complications because of routine hospital care termination after discharge because of limitations and barriers that Covid can create for the infant and the parents. It is necessary to develop a program that provides ongoing care for these infants. Telecare is one feasible option that can be used to implement this program. The study aims to develop a post-discharge telecare program for premature infants in the Covid era in Iran.

MATERIAL AND METHODS

This is an exploratory mixed-methods study that will be conducted by Qualitative-quantitative methods in three consecutive phases at Isfahan University of Medical Sciences in January 2022. In the first phase, a qualitative study will be conducted to identify and determine the needs and strategies in the Covid 19 era to promote premature infant care after discharge. The data will be collected through deep semi-structured interviews. Participants (parents, physicians, and nurses) will be selected by purposive sampling methods, and the conventional content analysis method will be used for data analysis. In the second phase, the identified infants' and parents' needs as an initial draft of the program will be prioritized and confirmed by the modified Delphi method and a panel of experts. The final program will be developed in this phase. In the quantitative third phase, the confirmed program will be implemented as a semi-experimental study that uses a telecare strategy. Finally, we will evaluate the effectiveness of this telecare program.

RESULT

A program that uses qualitative and quantitative methods can provide evidence for promoting premature infant health after hospital discharge in Covid 19 era.

CONCLUSION

We anticipate that this program will promote knowledge and empower health team members, especially nurses, to provide ongoing telecare for premature infants.

Are Parent Discharge Readiness Scores Effective for the Congenital Heart Disease Patients After Cardiac Surgery?

OBJECTIVE

To assess discharge readiness and clinical engagement post-discharge in familes of children undergoing congenital heart surgery (CHS).

STUDY DESIGN

This prospective cross-sectional study was performed at a major tertiary pediatric cardiac referral center. Eligible parents and caregivers completed a discharge readiness tool, the Readiness for Hospital Discharge Scale for Parents of Hospitalized Children (PedRHDS), via online survey on the day of discharge. Clinical engagement data included subsequent phone calls, clinic visits, emergency department (ED) visits, and hospital readmissions. PedRHDS scores were measured as follows: Very High (9-10), High (8-8.9), Moderate (7-7.9), and Low (<7). Descriptive statistics were used to describe demographic data.

RESULTS

128 families enrolled between April and December 2021. Parent discharge readiness scores ranged from 'High' to 'Very High.' Families with lower socioeconomic status and younger patients (especially single ventricle infants or "interstage") had a higher proportion of clinic visits, ED visits, and hospital readmissions within 30-days post-discharge compared with other groups.

CONCLUSIONS

Discharge readiness scores were not associated with clinical engagement. We identified vulnerable populations as evidenced by a higher frequency of clinical engagement in the immediate post-operative period, particularly younger patients and first time surgeries. While these visits may be appropriate, novel programs could enhance education and emotional support to prevent delay in seeking care or creating excessive stress and anxiety after discharge.

Factors Correlated With Successful Pediatric Post-Discharge Phone Call Attempt and Connection

OBJECTIVES

Postdischarge phone calls can identify discharge errors and gather information following hospital-to-home transitions. This study used the multisite Project IMPACT (Improving Pediatric Patient Centered Care Transitions) dataset to identify factors associated with postdischarge phone call attempt and connectivity.

METHODS

This study included 0- to 18-year-old patients discharged from 4 sites between January 2014 and December 2017. We compared demographic and clinical factors between postdischarge call attempt and no-attempt and connectivity and no-connectivity subgroups and used mixed model logistic regression to identify significant independent predictors of call attempt and connectivity.

RESULTS

Postdischarge calls were attempted for 5528 of 7725 (71.6%) discharges with successful connection for 3801 of 5528 (68.8%) calls. Connection rates varied significantly among sites (52% to 79%, P < .001). Age less than 30 days (P = .03; P = .01) and age 1 to 6 years (P = .04; P = .04) were independent positive predictors for both call attempt and connectivity, whereas English as preferred language (P < .001) and the chronic noncomplex clinical risk group (P = .02) were independent positive predictors for call attempt and connectivity, respectively. In contrast, readmission within 3 days (P = .004) and federal or state payor (P = .02) were negative independent predictors for call attempt and call connectivity, respectively.

CONCLUSIONS

This study suggests that targeted interventions may improve postdischarge call attempt rates, such as investment in a reliable call model or improvement in interpreter use, and connectivity, such as enhanced population-based communication.

Improving Documentation of Postdischarge Issue Mitigation during Postdischarge Phone Calls

Postdischarge phone calls (PDPCs) are recommended to identify and mitigate postdischarge issues such as missed follow-up appointments, medication errors, and failure to activate contingency plans. A current state assessment showed variability in documenting PDPC content and postdischarge issue mitigation. Therefore, the primary aim was to improve the postdischarge issue mitigation documentation rate from 65% to 100% over 16 months.

METHODS

An interdisciplinary quality improvement team used the Model for Improvement to perform planned sequential interventions over 16 months. The outcome measure was documentation of postdischarge issue mitigation. Process measures included PDPC template use and completion and postdischarge issue identification. Balancing measures included call attempts and caller perceptions of ease of documentation. Interventions included creating a flowsheet note template, creating caller template training sessions, and sharing team data and feedback. We gathered data via reports generated from the electronic medical record, chart review, and survey. Data were analyzed using statistical process control charts and established rules for detecting special cause variation.

RESULTS

The postdischarge issue mitigation documentation increased from 65% to 91% over 16 months. Template use and completion increased from 0% to 100% and 98%, respectively. The number of postdischarge issues identified remained unchanged. Call attempts increased from 40% to 59%. Caller perceptions remained unchanged.

CONCLUSIONS

Documentation of postdischarge issues and issue mitigation promotes adequate communication with the patient's care providers, improving the quality and safety of care. Data sharing to promote team engagement was the key factor in improving documentation of postdischarge issue mitigation.

Improving Discharge Safety in a Pediatric Emergency Department

BACKGROUND AND OBJECTIVES

Discharge from the emergency department (ED) involves a complex series of steps to ensure a safe transition to home and follow-up care. Preventable, discharge-related serious safety events (SSEs) in our ED highlighted local vulnerabilities. We aimed to improve ED discharge by implementing a standardized discharge process with emphasis on multidisciplinary communication and family engagement.

METHODS

At a tertiary children's hospital, we used the model for improvement to revise discharge care. Interventions included a new discharge checklist, a provider huddle emphasizing discharge vital signs, and a scripted discharge review of instructions with families. We used statistical process control to evaluate performance. Primary outcomes included elimination of preventable, discharge-related SSEs and Press Ganey survey results assessing caregiver information for care of child at home. A secondary outcome was number of days between preventable low-level (near-miss, no or minimal harm) events. Process measures included discharge checklist adoption and vital sign acquisition. Balancing measures were length of stay (LOS) and return rates.

RESULTS

Over the study period, there were no preventable SSEs and low-level event frequency improved to a peak of &gt;150 days between events. Press Ganey responses regarding quality of discharge information did not change (62%). Checklist use was rapidly adopted, reaching 94%. Vital sign acquisition increased from 67% to 83%. There was no change in the balancing measures of median LOS or return visit rates.

CONCLUSIONS

The development and implementation of a standardized discharge process led to the elimination of reported discharge-related events, without increasing LOS or return visits.

Development and Validation of an Integrated Suite of Prediction Models for All-Cause 30-Day Readmissions of Children and Adolescents Aged 0 to 18 Years

IMPORTANCE

Readmission is often considered a hospital quality measure, yet no validated risk prediction models exist for children.

OBJECTIVE

To develop and validate a tool identifying patients before hospital discharge who are at risk for subsequent readmission, applicable to all ages.

DESIGN, SETTING, AND PARTICIPANTS

This population-based prognostic analysis used electronic health record-derived data from a freestanding children's hospital from January 1, 2016, to December 31, 2019. All-cause 30-day readmission was modeled using 3 years of discharge data. Data were analyzed from June 1 to November 30, 2021.

MAIN OUTCOMES AND MEASURES

Three models were derived as a complementary suite to include (1) children 6 months or older with 1 or more prior hospitalizations within the last 6 months (recent admission model [RAM]), (2) children 6 months or older with no prior hospitalizations in the last 6 months (new admission model [NAM]), and (3) children younger than 6 months (young infant model [YIM]). Generalized mixed linear models were used for all analyses. Models were validated using an additional year of discharges.

RESULTS

The derivation set contained 29 988 patients with 48 019 hospitalizations; 50.1% of these admissions were for children younger than 5 years and 54.7% were boys. In the derivation set, 4878 of 13 490 admissions (36.2%) in the RAM cohort, 2044 of 27 531 (7.4%) in the NAM cohort, and 855 of 6998 (12.2%) in the YIM cohort were followed within 30 days by a readmission. In the RAM cohort, prior utilization, current or prior procedures indicative of severity of illness (transfusion, ventilation, or central venous catheter), commercial insurance, and prolonged length of stay (LOS) were associated with readmission. In the NAM cohort, procedures, prolonged LOS, and emergency department visit in the past 6 months were associated with readmission. In the YIM cohort, LOS, prior visits, and critical procedures were associated with readmission. The area under the receiver operating characteristics curve was 83.1 (95% CI, 82.4-83.8) for the RAM cohort, 76.1 (95% CI, 75.0-77.2) for the NAM cohort, and 80.3 (95% CI, 78.8-81.9) for the YIM cohort.

CONCLUSIONS AND RELEVANCE

In this prognostic study, the suite of 3 prediction models had acceptable to excellent discrimination for children. These models may allow future improvements in tailored discharge preparedness to prevent high-risk readmissions.

Using Geomarkers and Sociodemographics to Inform Assessment of Caregiver Adversity and Resilience

BACKGROUND AND OBJECTIVES

A high level of caregiver adverse childhood experiences (ACEs) and/or low resilience is associated with poor outcomes for both caregivers and their children after hospital discharge. It is unknown if sociodemographic or area-based measures (ie, "geomarkers") can inform the assessment of caregiver ACEs or resilience. Our objective was to determine if caregiver ACEs or resilience can be identified by using any combinations of sociodemographic measures, geomarkers, and/or caregiver-reported household characteristics.

METHODS

Eligible participants for this cohort study were English-speaking caregivers of children hospitalized on a hospital medicine team. Caregivers completed the ACE questionnaire, Brief Resilience Scale, and strain surveys. Exposures included sociodemographic characteristics available in the electronic health record (EHR), geomarkers tied to a patient's geocoded home address, and household characteristics that are not present in the EHR (eg, income). Primary outcomes were a high caregiver ACE score (≥4) and/or a low BRS Score (<3).

RESULTS

Of the 1272 included caregivers, 543 reported high ACE or low resilience, and 63 reported both. We developed the following regression models: sociodemographic variables in EHR (Model 1), EHR sociodemographics and geomarkers (Model 2), and EHR sociodemographics, geomarkers, and additional survey-reported household characteristics (Model 3). The ability of models to identify the presence of caregiver adversity was poor (all areas under receiver operating characteristics curves were <0.65).

CONCLUSIONS

Models using EHR data, geomarkers, and household-level characteristics to identify caregiver adversity had limited utility. Directly asking questions to caregivers or integrating risk and strength assessments during pediatric hospitalization may be a better approach to identifying caregiver adversity.

Effects of a Nurse-Led Telehealth Self-care Promotion Program on the Quality of Life of Community-Dwelling Older Adults: Systematic Review and Meta-analysis

BACKGROUND

In recent years, telehealth has become a common channel for health care professionals to use to promote health and provide distance care. COVID-19 has further fostered the widespread use of this new technology, which can improve access to care while protecting the community from exposure to infection by direct personal contact, and reduce the time and cost of traveling for both health care users and providers. This is especially true for community-dwelling older adults who have multiple chronic diseases and require frequent hospital visits. Nurses are globally recognized as health care professionals who provide effective community-based care to older adults, facilitating their desire to age in place. However, to date, it is unclear whether the use of telehealth can facilitate their work of promoting self-care to community-dwelling older adults.

OBJECTIVE

This review aims to summarize findings from randomized controlled trials on the effect of nurse-led telehealth self-care promotion programs compared with the usual on-site or face-to-face services on the quality of life (QoL), self-efficacy, depression, and hospital admissions among community-dwelling older adults.

METHODS

A search of 6 major databases was undertaken of relevant studies published from May 2011 to April 2021. Standardized mean differences (SMDs) and their 95% CIs were calculated from postintervention outcomes for continuous data, while the odds ratio was obtained for dichotomous data using the Mantel-Haenszel test.

RESULTS

From 1173 possible publications, 13 trials involving a total of 4097 participants were included in this meta-analysis. Compared with the control groups, the intervention groups of community-dwelling older adults significantly improved in overall QoL (SMD 0.12; 95% CI 0.03 to 0.20; P=.006; I2=21%), self-efficacy (SMD 0.19; 95% CI 0.08 to 0.30; P<.001; I2=0%), and depression level (SMD -0.22; 95% CI -0.36 to -0.08; P=.003; I2=89%).

CONCLUSIONS

This meta-analysis suggests that employing telehealth in nurse-led self-care promotion programs may have a positive impact on older adults, although more studies are needed to strengthen the evidence base, particularly regarding organization and delivery.

TRIAL REGISTRATION

PROSPERO (Prospective International Register of Systematic Reviews) CRD42021257299; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=257299.

The Association of the Childhood Opportunity Index on Pediatric Readmissions and Emergency Department Revisits

OBJECTIVE

Reutilization following discharge is costly to families and the health care system. Singular measures of the social determinants of health (SDOH) have been shown to impact utilization; however, the SDOH are multifactorial. The Childhood Opportunity Index (COI) is a validated approach for comprehensive estimation of the SDOH. Using the COI, we aimed to describe the association between SDOH and 30-day revisit rates.

METHODS

This retrospective study included children 0 to 17 years within 48 children's hospitals using the Pediatric Health Information System from 1/1/2019 to 12/31/2019. The main exposure was a child's ZIP code level COI. The primary outcome was unplanned readmissions and emergency department (ED) revisits within 30 days of discharge. Primary outcomes were summarized by COI category and compared using chi-square or Kruskal-Wallis tests. Adjusted analysis used generalized linear mixed effects models with adjustments for demographics, clinical characteristics, and hospital clustering.

RESULTS

Of 728,997 hospitalizations meeting inclusion criteria, 30-day unplanned returns occurred for 96,007 children (13.2%). After adjustment, the patterns of returns were significantly associated with COI. For example, 30-day returns occurred for 19.1% (95% confidence interval [CI]: 18.2, 20.0) of children living within very low opportunity areas, with a gradient-like decrease as opportunity increased (15.5%, 95% CI: 14.5, 16.5 for very high). The relative decrease in utilization as COI increased was more pronounced for ED revisits.

CONCLUSIONS

Children living in low opportunity areas had greater 30-day readmissions and ED revisits. Our results suggest that a broader approach, including policy and system-level change, is needed to effectively reduce readmissions and ED revisits.

Targeted Clinical Interventions for Reducing Pediatric Readmissions

BACKGROUND

In this interventional study, we addressed the selection and application of clinical interventions on pediatric patients identified as at risk by a predictive model for readmissions.

METHODS

A predictive model for readmissions was implemented, and a team of providers expanded corresponding clinical interventions for at-risk patients at a freestanding children's hospital. Interventions encompassed social determinants of health, outpatient care, medication reconciliation, inpatient and discharge planning, and postdischarge calls and/or follow-up. Statistical process control charts were used to compare readmission rates for the 3-year period preceding adoption of the model and clinical interventions with those for the 2-year period after adoption of the model and clinical interventions. Potential financial savings were estimated by using national estimates of the cost of pediatric inpatient readmissions.

RESULTS

The 30-day all-cause readmission rates during the periods before and after predictive modeling (and corresponding 95% confidence intervals [CI]) were 12.5% (95% CI: 12.2%-12.8%) and 11.1% (95% CI: 10.8%-11.5%), respectively. More modest but similar improvements were observed for 7-day readmissions. Statistical process control charts indicated nonrandom reductions in readmissions after predictive model adoption. The national estimate of the cost of pediatric readmissions indicates an associated health care savings due to reduced 30-day readmission during the 2-year predictive modeling period at $2 673 264 (95% CI: $2 612 431-$2 735 364).

CONCLUSIONS

A combination of predictive modeling and targeted clinical interventions to improve the management of pediatric patients at high risk for readmission was successful in reducing the rate of readmission and reducing overall health care costs. The continued prioritization of patients with potentially modifiable outcomes is key to improving patient outcomes.

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.

Differential Impact of Home Nurse Contact After Discharge by Financial Strain, Primary Care Access, and Medical Complexity

BACKGROUND

The Hospital to Home Outcomes (H2O) trials examined the effectiveness of postdischarge nurse support on reuse after pediatric discharge. Unexpectedly, children randomly assigned to a nurse visit had higher rates of reuse than those in the control group. Participants in randomized control trials are heterogeneous. Thus, it is possible that the effect of the intervention differed across subgroups (ie, heterogeneity of treatment effect [HTE]). We sought to determine if different subgroups responded differently to the interventions.

METHODS

The H2O trial is a randomized controlled trial comparing standard hospital discharge processes with a nurse home visit within 96 hours of discharge. The second trial, H2O II, was similar, except the tested intervention was a postdischarge nurse phone call. For the purposes of the HTE analyses, we examined our primary trial outcome measure: a composite of unplanned 30-day acute health care reuse (unplanned readmission or emergency department or urgent care visit). We identified subgroups of interest before the trials related to (1) financial strain, (2) primary care access, (3) insurance, and (4) medical complexity. We used logistic regression modeling with an interaction term between subgroup and treatment group (intervention or control).

RESULTS

For the phone call trial (H2O II), financial strain significantly modified the effect of the intervention such that the subgroup of children with high financial strain who received the intervention experienced more reuse than their control counterparts.

CONCLUSIONS

In HTE analyses of 2 randomized controlled trials, only financial strain significantly modified the nurse phone call. A family's financial resources may affect the utility of postdischarge support.

Randomized controlled trial evaluating a collaborative model of care for transitioning children with medical complexity from hospital to home healthcare: Study protocol

This article describes the study protocol for an evaluation of an innovative model of care that supports home health nurses (HHN) who serve children with medical complexity (CMC). CMC constitute a small proportion of children, but have very high need for health services, are hospitalized frequently, and account for significant proportion of pediatric healthcare expenditures. High-quality home health nursing services are important for CMC, but models of care of home healthcare, after discharge of CMC from the hospital, have not been tested. Our project aims are to develop, implement, and test a model of care, called ICollab, to improve home healthcare delivery for CMC. The ICollab model consists of collaboration between HHN, primary-care physicians and clinicians of the complex care program of a tertiary-care children's hospital in the care of CMC. In this randomized clinical trial, we will recruit 110 CMC discharged home on home health nursing services. The intervention group (n = 55) will receive the ICollab intervention for 6 months post-discharge from the hospital, in addition to usual care. Children in the control group (n = 55) will receive only usual care. Outcome measures will include healthcare utilization metrics (hospitalization rates, emergency room visit rates, and days to readmission), caregiver burden and caregiver satisfaction with home healthcare, HHN retention, and HHN collaboration with other healthcare providers. We hypothesize that ICollab will reduce healthcare utilization and caregiver burden, and improve caregiver satisfaction with home healthcare, increase HHN retention, and increase HHN collaboration with other healthcare providers. Results of this study have the potential to provide a critically needed evidence-base for interventions to improve the quality of healthcare delivery for CMC. This study is registered on clinicaltrials.gov (NCT03978468) and is ongoing.

Performance of Pediatric Readmission Measures

BACKGROUND

Readmission rates are frequently used as a hospital quality metric; yet multiple measures exist to evaluate pediatric readmission rates. We sought to assess how four different measures of pediatric readmission compare with assessment of both preventable and unplanned readmission.

METHODS

Clinicians on hospital medicine, cardiology, neonatology, and neurology teams reviewed medical records for 30-day readmissions using an abstraction tool with high interrater reliability for preventability assessment. Readmissions between July 2014 and June 2016 were classified separately as preventable or not preventable and planned or unplanned. We compared the classifications to four existing readmission metrics: all-cause readmission, unplanned readmission/time flag classification, the pediatric all-condition readmission, and potentially preventable readmission. We calculated sensitivity and specificity for all readmission metrics.

RESULTS

Among 30-day readmissions considered, 1,643 were eligible for medical record review; 1,125 reviews were completed by the clinical teams (68%). On medical record review, the majority of readmissions were determined not preventable (85%). Only 15% were classified as unplanned and preventable. None of the four readmission measures had appropriate sensitivity or specificity for identifying preventable readmission. The unplanned readmission/time flag classification had the highest sensitivity (95%) and specificity (90%) in identifying unplanned readmissions.

CONCLUSION

None of the existing pediatric readmission measures can reliably determine preventability. The unplanned readmission/time flag measure performed best in identifying unplanned readmissions.

Effect of Parental Adverse Childhood Experiences and Resilience on a Child's Healthcare Reutilization

BACKGROUND

Adverse childhood experiences (ACEs) are associated with poor health outcomes in adults. Resilience may mitigate this effect. There is limited evidence regarding how parents' ACEs and resilience may be associated with their children's health outcomes.

OBJECTIVE

To determine the association of parental ACEs and resilience with their child's risk of unanticipated healthcare reutilization.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a prospective cohort study (August 2015 to October 2016) at a tertiary, freestanding pediatric medical center in Cincinnati, Ohio. Eligible participants were English-speaking parents of children hospitalized on a Hospital Medicine or Complex Services team. A total of 1,320 parents of hospitalized children completed both the ACE questionnaire and the Brief Resilience Scale Survey.

EXPOSURE

Number of ACEs and Brief Resilience Scale Score among parents.

MAIN OUTCOMES

Unanticipated reutilization by children, defined as returning to the emergency room, urgent care, or being readmitted to the hospital within 30 days of hospital discharge.

RESULTS

In adjusted analyses, children of parents with 4 or more ACEs had 1.69-times higher odds (95% CI, 1.11-2.60) of unanticipated reutilization after an index hospitalization, compared with children of parents with no ACEs. Resilience was not significantly associated with reutilization.

CONCLUSION

Parental history of ACEs is strongly associated with higher odds of their child having unanticipated healthcare reutilization after a hospital discharge, highlighting an intergenerational effect. Screening may be an important tool for outcome prediction and intervention guidance following pediatric hospitalization.

A Qualitative Study of Increased Pediatric Reutilization After a Postdischarge Home Nurse Visit

BACKGROUND

The Hospital to Home Outcomes (H2O) trial was a 2-arm, randomized controlled trial that assessed the effects of a nurse home visit after a pediatric hospital discharge. Children randomized to the intervention had higher 30-day postdischarge reutilization rates compared with those with standard discharge. We sought to understand perspectives on why postdischarge home nurse visits resulted in higher reutilization rates and to elicit suggestions on how to improve future interventions.

METHODS

We sought qualitative input using focus groups and interviews from stakeholder groups: parents, primary care physicians (PCP), hospital medicine physicians, and home care registered nurses (RNs). A multidisciplinary team coded and analyzed transcripts using an inductive, iterative approach.

RESULTS

Thirty-three parents participated in interviews. Three focus groups were completed with PCPs (n = 7), 2 with hospital medicine physicians (n = 12), and 2 with RNs (n = 10). Major themes in the explanation of increased reutilization included: appropriateness of patient reutilization; impact of red flags/warning sign instructions on family's reutilization decisions; hospital-affiliated RNs "directing traffic" back to hospital; and home visit RNs had a low threshold for escalating care. Major themes for improving design of the intervention included: need for improved postdischarge communication; individualizing home visits-one size does not fit all; and providing context and framing of red flags.

CONCLUSION

Stakeholders questioned whether hospital reutilization was appropriate and whether the intervention unintentionally directed patients back to the hospital. Future interventions could individualize the visit to specific needs or diagnoses, enhance postdischarge communication, and better connect patients and home nurses to primary care.

Impact of a Follow-up Telephone Call Program on 30-Day Readmissions (FUTR-30): A Pragmatic Randomized Controlled Real-world Effectiveness Trial

BACKGROUND

Telephone call programs are a common intervention used to improve patients' transition to outpatient care after hospital discharge.

OBJECTIVE

To examine the impact of a follow-up telephone call program as a readmission reduction initiative.

RESEARCH DESIGN

Pragmatic randomized controlled real-world effectiveness trial.

SUBJECTS

We enrolled and randomized all patients discharged home from a hospital general medicine service to a follow-up telephone call program or usual care discharge. Patients discharged against medical advice were excluded. The intervention was a hospital program, delivering a semistructured follow-up telephone call from a nurse within 3-7 days of discharge, designed to assess understanding and provide education, and assistance to support discharge plan implementation.

MEASURES

Our primary endpoint was hospital inpatient readmission within 30 days identified by the electronic health record. Secondary endpoints included observation readmission, emergency department revisit, and mortality within 30 days, and patient experience ratings.

RESULTS

All 3054 patients discharged home were enrolled and randomized to the telephone call program (n=1534) or usual care discharge (n=1520). Using a prespecified intention-to-treat analysis, we found no evidence supporting differences in 30-day inpatient readmissions [14.9% vs. 15.3%; difference -0.4 (95% confidence interval, 95% CI), -2.9 to 2.1; P=0.76], observation readmissions [3.8% vs. 3.6%; difference 0.2 (95% CI, -1.1 to 1.6); P=0.74], emergency department revisits [6.1% vs. 5.4%; difference 0.7 (95% CI, -1.0 to 2.3); P=0.43], or mortality [4.4% vs. 4.9%; difference -0.5 (95% CI, -2.0 to 1.0); P=0.51] between telephone call and usual care groups.

CONCLUSIONS

We found no evidence of an impact on 30-day readmissions or mortality due to the postdischarge telephone call program.

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.

Accuracy of Parent Perception of Comprehension of Discharge Instructions: Role of Plan Complexity and Health Literacy

OBJECTIVE

Inpatient discharge education is often suboptimal. Measures of parents' perceived comprehension of discharge instructions are included in national metrics given linkage to morbidity; few studies compare parents' perceived and actual comprehension. We 1) compared parent perceived and actual comprehension of discharge instructions and 2) assessed associations between plan complexity and parent health literacy with overestimation of comprehension (perceive comprehension but lack actual comprehension).

METHODS

Prospective cohort study of English/Spanish-speaking parents (n = 192) of inpatients ≤12 years old and discharged on ≥1 daily medication from an urban public hospital. We used McNemar's tests to compare parent perceived (agree/strongly agree on 5-point Likert scale) and actual comprehension (concordance of parent report with medical record) of instructions (domains: medications, appointments, return precautions, and restrictions). Generalized estimating equations were performed to assess associations between low parent health literacy (Newest Vital Sign score ≤3) and plan complexity with overestimation of comprehension.

RESULTS

Medication side effects were the domain with lowest perceived comprehension (80%), while >95% of parents perceived comprehension for other domains. Actual comprehension varied by domain (41%-87%) and was lower than perceived comprehension. Most (84%) parents overestimated comprehension in ≥1 domain. Plan complexity (adjusted odds ratio 3.6; 95% confidence interval 2.9-4.7) and low health literacy (adjusted odds ratio 1.9; 1.3-2.6) were associated with overestimation of comprehension.

CONCLUSIONS

Parental perceived comprehension of discharge instructions overestimated actual comprehension in most domains. Plan complexity and low health literacy were associated with overestimation of comprehension. Future interventions should incorporate assessment of actual comprehension and standardization of discharge instructions.

A Statistical-Learning Model for Unplanned 7-Day Readmission in Pediatrics

OBJECTIVES

The rate of pediatric 7-day unplanned readmissions is often seen as a measure of quality of care, with high rates indicative of the need for improvement of quality of care. In this study, we used machine learning on electronic health records to study predictors of pediatric 7-day readmissions. We ranked predictors by clinical significance, as determined by the magnitude of the least absolute shrinkage and selection operator regression coefficients.

METHODS

Data consisting of 50 241 inpatient and observation encounters at a single tertiary pediatric hospital were retrieved; 50% of these patients' data were used for building a least absolute shrinkage and selection operator regression model, whereas the other half of the data were used for evaluating model performance. The categories of variables included were demographics, social determinants of health, severity of illness and acuity, resource use, diagnoses, medications, psychosocial factors, and other variables such as primary care no show.

RESULTS

Previous hospitalizations and readmissions, medications, multiple comorbidities, longer current and previous lengths of stay, certain diagnoses, and previous emergency department use were the most significant predictors modifying a patient's risk of 7-day pediatric readmission. The model achieved an area under the curve of 0.778 (95% confidence interval 0.763-0.793).

CONCLUSIONS

Predictors such as medications, previous and current health care resource use, history of readmissions, severity of illness and acuity, and certain psychosocial factors modified the risk of unplanned 7-day readmissions. These predictors are mostly unmodifiable, indicating that intervention plans on high-risk patients may be developed through discussions with patients and parents to identify underlying modifiable causal factors of readmissions.

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.

Progress (?) Toward Reducing Pediatric Readmissions

Many children's hospitals are actively working to reduce readmissions to improve care and avoid financial penalties. We sought to determine if pediatric readmission rates have changed over time. We used data from 66 hospitals in the Inpatient Essentials Database including index hospitalizations from January, 2010 through June, 2016. Seven-day all cause (AC) and potentially preventable readmission (PPR) rates were calculated using 3M PPR software. Total and condition-specific quarterly AC and PPR rates were generated for each hospital and in aggregate. We included 4.52 million hospitalizations across all study years. Readmission rates did not vary over the study period. The median seven-day PPR rate across all quarters was 2.5% (range 2.1%-2.5%); the median seven-day AC rate across all quarters was 5.1% (range 4.3%-5.3%). Readmission rates for individual conditions fluctuated. Despite significant national efforts to reduce pediatric readmissions, both AC and PPR readmission rates have remained unchanged over six years.

Does participation in the community outreach for asthma care and healthy lifestyles (COACH) program alter subsequent use of hospital services for children discharged with asthma?

Introduction: Transition from hospital to home is a challenging time for children with asthma and their caregivers because of the high risk for reutilization of acute hospital services. Detecting effective quality improvement initiatives to reduce utilization of urgent services in children discharged with asthma is an important clinical and public health question. This study was designed to identify the role of a multimodal, nurse-driven, inpatient initiated Community Outreach for Asthma Care and Healthy lifestyles (COACH) program on subsequent use of hospital services for pediatric patients with asthma.Methods: We utilized comparative effectiveness design to identify the difference in recurrent emergency department (ED) visits and/or admissions within 12-months after discharge between patients with asthma who engaged in the COACH program (Intervention group) and those who did not (Comparison group). We used administrative databases of hospitals included in the Meridian Health system to identify the number of and time to asthma-related readmissions and ED re-attendances.Results: We found no difference in the rate or number of recurrent hospital-based services used within 12 months, but found a reduction in ED re-visitation and/or readmission within 30 days for COACH program participants prior to and after adjustment for age, race/ethnicity, insurance status, and clinical presentation (Odd Ratio 0.44, 95% Confidence Interval 0.20, 0.93).Conclusion: Participation in the COACH program decreases the likelihood for subsequent use of hospital services within a month of discharge for children with asthma. Enhanced post-discharge interactions with families may reduce long-term reuse of hospital-based services for COACH program participants.