Innovative Discharge Process for Families with Pediatric Short Bowel Syndrome: A Prospective Nonrandomized Trial

Nutrition and Intestinal Rehabilitation of Children With Short Bowel Syndrome: A Position Paper of the ESPGHAN Committee on Nutrition. Part 1: From Intestinal Resection to Home Discharge

Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The mainstay of treatment for IF is parenteral nutrition (PN). The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their experience. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. The first part of this position paper focuses on the physiological mechanism of intestinal adaptation after surgical resection. It subsequently provides some clinical practice recommendations for the primary management of children with SBS from surgical resection until discharged home on PN.

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.

Readiness for Hospital Discharge and Its Correlation with the Quality of Discharge Teaching among the Parents of Premature Infants in NICU

Objectives

To assess the extent of the readiness for hospital discharge and the correlation with discharge teaching quality among parents of premature infants' in the NICU.

Background

Low readiness for discharge from the hospital can lead to negative outcomes in healthcare for infants born prematurely and their parents. Discharge guidelines are a basic approach to ensure the readiness of the parents for discharge from the hospital. No investigation has ever been conducted into the sufficiency of hospital discharge guidelines for premature infants and their impact on parental readiness for hospital discharge.

Design

Data was collected from four hospitals in China using a correlational descriptive study.

Methods

Two hundred and eight parents of premature NICU-hospitalized infants of four tertiary hospitals in Henan Province from May to October 2020 were enrolled. The general information questionnaire, the readiness for hospital discharge scale- (RHDS-) parent form, and the quality of discharge teaching scale- (QDTS-) parent form were used for data collection. Spearman correlation analysis and descriptive statistics were used to analyze the data.

Results

The total score for hospital discharge readiness was high (8.05 ± 1.11). The total score of the quality of discharge guidelines was moderate (7.44 ± 1.44). Moreover, the discharge teaching quality was positively correlated with the parents' readiness. Positive correlations were found between PRHDS and QDTS subscales, including content received and delivery, physical-emotional status, knowledge, and expected support.

Conclusion

The quality of the discharge guidelines perceived by parents of premature infants was moderate, which may have reduced their readiness for hospital discharge. Relevance to Clinical Practice. This study furnishes basic information on the importance of readiness of discharge for the parents of premature infants. The teaching guides nurses to enhance the quality of discharge teaching and the readiness of parents for discharge from the hospital.

Safe care transitions for patients receiving parenteral nutrition

Transitions of care require coordination between inpatient healthcare providers, care managers, outpatient/ambulatory providers, and the patient/caregiver and family members. Poor communication during transitions of care can affect health outcomes and economic costs for patients/caregivers, healthcare providers, and healthcare systems. The goal of this paper is to identify risk-prone processes in the transition of care for patients requiring parenteral nutrition (PN) between healthcare environments, including the hospital, home, skilled nursing facility, and long-term acute care hospital settings. To facilitate the evaluation of the transition, a sequential series of steps in the transition process were identified: initial notification, assessment in preparation for transfer, identifying the receiving organization, identifying accountable providers at each sending/receiving organization, communicating the nutrition care plan, implementing the plan and additional considerations regarding PN preparation and readmissions. Safety concerns with risk-prone processes are identified and recommended best practices are proposed for improving processes at each step of the transition. Pediatric considerations are included in the evaluation of the various steps in the transition of care. This paper was approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.

Understanding preparation for preterm infant discharge from parents' and healthcare providers' perspectives: Challenges and opportunities

AIM

To describe the facilitating/inhibiting factors of preparation for preterm infant discharge and recommendations for increasing discharge readiness from parents' and healthcare providers' perspectives based on Meleis's Transitions Theory.

DESIGN

A qualitative cross-sectional descriptive design.

METHODS

We selected a purposive sample of 17 parents (9 fathers and 8 mothers) and 13 healthcare providers (10 nurses and 3 clinicians) from the neonatal intensive care unit of a tertiary hospital in Eastern China. Data were collected between May -July 2018. Data from audio-recorded semi-structured individual interviews were coded with content analysis both inductively and deductively.

RESULTS

The analyses yielded four themes: personal conditions, community conditions, nursing therapeutics, and patterns of response. Parents and healthcare providers had unique opinions about the themes.

CONCLUSION

Meleis's Transitions Theory seems to be an applicable and practicable framework for understanding the discharge preparation of parents with preterm infants and may be used to help healthcare providers to develop appropriate interventions on discharge preparation practice.

IMPACT

To address the lack of discharge readiness of preterm infants in China and countries with a similar clinical context, healthcare providers should help parents play a more active role to promote their engagement in discharge preparation. In a wider global community, healthcare providers should consider parents' personal conditions and their practical needs in performing discharge preparation.

Parental readiness for hospital discharge as a mediator between quality of discharge teaching and parental self-efficacy in parents of preterm infants

AIMS AND OBJECTIVES

To examine the extent to which parental readiness for hospital discharge mediates the relationship between quality of discharge teaching and parental self-efficacy in parents of preterm infants.

BACKGROUND

Parental readiness for hospital discharge and self-efficacy should be considered to establish whether preterm infants and their families are prepared for the discharge. High-quality discharge teaching could facilitate a smooth discharge transition. However, little is known about how quality of discharge teaching influences parental readiness for hospital discharge and self-efficacy.

DESIGN

This was a descriptive cross-sectional study of 202 parents with preterm infants in a tertiary hospital in Eastern China.

METHODS

The key variables of interest were measured using the Chinese versions of the Quality of Discharge Teaching Scale, Readiness for Hospital Discharge Scale-Parent Form, and Preterm Parenting and Self-Efficacy Checklist. Path analyses were conducted to test the mediation models. STROBE checklist was used to compile the study's report.

RESULTS

Parental readiness for discharge (overall and knowledge dimension) partially mediated the relationship between the quality of discharge teaching and parental self-efficacy. The two dimensions (content received and delivery) of quality of discharge teaching positively influenced parental self-efficacy by improving parental readiness for discharge.

CONCLUSIONS

Parental readiness for hospital discharge, especially the knowledge dimension, was an important factor in quality of discharge teaching's association with self-efficacy in parents of preterm infants. Improving the quality of discharge teaching could increase parental readiness for discharge and thus promote parental self-efficacy.

RELEVANCE TO CLINICAL PRACTICE

Improving discharge instructions is essential to help parents of preterm infants prepare for the transition to home care. Assessing readiness and confidence at an early stage and continuing to do so throughout the hospital stay may provide additional ways for nurses to identify parents' knowledge gaps and to provide tailored interventions at more opportune times before hospital discharge.

Learning Gaps and Family Experience, Nurse-Facilitated Home Parenteral Nutrition Simulation-Based Discharge Training: Proof-of-Concept Study

BACKGROUND

Home parenteral nutrition (HPN) is a life-sustaining therapy for children and adults suffering with severe digestive diseases, yet complications are commonplace, and predischarge trainings are variable. High-fidelity simulation training provides participants with an immersive experience using realistic equipment, supplies, and scenarios. Simulation training is rapidly becoming a potential gold standard for healthcare but is currently underutilized for families and caregivers.

METHODS

We prospectively collected data on pediatric patients managed at a single HPN program from September 1, 2016, to September 30, 2018. Participants in a pilot simulation-based training program (orientation, high-fidelity mannequin, realistic homelike space, standardized clinical scenarios, and structured debriefing) were compared with historical controls. We excluded patients with short-term HPN use and strictly palliative goals of care.

RESULTS

Nineteen (90%) families participated in the pilot initiative with a median (interquartile range) age of 0.9 (3.7) years and diagnosis of short-bowel syndrome in 14 (74%). During teaching scenarios, learning gaps were identified for aseptic needleless changes (53%), HPN equipment setup (84%) with specific difficulty adding multivitamin (32%), and dressing changes (63%). Thirty-day readmission rates in simulation-based training group vs historical cases were 42% vs 63% (P = not significant). There was no difference in length of stay between groups. All (100%) simulation-based training group participants would recommend this learning experience to others.

CONCLUSION

HPN discharge training is a novel use for high-fidelity simulation to address family/caregiver satisfaction and to identify learning gaps. Further studies are needed to refine predischarge training materials and examine the impact on postdischarge outcomes.

Short bowel syndrome in children and adults: from rehabilitation to transplantation

Short bowel syndrome (SBS) is a dramatic clinical condition in both children and adults; the residual bowel length is not sufficient to avoid intestinal failure, with subsequent malnutrition and growth retardation, and intravenous support is required to provide the nutrients normally coming from the intestine. Apart from the primary disease, the medical status can be worsened by complications of intestinal failure: if there are irreversible, the prognosis is poor unless a successful intestinal rehabilitation is achieved. Areas covered: The rescue of the remnant small bowel requires a multidisciplinary expertise to achieve digestive autonomy. The use of intestinal trophic factors has shown encouraging results in improving the intestinal adaptation process. Whenever the residual bowel length is inadequate, in a well-selected population weaning parenteral nutrition (PN) off could be attempted by surgery through lengthening procedures. A further subset of patients, with total and irreversible intestinal failure and severe complications on PN, may have an indication to intestinal transplantation. This procedure is still affected by poor long-term results. Expert commentary: Novel approaches developed through a multidisciplinary team work, such as manipulation of microbiota or tissue bioengineering, should be added to current therapies to treat successfully SBS.

Pediatric Home Parenteral Nutrition: Indications and Short-Term Outcomes in a Large National Sample of Commercially Insured Children and Adolescents

BACKGROUND

To support families managing the complex requirements of home parenteral nutrition (HPN) in pediatric patients, health professionals need information about HPN indications and complications. Nationally representative information is limited.

METHODS

A retrospective cohort analysis of the Truven Health MarketScan Commercial Claims and Encounters Database was performed and identified 683 patients aged ≤18 years receiving HPN during dates of service from January 2013 through September 2015. Baseline diagnoses were measured in the 30 days before the first observed HPN claim (preindex). Indications for older (aged 13-18 years) and younger (aged ≤12 years) children were compared. Hospital and emergency department (ED) utilization rates were measured for 30 postindex days.

RESULTS

Gastrointestinal diagnoses and/or symptoms affected more than three-quarters of patients. Short bowel syndrome was more common in younger than in older patients (24% vs 7%, respectively), and colitis was less common (13% vs 33%; both P < .01). Cancer was common in both age groups (22%-23%). Additional diagnoses indicating complex medical conditions were observed in a minority of patients: sepsis (9%), convulsions/epilepsy (7%), encephalopathy (3%), and immune deficiency (3%). From the preindex to postindex periods, rates of inpatient hospitalization declined from 78% to 41%, but hospital ED visits increased from 10% to 14%. In both periods, >95% of hospital and ED use was disease related.

CONCLUSION

In a nationally representative sample of commercially insured pediatric patients treated with HPN, complex medical conditions were common. Findings highlight the importance of American Society for Parenteral and Enteral Nutrition recommendations for team-based care.