Caregiver Perceptions of Hospital to Home Transitions According to Medical Complexity: A Qualitative Study

Designing eHealth interventions for children with complex care needs requires continuous stakeholder collaboration and co-creation

Objective

Hospital-to-home (H2H) transitions challenge families of children with medical complexity (CMC) and healthcare professionals (HCP). This study aimed to gain deeper insights into the H2H transition process and to work towards eHealth interventions for its improvement, by applying an iterative methodology involving both CMC families and HCP as end-users.

Methods

For 20-weeks, the Dutch Transitional Care Unit consortium collaborated with the Amsterdam University of Applied Sciences, HCP, and CMC families. The agile SCREAM approach was used, merging Design Thinking methods into five iterative sprints to stimulate creativity, ideation, and design. Continuous communication allowed rapid adaptation to new information and the refinement of solutions for subsequent sprints.

Results

This iterative process revealed three domains of care - care coordination, social wellbeing, and emotional support - that were important to all stakeholders. These domains informed the development of our final prototype, 'Our Care Team', an application tailored to meet the H2H transition needs for CMC families and HCP.

Conclusion

Complex processes like the H2H transition for CMC families require adaptive interventions that empower all stakeholders in their respective roles, to promote transitional care that is anticipatory, rather than reactive.

Innovation

A collaborative methodology is needed, that optimizes existing resources and knowledge, fosters innovation through collaboration while using creative digital design principles. This way, we might be able to design eHealth solutions with end-users, not just for them.

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.

Care Models and Discharge Services for Children With Medical Complexity

BACKGROUND AND OBJECTIVES

Children with medical complexity (CMC) are high health care utilizers prompting hospitals to implement care models focused on this population, yet practices have not been evaluated on a national level. Our objective with this study is to describe the presence and structure of care models and the use of discharge services for CMC admitted to freestanding children's hospitals across the nation.

METHODS

We distributed an electronic survey to 48 hospitals within the Pediatric Health Information System exploring the availability of care models and discharge services for CMC. Care models were grouped by type and number present at each institution. Discharge services were grouped by low (never, rarely), medium (sometimes), and high (most of the time, always) frequency use.

RESULTS

Of 48 eligible hospitals, 33 completed the survey (69%). There were no significant differences between responders and non-responders for both hospital and patient characteristics. Most participants identified an outpatient care model (67%), whereas 21% had no dedicated care model for CMC in the inpatient or outpatient setting. High-frequency discharge services included durable medical equipment delivery, medication delivery, and communication with outpatient provider before discharge. Low-frequency discharge services included the use of a structured handoff tool for outpatient communication, personalized access plans, inpatient team follow-up with family after discharge, and the use of discharge checklists.

CONCLUSIONS

Children's hospitals vary largely in care model structure and discharge services. Future work is needed to evaluate the associations between care models and discharge services for CMC with various health care outcomes.

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).

Delineating family needs in the transition from hospital to home for children with medical complexity: part 2, a phenomenological study

BACKGROUND

A systematic literature review on the transition from hospital-to-home (H2H) of families with a child with medical complexity (CMC), resulted in nine overarching themes. These demonstrated common needs and experiences despite the widely differing CMC diagnoses and family characteristics. However, none of the reported studies was conducted in the Netherlands, which hampers the creation of a tailored H2H care pathway, deemed essential for our recently established Transitional Care Unit in the Netherlands: the 'Jeroen Pit Huis'. Therefore, the aim of this study was to gain a deeper understanding of the needs and experiences of Dutch CMC parents on H2H transition and integrate these insights with the literature review into an evidence-based H2H care pathway for CMC and their families.

METHODS

A descriptive phenomenological approach was applied. Heterogeneous purposeful sampling methods were used to recruit participants according to the following criteria: parents of CMC from various regions in the Netherlands, who spoke Dutch fluently and who had been discharged home from a tertiary hospital within the previous five years. Semi-structured, open-ended interviews were conducted via video call by two researchers, who transcribed the audio recordings verbatim. Thematic analysis methods were used to identify emerging themes from the individual transcripts, involving a third and fourth researcher to reach consensus.

RESULTS

Between March and August 2021, 14 mothers and 7 fathers participated in 14 interviews. They elaborated on the H2H transition of 14 CMC with a wide range of underlying diseases: 7 male, 7 female, aged 6 months to 10 years. Eight overarching themes, consistent with the results of the systematic review, represent CMC parental needs and experiences during the H2H process in the Netherlands: (1) autonomy, (2) division of tasks and roles, (3) family emotions, (4) impact on family life, (5) communication, (6) coordination of care, (7) support system and (8) adaptation.

CONCLUSIONS

The H2H needs and experiences reported by the CMC families in this study align with the results of our systematic review. The H2H transition process is not linear but continuous, and should extend beyond the specific medical needs of the CMC to holistic care for the family as a whole. The overarching care needs and experiences, expressed by all CMC families, regardless of underlying symptoms and diagnoses, inform the H2H care pathway and its future evaluation. Our studies highlight the necessity to focus on the family needs rather than on the specific illness of the child, as well as the value of our interdisciplinary care team partnering with parents in the 'Jeroen Pit Huis' towards a safe and sustainable transition home.

Delineating family needs in the transition from hospital to home for children with medical complexity: part 1, a meta-aggregation of qualitative studies

BACKGROUND

Advances in diagnostic and therapeutic interventions for rare diseases result in greater survival rates, with on the flipside an expanding group of children with medical complexity (CMC). When CMC leave the protective hospital environment to be cared for at home, their parents face many challenges as they take on a new role, that of caregiver rather than care-recipient. However, an overview of needs and experiences of parents of CMC during transition from hospital-to-home (H2H) is lacking, which hampers the creation of a tailored H2H care pathway. Here we address this unmet medical need by performing a literature review to systematically identify, assess and synthesize all existing qualitative evidence on H2H transition needs of CMC parents.

METHODS

An extensive search in Medline, PsychINFO and CINAHL (up to September 2022); selection was performed to include all qualitative studies describing parental needs and experiences during H2H transition of CMC. All papers were assessed by two independent investigators for methodological quality before data (study findings) were extracted and pooled. A meta-aggregation method categorized the study findings into categories and formulated overarching synthesized findings, which were assigned a level of confidence, following the ConQual approach.

RESULTS

The search yielded 1880 papers of which 25 met eligible criteria. A total of 402 study findings were extracted from the included studies and subsequently aggregated into 50 categories and 9 synthesized findings: (1) parental empowerment: shifting from care recipient to caregiver (2) coordination of care (3) communication and information (4) training skills (5) preparation for discharge (6) access to resources and support system (7) emotional experiences: fatigue, fear, isolation and guilt (8) parent-professional relationship (9) changing perspective: finding new routines and practices. The overall ConQual Score was low for 7 synthesized findings and very low for 2 synthesized findings.

CONCLUSIONS

Despite the variability in CMC symptoms and underlying (rare disease) diagnoses, overarching themes in parental needs during H2H transition emerged. We will augment this new knowledge with an interview study in the Dutch setting to ultimately translate into an evidence-based tailored care pathway for implementation by our interdisciplinary team in the newly established 'Jeroen Pit Huis', an innovative care unit which aims for a safe and sustainable H2H transition for CMC and their families.

Home experiences of parents of children undergoing hematopoietic stem cell transplantation: A qualitative study

PURPOSE

This study aimed to describe the home experiences of parents of children undergoing hematopoietic stem cell transplantation.

DESIGN AND METHODS

This study was conducted using a descriptive qualitative research design. The study sample consisted of 12 parents with a child treated with hematopoietic stem cell transplantation (HSCT) at a university hospital in Turkey. Semi-structured individual interviews and researcher observations were used for data collection. The interview transcripts of the study were analyzed using content analysis.

RESULTS

Five main themes were obtained, each of which had associated sub-themes: difficulties faced in home experiences, changes in family life, feelings about home experiences, parents' ways of coping with difficulties, and parents' suggestions.

CONCLUSIONS

Parents faced various difficulties in their own home experiences, and they felt fear, anxiety and stress during this period. Following the child's HSCT, there were changes in health, physical, psychological and social aspects of family life. Some parents used distraction techniques, and the support of their spouses and health professionals to cope with difficulties.

PRACTICE IMPLICATIONS

For pediatric nurses to comprehensively assess and support the home care needs of the child and parents, they should understand the difficulties parents face in home experiences, as well as their feelings, changes in their lives, suggestions regarding home experiences, and ways of coping. Regular health screening and psychosocial support can be provided for parents of children after HSCT, and regular training can be given for parents' management of care-related problems and increasing their self-efficacy for this management.

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.

Caring for children with new medical technology at home: parental perspectives

OBJECTIVES

This qualitative descriptive study explores the experiences of family caregivers (FCs) of children with medical complexity who are initiated on new medical technology in the hospital and transition to new daily life at home. The study aims to investigate FCs' response and readiness for medical technology use, the value of education and transition support and the challenges associated with managing new medical technology in the home.

STUDY DESIGN

A qualitative descriptive approach was used to conduct and analyse 14 semistructured interviews with a group of FCs composed of 11 mothers and 3 fathers. Content analysis was used to analyse transcripts of the caregiver interviews. The study was conducted at a tertiary paediatric hospital in Toronto, Canada.

RESULTS

Our study revealed three main themes: FC's response and readiness for medical technology use, the value of education and transition support for initiation of new medical technology and the challenges associated with managing new medical technology in the home. FCs expressed emotional distress related to coping with the realisation that their child required medical technology. Although the theoretical and hands-on practice training instilled confidence in families, FCs reported feeling overwhelmed when they transitioned home with new medical technology. Finally, FCs reported significant psychological, emotional and financial challenges while caring for their technology-dependent child.

CONCLUSIONS

Our study reveals the unique challenges faced by FCs who care for technology-dependent children. These findings highlight the need to implement a comprehensive education and transition programme that provides longitudinal support for all aspects of care.

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.

Hospital-to-home transitions for children with medical complexity: part 2-a core outcome set

Appropriate outcome measures as part of high-quality intervention trials are critical to advancing hospital-to-home transitions for Children with Medical Complexity (CMC). Our aim was to conduct a Delphi study and focus groups to identify a Core Outcome Set (COS) that healthcare professionals and parents consider essential outcomes for future intervention research. The development process consisted of two phases: (1) a three-round Delphi study in which different professionals rated outcomes, previously described in a systematic review, for inclusion in the COS and (2) focus groups with parents of CMC to validate the results of the Delphi study. Forty-five professionals participated in the Delphi study. The response rates were 55%, 57%, and 58% in the three rounds, respectively. In addition to the 24 outcomes from the literature, the participants suggested 12 additional outcomes. The Delphi rounds resulted in the following core outcomes: (1) disease management, (2) child's quality of life, and (3) impact on the life of families. Two focus groups with seven parents highlighted another core outcome: (4) self-efficacy of parents.   Conclusion: An evidence-informed COS has been developed based on consensus among healthcare professionals and parents. These core outcomes could facilitate standard reporting in future CMC hospital to home transition research. This study facilitated the next step of COS development: selecting the appropriate measurement instruments for every outcome. What is Known: • Hospital-to-home transition for Children with Medical Complexity is a challenging process. • The use of core outcome sets could improve the quality and consistency of research reporting, ultimately leading to better outcomes for children and families. What is New: • The Core Outcome Set for transitional care for Children with Medical Complexity includes four outcomes: disease management, children's quality of life, impact on the life of families, and self-efficacy of parents.

Long-term non-invasive ventilation in children: Transition from hospital to home

Long-term non-invasive ventilation (NIV) is an accepted therapy for sleep-related respiratory disorders and respiratory insufficiency or failure. Increase in the use of long-term NIV may, in part, be driven by an increase in the number of children surviving critical illness with comorbidities. As a result, some children start on long-term NIV as part of transitioning from hospital to home. NIV may be used in acute illness to avoid intubation, facilitate extubation or support tracheostomy decannulation, and to avoid the need for a tracheostomy for long-term invasive ventilation. The decision about whether long-term NIV is appropriate for an individual child and their family needs to be made with care. Preparing for transition from the hospital to home involves understanding how NIV equipment is obtained and set-up, education and training for parents/caregivers, and arranging a plan for clinical follow-up. While planning for these transitions is challenging, the goals of a shorter time in hospital and a child living well at home with their family are important.

"Why Do We Always Have to Focus on the Bad": A Strengths-Based Approach to Identify the Positive Aspects of Care From the Perspective of Older Adults Using a Secondary Qualitative Analysis

Hospitalization is often viewed as a burdensome and stressful period for older adults and their family caregivers; however, little attention has been given to the positive aspects of the care continuum journey. The purpose of this article is to highlight the positive aspects of healthcare from the perspective of Canadian older adults with complex needs and their family caregivers. This study utilized a strengths-based theoretical perspective to conduct a secondary qualitative analysis of interviews with 12 older adults and seven family caregivers. Four themes relating to positive aspects of care were identified, including: (1) looking beyond illness, (2) emotional support from healthcare providers, (3) timely discharge, and (4) upholding independence. Focusing on the positive aspects can help determine areas of care practice that currently work well. These insights will be valuable for current and future initiatives seeking to restructure and optimize healthcare services for older adults.

Caregiver and Clinician Perspectives on Discharge Medication Counseling: A Qualitative Study

OBJECTIVES

Children are at increased risk for medication errors and the transition from hospital-to-home is a vulnerable time for errors to occur. This study aimed to explore the perspectives of multidisciplinary clinicians and caregivers regarding discharge medication counseling and to develop a conceptual model to inform intervention efforts to reduce discharge medication dosing errors.

METHODS

We conducted semistructured interviews with clinicians and caregivers of children <4 years old discharged from the hospital on a liquid medication. A hierarchical coding system was developed using the interview guide and several transcripts. Qualitative analysis employed an iterative inductive-deductive approach to identify domains and subthemes and inform a conceptual framework.

RESULTS

We conducted focus groups and individual interviews with 17 caregivers and 16 clinicians. Using the Donabedian structure-process-outcomes model of quality evaluation, domains and subthemes included: (1) infrastructure of healthcare delivery, including supplies for counseling, content and organization of discharge instructions, clinician training and education, roles and responsibilities of team members, and hospital pharmacy delivery and counseling program; (2) processes of healthcare delivery, including medication reconciliation, counseling content, counseling techniques, and language barriers and health literacy; and (3) measurable outcomes, including medication dosing accuracy and caregiver understanding and adherence to discharge instructions.

CONCLUSIONS

The conceptual model resulting from this analysis can be applied to the development and evaluation of interventions to reduce discharge medication dosing errors following a hospitalization. Interventions should use a health literacy universal precautions approach-written materials with plain language and pictures and verbal counseling with teach-back and show-back.

Caregiver Perspectives on Telemedicine for Postdischarge Care for Children With Medical Complexity: A Qualitative Study

INTRODUCTION

The objectives of this study were to describe the perspectives of caregivers of children with medical complexity on telemedicine video visits (TMVV) for posthospitalization care and determine whether TMVV may be a viable alternative to in-person follow-up.

METHOD

Our qualitative descriptive study included semistructured telephone interviews with 12 caregivers. Data analysis was conducted using an adapted Colaizzi's descriptive phenomenological method for thematic construction.

RESULTS

Results were organized into four themes describing caregivers' experiences with TMVV: (1) promoted caregiver self-efficacy and sense of independence; (2) TMVV as convenient, cost-effective, comprehensive, and acceptable; (3) supported caregiver decision-making and problem-solving; and (4) fostered delivery of family-centered care.

DISCUSSION

Although in-person visits are necessary for some circumstances, TMVV can serve as a convenient and acceptable alternative for posthospitalization follow-up in children with medical complexity. Overall, caregivers in this study were satisfied with the quality of care and individualized experience of TMVV.

Parent-reported penicillin allergies in children: A qualitative study

BACKGROUND

Penicillin allergies are commonly reported in children. Most reported penicillin allergies are false, resulting in the unnecessary selection of alternative antibiotic treatments that promote antibiotic resistance. While formal allergy testing is encouraged to establish a diagnosis of penicillin allergy, children are rarely referred for allergy testing, and study of parents' experiences and perceptions of their child's reported penicillin allergy is limited. We aimed to describe parents' experiences and perceptions of their child's penicillin allergy and attitudes towards penicillin allergy testing to identify opportunities to engage parents in antimicrobial stewardship efforts.

METHODS

This was a qualitative descriptive study.

RESULTS

Eighteen parents participated in this study. Parents' children were on average 2 years old when the index reaction occurred, and 7 years had passed since the reaction. Transcripts revealed that participants were receptive to penicillin allergy testing for their child after learning the consequences of penicillin allergy and availability of allergy testing. Four major themes emerged from data (1) parents' making sense of allergy; (2) parents' impressions of allergy label, (3) parents' attitudes towards allergy testing, and (4) parents' desire to be informed of testing availability.

CONCLUSIONS

Efforts are needed to engage parents in addressing spuriously reported penicillin allergies.

A parent first: Exploring the support needs of parents caring for a child with medical complexity in Australia

PURPOSE

In a recent paediatric nursing research priority setting study, youth, parents and healthcare professionals included 'practical and emotional support' among the top ten areas to focus on. The aim of this study was to explore the support needs of parents who have a child with medical complexity living in the family home.

DESIGN

Exploratory with a qualitative inductive approach.

METHODS

Semi-structured interviews with 12 mothers of children living with heterogenous medical complexity. Interviews were recorded, transcribed and analysed using thematic analysis. The COREQ checklist was used as a reporting guide.

RESULTS

Three themes were tied together by the finding that participants identified as 'a parent first'. The first theme represents the early days where participants desired emotional and practical support for becoming a parent of a child with medical complexity. In the second theme, participants desired more support for the discharge home from the hospital. In the last theme, participants described high levels of knowledge and expertise in relation to their child's unique needs and desired highly accessible support for keeping their child out of hospital.

CONCLUSION

Parents' support needs change over time and are similar despite the heterogeneity of their children's medical complexity. Parents seek services that support an independent family life and are responsive to their confidence and competence in caring for their child at home.

PRACTICE IMPLICATIONS

Interventions should be tailored to the changing support needs of parents over time.

Parents' process of recognition and response to clinical deterioration of their children with medical complexity at home: A grounded theory

AIM

To explore the process of recognition and response to clinical deterioration of children with medical complexity at home by their parents.

BACKGROUND

Children with medical complexity are characterised by known chronic conditions associated with frailty and functional limitations, dependence on healthcare services and high use of technology and resources. Their medical complexity often leads to the onset of complications. Targeted care ensures timely recognition and response to clinical deterioration at home, thus avoiding serious sequelae, inappropriate hospitalisations and improving quality of life. Evidence on parents' process of the recognition and response to clinical deterioration at home is limited.

DESIGN

Qualitative study using a Grounded Theory methodology.

METHOD

Seven online focus groups were conducted with parents and healthcare providers experienced in their care. The interviews were transcribed verbatim and analysed through open, axial and selective coding, using a constant comparative iterative method. The COREQ guidelines guided the reporting of this work.

RESULTS

Four categories and one core category were identified: (1) Awareness of the unique and shared characteristics of children with medical complexity; (2) Parents' care maintenance and management; (3) Parents' care monitoring; (4) Parents' response to clinical deterioration and (5) Seeking the Shift of Agency, the core category as the foundation of the Process of Recognition and rEsponse of PAREnts to Deterioration (PRE-PARE-D) theory.

CONCLUSION

The role of parents of children with medical complexity is evolving into active care leaders, by developing care management and care monitoring competences and negotiating care with healthcare providers.

RELEVANCE TO CLINICAL PRACTICE

The shift of agency from healthcare providers to parents requires education and counselling pathways to promote the development of parent's self-efficacy, competencies and empowerment in the care management of their children. Home care delivery for children with medical complexity should aim at sustaining this partnership between healthcare providers and parents.

Caregiver perceptions of in-home COVID-19 testing for children with medical complexity: a qualitative study

BACKGROUND

In-home direct antigen rapid testing (DART) plays a major role in COVID-19 mitigation and policy. However, perceptions of DART within high-risk, intellectually impaired child populations are unknown. This lack of research could negatively influence DART uptake and utility among those who stand to benefit most from DART. The purpose of this study was to describe caregivers' perceptions of an in-home COVID-19 DART regimen in children with medical complexity, including the benefits and limitations of DART use.

METHODS

This qualitative study was a subproject of the NIH Rapid Acceleration of Diagnostics Underserved Populations research program at the University of Wisconsin. We combined survey data and the thematic analysis of semi-structured interview data to understand caregivers' perceptions of in-home COVID-19 testing and motivators to perform testing. Caregivers of children with medical complexity were recruited from the Pediatric Complex Care Program at the University of Wisconsin (PCCP). Data were collected between May and August 2021.

RESULTS

Among n = 20 caregivers, 16/20 (80%) of their children had neurologic conditions and 12/20 (60%) used home oxygen. Survey data revealed that the largest caregiver motivators to test their child were to get early treatment if positive (18/20 [90%] of respondents agreed) and to let the child's school know if the child was safe to attend (17/20 [85%] agreed). Demotivators to testing included that the child could still get COVID-19 later (7/20 [35%] agreed), and the need for officials to reach out to close contacts (6/20 [30%] agreed). From interview data, four overarching themes described perceptions of in-home COVID-19 testing: Caregivers perceived DART on a spectrum of 1) benign to traumatic and 2) simple to complex. Caregivers varied in the 3) extent to which DART contributed to their peace of mind and 4) implications of test results for their child.

CONCLUSIONS

Although participants often described DART as easy to administer and contributing to peace of mind, they also faced critical challenges and limitations using DART. Future research should investigate how to minimize the complexity of DART within high-risk populations, while leveraging DART to facilitate safe school attendance for children with medical complexity and reduce caregiver burden.

Management pathway for infants requiring chronic care in neonatal units-a scoping review of practices

Improvements in diagnostic and therapeutic modalities of antenatal care has meant that the neonatal intensive care units (NICU) need to care for infants with complex congenital conditions who need ongoing care post discharge. This, along with improved survival of the extreme preterm infants, provides the neonatal team with a cohort of infants who require long-standing multi-disciplinary input. However, provision of dedicated teams looking after infants with complex medical needs is not commonly reported in NICU workforce structure. The objective of this study is to perform a scoping review of literature on the presence of structured and dedicated complex care management teams in neonatal intensive care unit and their outcomes on care delivery. A scoping review was undertaken to identify all reported literature on existence of chronic care teams in NICU searching medical databases. A narrative synthesis of results was prepared.   Conclusions: The review identified very few clinical models reported with no robust data on clinical outcome measures. What is Known: • Neonatal units are increasingly providing care for infants who require chronic ongoing input from multiple specialties or allied health professionals. A majority of this cohort is formed by extreme preterm infants who require long term respiratory support or nutritional rehabilitation. • There are examples of dedicated clinical teams looking after complex patients in adult and pediatric intensive care outfits leading to improvements in outcome. What is New: • This is first literature review in the authors' knowledge on the use of complex care teams in neonatal intensive care unit. • This article provides a narrative synthesis of the clinical models that have been used by complex care teams in neonatal intensive care unit and whether they have demonstrated tangible benefits in patient outcome.

Feasibility Testing of Tubes@HOME: A Mobile Application to Support Family-Delivered Enteral Care

BACKGROUND

Assistance from medical devices is common for children with medical complexity (CMC) but introduces caregiving challenges. We tested the feasibility of "Tubes@HOME," a mobile application supporting CMC family-delivered care using enteral care as a model.

METHODS

Caregivers of CMC with enteral tubes participated in a 30-day feasibility study of Tubes@HOME November 2020 through January 2021. Tubes@HOME was available on mobile devices and designed to support collaborative care and tracking over time. Key features include child profile, caregiving network management, care routines, feedback loop, and action plans. Care routines delineated nutrition, medication, and procedural tasks needed for the child: frequencies, completions, and reminders. Metadata summarized feature use among users. Feasibility was evaluated with postuse questionnaires and interviews. Measures of Tubes@HOME's usability and usefulness included the NASA Task Load Index (TLX), System Usability Scale (SUS), and Acceptability and Use of Technology Questionnaire (AUTQ).

RESULTS

Among n = 30 children, there were 30 primary (eg, parent) and n = 22 nonprimary caregivers using Tubes@HOME. Children had a median (IQR) 10 (5.5-13) care routines created. For care routines created, 93% were marked complete at least once during the study period, with participants engaging with routines throughout study weeks 2 to 4. Results (mean [SD]) indicated low mental workload (TLX) 30.9 (12.2), good usability (SUS) 75.4 (14.7), and above-average usefulness (AUTQ) 4.0 (0.7) associated with Tubes@HOME, respectively. Interviews contextualized usefulness and suggested improvements.

CONCLUSIONS

Longitudinal use of Tubes@HOME among caregiving networks appeared feasible. Efficacy testing is needed, and outcomes could include reliability of care delivered in home and community.

Caregiver Expectations for Interfacing with Voice Assistants to Support Complex Home Care: Mixed-Methods Study (Preprint)

Background

Providing care in home environments is complex, and often the pressure is on caregivers to document information and ensure care continuity. Digital information management and communication technologies may support care coordination among caregivers. However, they have yet to be adopted in this context, partly because of issues with supporting long-term disease progression and caregiver anxiety. Voice assistant (VA) technology is a promising method for interfacing with digital health information that may aid in multiple aspects of being a caregiver, thereby influencing adoption. Understanding the expectations for VAs to support caregivers is fundamental to inform the practical development of this technology.

Objective

This study explored caregivers’ perspectives on using VA technology to support caregiving and inform the design of future digital technologies in complex home care.

Methods

This study was part of a larger study of caregivers across North America on the design of digital health technologies to support health communication and information management in complex home care. Caregivers included parents, guardians, and hired caregivers such as personal support workers and home care nurses. Video interviews were conducted with caregivers to capture their mental models on the potential application of VAs in complex home care and were theoretically analyzed using the technology acceptance model. Interviews were followed up with Likert-scale questions exploring perspectives on other VA applications beyond participants’ initial perceptions.

Results

Data were collected from 22 caregivers, and 3 themes were identified: caregivers’ perceived usefulness of VAs in supporting documentation, care coordination, and person-centered care; caregivers’ perceived ease of use in navigating information efficiently (they also had usability concerns with this interaction method); and caregivers’ concerns, excitement, expected costs, and previous experience with VAs that influenced their attitudes toward use. From the Likert-scale questions, most participants (21/22, 95%) agreed that VAs should support prompted information recording and retrieval, and all participants (22/22, 100%) agreed that they should provide reminders. They also agreed that VAs should support them in an emergency (18/22, 82%)—but only for calling emergency services—and guide caregivers through tasks (21/22, 95%). However, participants were less agreeable on VAs expressing a personality (14/22, 64%)—concerned they would manipulate caregivers’ perceptions—and listening ambiently to remind caregivers about their documentation (16/22, 73%). They were much less agreeable about VAs providing unprompted assistance on caregiving tasks (9/22, 41%).

Conclusions

The interviews and Likert-scale results point toward the potential for VAs to support family caregivers and hired caregivers by easing their information management and health communication at home. However, beyond information interaction, the potential impact of VA personality traits on caregivers’ perceptions of the care situation and the passive collection of audio data to improve user experience through context-specific interactions are critical design considerations that should be further examined.

Feasibility of Post-hospitalization Telemedicine Video Visits for Children With Medical Complexity

OBJECTIVES

To evaluate feasibility and acceptability of post-hospitalization telemedicine video visits (TMVV) during hospital-to-home transitions for children with medical complexity (CMC); and explore associations with hospital utilization, caregiver self-efficacy (CSE), and family self-management (FSM).

METHOD

This non-randomized pilot study assigned CMC (n=28) to weekly TMVV for four weeks post-hospitalization; control CMC (n=20) received usual care without telemedicine. Feasibility was measured by time to connection and proportion of TMVV completed; acceptability was measured by parent-reported surveys. Pre/post-discharge changes in CSE, FSM, and hospital utilization were assessed.

RESULTS

64 TMVV were completed; 82 % of patients completed 1 TMVV; 54 % completed four TMVV. Median time to TMVV connection was 1 minute (IQR=2.5). Parents reported high acceptability of TMVV (mean 6.42; 1 -7 scale). CSE and FSM pre/post-discharge were similar for both groups; utilization declined in both groups post-discharge.

DISCUSSION

Post-hospitalization TMVV for CMC were feasible and acceptable during hospital-to-home transitions.

Reducing Patient Length of Stay After Surgical Correction for Neuromuscular Scoliosis

BACKGROUND

Surgical correction remains the most effective treatment of patients with severe neuromuscular scoliosis (NMS). However, postoperative inpatient clinical care after spinal surgery for NMS patients is highly complex and variable, depending on the provider and/or institution. Our project used a quality improvement methodology to implement a standardized clinical care pathway for NMS patients during their primary spinal surgery, with the global aim of decreasing postoperative hospitalized length of stay (LOS).

METHODS

A multidisciplinary team developed a postoperative pathway for nonambulatory patients with NMS after their primary, nonstaged corrective spinal surgery. The outcome measure was mean LOS, and the process measure was percentage compliance with the newly implemented NMS pathway. The team used statistical process control charts and measures were evaluated over 3 phases to assess the impact of the interventions over time: pretesting, testing, and sustain.

RESULTS

The mean LOS decreased from 8.0 to 5.3 days; a statistically significant change based on statistical process control chart rules. Percentage compliance with the NMS pathway improved during the testing and sustain phases, compared with the pretesting phase. LOS variability decreased from pretesting to the combined testing and sustain phases.

CONCLUSIONS

Using quality improvement methodology, we successfully standardized major components of clinical care for patients with NMS after spinal corrective surgery. Through enhanced care consistency, the mean postoperative LOS decreased by nearly 3 days and decreased LOS variability. Robust multidisciplinary involvement with key stakeholders ensured sustainability of these improvements.

Designing a Mobile Health Solution to Facilitate the Transition from NICU to Home: A Qualitative Study

There is limited information about caregiver and provider perspectives regarding the design of a mobile health solution to facilitate the transition from the neonatal intensive care unit (NICU) to home. Focus groups were conducted with English- or Spanish-speaking families enrolled in an urban high-risk infant follow-up clinic and with their care providers. We generated salient themes using an inductive thematic analysis. Twenty-two participants completed the study. Among caregivers, the infant's median gestational age (IQR) was 29 (23, 34) weeks and 63% were Hispanic. Among the providers, 55% had practiced for more than 10 years and 18% were bilingual. Key stakeholder (family and provider) priorities for designing a mobile health solution were organized into eight domains, i.e., implementation ideas around user interface and timing, providing path planning and information, increasing support, improving engagement with providers and services, mitigating barriers to care after discharge and strengthening parenting role and confidence. The results from this study suggest that families and healthcare providers prioritize path planning, information and support as the pillars for designing an effective NICU-to-home transition mobile health application. Implications for product development include family empowerment, being a credible source of information and creating a resource for caregiver support and mental health.

Below the Surface: Caregivers' Experience of Hospital-to-Home Transitions

OBJECTIVE

Our aim was to understand the breadth of the hospital-to-home experience from the caregiver perspective using a mixed method approach.

METHODS

Caregivers of children who experienced an inpatient admission (N = 184) completed a hospital-to-home transition questionnaire after discharge. Twenty-six closed-ended survey items captured child's hospitalization, discharge, and postdischarge experiences and were analyzed using descriptive statistics. Four additional free-response items allowed caregivers to expand on specific challenges or issues. A conventional content analysis coding framework was applied to the free responses.

RESULTS

Ninety-one percent of caregivers reported satisfaction with the hospital experience and 88% reported they understood how to manage their child's health after discharge. A majority of survey respondents (74%) provided answers to 1 or more of the qualitative free-response items. In the predischarge period, qualitative responses centered on concerns related to finances or available resources and support, communication, hospital environment, and the discharge process. Responses for the postdischarge time period centered on family well-being (child health, other family member health), finances (bills, cost of missed work), and medical follow-up (supplies, appointments, instruction).

CONCLUSIONS

Caregivers were generally satisfied with their hospital experience; however, incorporating survey items specifically related to family stressors either through closed- or open-ended questions gave a richer context for caregiver-identified concerns. Basing future quality improvement efforts on supporting caregiver needs and identifying stressors before discharge may make for a more robust and successful transition to home.

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.

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.

A National Mental Health Profile of Parents of Children With Medical Complexity

OBJECTIVES

The mental health of parents of children with medical complexity (CMC) is poorly understood, yet it drives child and family health outcomes. For parents of CMC, compared with parents of noncomplex children with special health care needs (CSHCN) and children without special health care needs (non-CSHCN), we examined self-reported mental health, knowledge of community sources for help, and emotional support.

METHODS

Using parent-reported data from the combined 2016-2017 National Survey of Children's Health, we divided the population into 3 groups: households with CMC, noncomplex CSHCN, and non-CSHCN. We compared these groups regarding the following: (1) parents' risks for poor or fair mental health and knowledge of where to go for community help and (2) parent-reported sources of emotional support.

RESULTS

Of 63 955 588 parent-child dyads (weighted from a sample of 65 204), parents of CMC had greater adjusted odds of reporting poor or fair mental health compared with parents of noncomplex CSHCN (adjusted odds ratio [aOR] 2.0; 95% confidence interval [CI] 1.1-3.8) and non-CSHCN (aOR 4.6; 95% CI 2.5-8.6). Parents of CMC had greater odds of not knowing where to find community help compared with parents of noncomplex CSHCN (aOR 2.1; 95% CI 1.4-3.1) and non-CSHCN (aOR 2.9; 95% CI 2.0-4.3). However, parents of CMC were most likely to report receiving emotional support from health care providers and advocacy groups (P < .001).

CONCLUSIONS

Among all parents, those with CMC were at the highest risk to report suboptimal mental health. They more often reported that they do not know where to find community help, but they did say that they receive emotional support from health care providers and advocacy groups. Future researchers should identify ways to directly support the emotional wellness of parents of CMC.

Health Literacy-Related Safety Events: A Qualitative Study of Health Literacy Failures in Patient Safety Events

Introduction

Communication failures are the leading root cause of safety events. Although much communication research focuses on the healthcare team, there is little focus on communication with patients and families. It is not known what deficits in health literate patient communication lead to patient safety events. We aimed to identify themes of health literacy-related safety events to describe the impact of health literate communication on patient safety.

Methods

The safety events were entered into a system-wide self-reported safety event collection database. A patient safety specialist trained in health literacy prospectively tagged events for health literacy. The authors retrospectively queried the database for all health literacy tagged events during 9 months (September 2017-May 2018). The authors reviewed and independently coded health literacy-associated safety events. Qualitative content analysis of events facilitated by software (NVivo) was completed to identify the health literacy-related safety event themes.

Results

Health literacy events comprised 4% (152/3911) of self-reported safety events during the 9 months. Main themes of the health literacy safety events related to (1) medication; (2) system processes; and (3) discharge/transition. Subthemes of each of the events further described the event types. Health literacy-associated safety events encompass all safety event outcomes (near miss, precursor, and serious safety events).

Conclusions

Health literacy-related safety events occur in the healthcare environment. This review characterizing health literacy-related safety events prioritizes areas to implement health literate safety practices. Many opportunities exist to address communication-related safety events around medication, system processes, and discharge using health literate best practices.

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.

Simulation-Based Discharge Education Program for Caregivers of Children With Tracheostomies

OBJECTIVES

To design, implement, and evaluate a simulation-based education (SBE) program for caregivers of children with tracheostomy.

METHODS

Self-reported comfort and confidence in knowledge as well as tracheostomy care skills were assessed before and after a single SBE session for 24 consecutively enrolled caregivers of children with tracheostomies aged <21 years who were hospitalized at an academic medical center from August 2018 to September 2019 by using a survey and checklist, respectively. Mean individual and aggregated scores were compared by using a paired samples t-test, and association between instruments was determined with Spearman correlation.

RESULTS

Post-SBE, there was a significant improvement in both self-reported comfort and confidence (P < .001) and checklist assessment of most tracheostomy care skills (P < .001). There were no significant correlations between caregivers' self-reported comfort and confidence and skills pre-SBE (ρ = 0.13) or post-SBE (ρ = 0.14). Cronbach's α coefficients for the survey ranged from 0.93 to 0.95 and for the checklist from 0.58 to 0.67. Seventeen percent of caregivers competently completed the entire checklist post-SBE, with most caregivers missing 1 or 2 critical skills such as obturator removal after tracheostomy insertion.

CONCLUSIONS

In this pilot study, we demonstrated successful design and implementation of an SBE program for caregivers of children with tracheostomies, revealing improvements in self-reported comfort and confidence as well as in their performance of tracheostomy care skills. Further optimization is needed, and caregivers may benefit from additional SBE sessions to achieve complete skills competency. Future research on the long-term impact of SBE and the peer-to-peer support element of the program is needed.

Perspectives of Parents and Providers on Reasons for Mental Health Readmissions: A Content Analysis Study

Pediatric hospitalizations for mental health conditions are rapidly increasing, with readmission rates for mental health conditions surpassing those for non-mental health conditions. The objective of this study was to identify reasons for pediatric mental health readmissions from the perspectives of parents and providers. We performed a retrospective content analysis of surveys administered to parents and providers of patients with a 14-day readmission to an inpatient pediatric psychiatry unit between 5/2017 and 8/2018. Open-ended survey items assessed parent and provider perceptions of readmission reasons. We used deductive coding to categorize survey responses into an a priori coding scheme based on prior research. We used inductive coding to identify and categorize responses that did not fit into the a priori coding scheme. All data were recoded using the revised schema and reliability of the coding process was assessed using kappa statistics and consensus building. We had completed survey responses from 89 (64%) of 138 readmission encounters (56 parent surveys; 61 provider surveys). The top three readmission reasons that we identified from parent responses were: discordant inpatient stay expectations with providers (41%), discharge hesitancy (34%), and treatment plan failure (13%). Among providers, the top readmission reasons that we identified were: access to outpatient care (30%), treatment adherence (13%), and a challenging home (11%) and social environment (11%). We identified inpatient stay expectations, discharge hesitancy, and suboptimal access to outpatient care as the most prominent reasons for mental health readmissions, which provide targets for future quality improvement efforts.

Linking Parent Confidence and Hospitalization through Mobile Health: A Multisite Pilot Study

OBJECTIVE

To evaluate the associations between parent confidence in avoiding hospitalization and subsequent hospitalization in children with medical complexity (CMC); and feasibility/acceptability of a texting platform, Assessing Confidence at Times of Increased Vulnerability (ACTIV), to collect repeated measures of parent confidence.

STUDY DESIGN

This prospective cohort study purposively sampled parent-child dyads (n = 75) in 1 of 3 complex care programs for demographic diversity to pilot test ACTIV for 3 months. At random days/times every 2 weeks, parents received text messages asking them to rate confidence in their child avoiding hospitalization in the next month, from 1 (not confident) to 10 (fully confident). Unadjusted and adjusted generalized estimating equations with repeated measures evaluated associations between confidence and hospitalization in the next 14 days. Post-study questionnaires and focus groups assessed ACTIV's feasibility/acceptability.

RESULTS

Parents were 77.3% mothers and 20% Spanish-speaking. Texting response rate was 95.6%. Eighteen hospitalizations occurred within 14 days after texting, median (IQR) 8 (2-10) days. When confidence was <5 vs ≥5, adjusted odds (95% CI) of hospitalization within 2 weeks were 4.02 (1.20-13.51) times greater. Almost all (96.8%) reported no burden texting, one-third desired more frequent texts, and 93.7% were very likely to continue texting. Focus groups explored the meaning of responses and suggested ACTIV improvements.

CONCLUSIONS

In this demographically diverse multicenter pilot, low parent confidence predicted impending CMC hospitalization. Text messaging was feasible and acceptable. Future work will test efficacy of real-time interventions triggered by parent-reported low confidence.

Healthcare Utilization of Complex Chronically Ill Children Managed by a Telehealth-Based Team

Objectives: Medical advances have improved survival of critically ill children, increasing the number that have substantial ongoing care needs. The first aim of this study was to compare healthcare utilization of children with complex chronic conditions across an extensive geographic area managed by a predominantly telehealth-based team (FamiLy InteGrated Healthcare Transitions-FLIGHT) compared to matched historical controls. The second aim was to identify risk factors for healthcare utilization within the FLIGHT population. Methods: We performed a retrospective cohort study of all patients enrolled in the care management team. First, we compared them to age- and technology-based matched historic controls across medical resource-utilization outcomes. Second, we used univariable and multivariable linear regression models to identify risk factors for resource utilization within the FLIGHT population. Results: Sixty-four FLIGHT patients were included, with 34 able to be matched with historic controls. FLIGHT patients had significantly fewer hospital days per year (13.6 vs. 30.3 days, p = 0.02) and shorter admissions (6.0 vs. 17.3 days, p = 0.02) compared to controls. Within the telehealth managed population, increased number of technologies was associated with more admissions per year (coefficient 0.90, CI 0.05 - 1.75) and hospital days per year (16.83, CI 1.76 - 31.90), although increased number of complex chronic conditions was not associated with an increase in utilization. Conclusion: A telehealth-based care coordination team was able to significantly decrease some metrics of healthcare utilization in a complex pediatric population. Future study is warranted into utilization of telemedicine for care coordination programs caring for children with medical complexity.

Hospital Consultation From Outpatient Clinicians for Medically Complex Children: A Randomized Clinical Trial

IMPORTANCE

Children with medical complexity (CMC) frequently experience fragmented care. We have demonstrated that outpatient comprehensive care (CC) reduces serious illnesses, hospitalizations, and costs for high-risk CMC. Yet continuity of care for CMC is often disrupted with emergency department (ED) visits and hospitalizations.

OBJECTIVE

To evaluate a hospital consultation (HC) service for CMC from their outpatient CC clinicians.

DESIGN, SETTING, AND PARTICIPANTS

Randomized quality improvement trial at the University of Texas Health Science Center at Houston with an outpatient CC clinic and tertiary pediatric hospital (Children's Memorial Hermann Hospital). Participants included high-risk CMC (≥2 hospitalizations or ≥1 pediatric intensive care unit [PICU] admission in the year before enrolling in our clinic) receiving CC. Data were analyzed between January 11, 2018, and December 20, 2019.

INTERVENTIONS

The HC included serial discussions between CC clinicians, ED physicians, and hospitalists addressing need for admission, inpatient treatment, and transition back to outpatient care. Usual hospital care (UHC) involved routine pediatric hospitalist care.

MAIN OUTCOMES AND MEASURES

Total hospital days (primary outcome), PICU days, hospitalizations, and health system costs in skeptical bayesian analyses (using a prior probability assuming no benefit).

RESULTS

From October 3, 2016, through October 2, 2017, 342 CMC were randomized to either HC (n = 167) or UHC (n = 175) before meeting the predefined bayesian stopping guideline (>80% probability of reduced hospital days). In intention-to-treat analyses, the probability that HC reduced total hospital days was 91% (2.72 vs 6.01 per child-year; bayesian rate ratio [RR], 0.61; 95% credible interval [CrI], 0.30-1.26). The probability of a reduction with HC vs UHC was 98% for hospitalizations (0.60 vs 0.93 per child-year; RR, 0.68; 95% CrI, 0.48-0.97), 89% for PICU days (0.77 vs 1.89 per child-year; RR, 0.59; 95% CrI, 0.26-1.38), and 94% for mean total health system costs ($24 928 vs $42 276 per child-year; cost ratio, 0.67; 95% CrI, 0.41-1.10). In secondary analysis using a bayesian prior centered at RR of 0.78, reflecting the opinion of 7 experts knowledgeable about CMC, the probability that HC reduced hospital days was 96%.

CONCLUSIONS AND RELEVANCE

Among CMC receiving comprehensive outpatient care, an HC service from outpatient clinicians likely reduced total hospital days, hospitalizations, PICU days, other outcomes, and health system costs. Additional trials of an HC service from outpatient CC clinicians are needed for CMC in other centers.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02870387.

Stakeholder impact on the implementation of integrated care: Opportunities to consider for patient-centered outcomes research

Nearly half of Americans live with chronic disease. Many have multiple chronic conditions that often present as a combination of physical and mental health conditions. Aligning stakeholder-driven, patient-centered outcomes research with population health strategies such as innovative ways to deliver care management can reduce the burden of multiple chronic conditions. In addition, successfully creating meaningful, inclusive research requires actively engaging stakeholders throughout the lifecycle of a study. This study integrates stakeholder engagement, using a large health plan in western Pennsylvania, to conduct a randomized controlled trial. Three care management strategies, High-Touch, High-Tech, and Usual Care, are compared for effectiveness among members with multiple chronic conditions. Care strategies are delivered via the Community Team, a multidisciplinary community-based team, offering in-person (High-Touch) and digital (High-Tech) care management in 14 counties across Pennsylvania. Participants are followed for 12months, with repeated measurements of self-reported health status and activation in care, while tracking administrative measurements of primary and specialty health service utilization. Quality of life, care satisfaction, engagement in care, and service utilization will be compared using generalized mixed models. Additionally, semi-structured interviews are conducted for both participants and care managers over the course of the study to evaluate feasibility. This manuscript presents implementation strategies, while noting that the implementation of patient-centered outcomes research in a real-world setting requires rapid evaluation, redesign of workflow, and tailored approaches for success.

Identifying Caregiver Needs for Children With a Tracheostomy Living at Home

This study sought to understand caregiver needs of children with tracheostomies (CWT) living at home and inform development of standardized tracheostomy simulation training curricula. Long-term goals are decreasing hospital readmissions following tracheostomy placement and improving family experiences while implementing a medical home model. We recruited caregivers of CWT and conducted semistructured interviews, subsequently recorded, transcribed, and analyzed for emerging themes using NVivo. Demographic data were collected via quantitative surveys. Twenty-seven caregivers participated. Emerging themes included the following: (1) caregivers felt overwhelmed, sad, frightened when learning need for tracheostomy; (2) training described as adequate, but individualized training desired; (3) families felt prepared to go home, but transition was difficult; (4) home nursing care fraught with difficulty and yet essential for families of CWT. Families of CWT have specific needs related to discharge training, resources, support, and home nursing. Provider understanding of caregiver needs is essential for child well-being, patient-/family-centered care, and may improve health outcomes.

Discharge Before Return to Respiratory Baseline in Children With Neurologic Impairment

BACKGROUND

Children with neurologic impairment (NI) are commonly hospitalized with acute respiratory infections (ARI). These children frequently require respiratory support at baseline and are often discharged before return to respiratory baseline.

OBJECTIVE

To determine if discharge before return to respiratory baseline is associated with reutilization among children with NI hospitalized with ARI.

METHODS

This single-center retrospective cohort study included children with NI aged 1 to 18 years hospitalized with ARI who required increased respiratory support between January 2010 and September 2015. The primary exposure was discharge before return to respiratory baseline. The primary outcome was 30-day hospital reutilization. A generalized estimating equation was used to examine the association between exposure and outcome while accounting for within-patient clustering and patient-level clinical complexity and illness severity.

RESULTS

In the 632 hospitalizations experienced by 366 children, children were discharged before return to respiratory baseline in 30.4% of hospitalizations. Compared with those hospitalizations in which children were discharged at baseline, hospitalizations with a discharge before return to respiratory baseline were more likely to be for privately insured, technology-dependent children with respiratory comorbidities. Compared with discharges at respiratory baseline, discharges with increased respiratory support had no difference in 30-day reutilization (32.8% vs 31.8%; P = .81; adjusted OR 0.80, 95% CI 0.51-1.26).

CONCLUSIONS

Among children with NI hospitalized with ARI, discharge before return to respiratory baseline was common, but it was not associated with hospital reutilization. Return to respiratory baseline may not be a necessary component of discharge criteria in this population.

Transitioning Children With Medical Complexity From Hospital to Home Health Care: Implications for Hospital-Based Clinicians

OBJECTIVES

There is limited research about best practices for transitioning children with medical complexity (CMC) from hospital to home. Our objectives were to describe issues related to transitioning CMC from hospital to home health care and identify strategies to improve this transition.

METHODS

This qualitative study was conducted in western North Carolina between 2012 and 2014 and involved a focus group of 14 hospital- and community-based stakeholders and 4 focus groups of 18 home health nurses. Focus groups were audio-recorded and transcribed verbatim, and transcriptions were managed in ATLAS.ti software. By using content analysis, recurrent themes related to transitioning CMC from hospital to home were identified.

RESULTS

Themes in 4 domains emerged. (1) Home health orders: home health care providers desired hospital-based providers to write accurate and specific orders, notify them in advance about discharge to order specialized supplies, and avoid changing orders at the last minute. (2) Communication: participants found discharge summaries useful but did not always receive them. Communication between hospital-based clinicians, home health care providers, and the child's primary care physician about the hospitalization and home care was important. (3) Resources: home health care providers needed hospital-based clinicians to be a resource during the early period of transition home. (4) Caregiver preparation: participants emphasized caregiver preparation about medical care of CMC, home health nursing, and the differences between hospital and home care practices in the care of CMC.

CONCLUSIONS

There are gaps in the system of transitional care of CMC. Potential strategies to improve transitional care of CMC between the hospital and home health care services exist.

Parents' experiences of transition from hospital to home of a child with complex health needs: A systematic literature review

AIMS AND OBJECTIVES

To critically appraise primary research on the views and experiences of parents of children with complex health needs during the transition from hospital to home.

BACKGROUND

Children with complex health needs frequently transition across and within healthcare systems, due to their age, care needs and ongoing health conditions. Repeated and unplanned admissions are significantly higher for children with complex health needs. Yet parents, as the primary providers of care, report being unsupported and unprepared during the transition from hospital back to home due to poor communication, inadequate discharge planning and education, resulting in stress and anxiety within the home environment.

DESIGN

Systematic review following PRISMA guidelines.

METHODS

A systematic search was completed of the databases CINAHL, MEDLINE, PsycINFO, EMBASE and the Cochrane Library Review between January 2009 and September 2019. Data were extracted, categorised and analysed using a thematic analysis approach. An adapted CASP qualitative assessment tool was utilised for quality assessment. All included articles were marked for validity and relevance to current research with an overall score from 0-20.

RESULTS

A total of 13 studies of mixed quality were identified. CASP quality scores ranged from 13-18. Four themes emerged highlighting parents' experiences of the emotional processes, communication, coordination and support and resources when transitioning from hospital to home.

CONCLUSIONS

Hospital discharge and transition from hospital to home is a complicated and at times frustrating process for parents of children with complex health needs. Parents report being exhausted and stressed during this often-challenging period of adjustment which was perceived as a difficult and emotional process. There is a clear lack of support available for parents both from hospital and community services.

Pediatric Hospitalists' Lessons Learned From an Innovation Award to Improve Care for Children With Medical Complexity

Children with medical complexity experience frequent hospitalizations and pose a unique challenge for the pediatric hospitalist and their healthcare team. Pediatric hospitalists are ideally positioned to champion improved care coordination for CMC and to address the areas of need in clinical practice, quality improvement and research. Lessons learned from programs who were Healthcare Innovation Award recipients from Center for Medicare and Medicaid Innovation that were aimed at improving care for this population are presented. We focused on care coordination activities implemented during hospitalization. Through a series of meetings with the participating programs, we identified common themes across awarded programs. Programs described key aspects of care coordination during the hospital stay, beginning on admission (multidisciplinary team goal setting, family partnership and action planning), through hospitalization (integrating outpatient and inpatient care), as well as during and after discharge (linking to community-based systems and supports, expanding the transition concept). Finally, we present actionable steps for inpatient providers seeking to improve care for this patient population at the time of hospitalization.

Challenges Following Hospital Discharge for Children With Medical Complexity

OBJECTIVES

The transition from hospital to home is a period of risk, particularly for children with medical complexity. Our aim was to identify and address discharge challenges through execution of postdischarge phone calls.

METHODS

In this prospective study, we designed and executed a postdischarge phone call for patients discharged from an inpatient complex care team between May and November 2018. The call included dichotomous and open-ended questions to identify challenges regarding health status, follow-up appointments, medications, home nursing, medical supplies and/or equipment, and discharge instructions. These were recorded in the electronic health record. Details regarding identified challenges and corrective actions were categorized by 2 reviewers and adjudicated by a third reviewer if disagreement occurred.

RESULTS

Descriptive statistics were used to summarize these findings. Sixty-seven phone calls were completed within 1 week of discharge. Two-thirds of calls identified at least 1 challenge, and more than one-third of calls identified 2 or more challenges for a total of 90 challenges. The most common challenges involved health status (26.7%), follow-up appointments (21.1%), and medications (20%). The majority of challenges were addressed by either caregivers or the multidisciplinary team, with the exception of home nursing challenges.

CONCLUSIONS

Discharge challenges were commonly identified by caregivers of children with medical complexity. The majority of postdischarge challenges were addressed, with some addressed by families themselves. These results can inform health care providers about challenges to anticipate and suggest future interventions to mitigate anticipated challenges for a safe discharge and transition of care for these at-risk patients.

Parent Perspectives During Hospital Readmissions for Children With Medical Complexity: A Qualitative Study

OBJECTIVES

Children with medical complexity (CMC) have high readmission rates, but relatively little is known from the parent perspective regarding care experiences surrounding and factors contributing to readmissions. We aimed to elicit parent perspectives on circumstances surrounding 30-day readmissions for CMC.

METHODS

We conducted 20 semistructured interviews with parents of CMC experiencing an unplanned 30-day readmission at 1 academic medical center between December 2016 and January 2018, asking about topics such as previous discharge experiences, medical services and resources, and home environment and social support. Interviews were recorded, professionally transcribed, and analyzed thematically by using a modified grounded theory approach.

RESULTS

Children ranged in age from 0 to 15 years, with neurologic complex chronic conditions being predominant (35%). Although the majority of parents did not identify any factors that they perceived to have contributed to readmission, themes emerged regarding challenges associated with chronicity of care and transitions of care that might influence readmissions, including frequency of hospital use, symptom confusion, lack of inpatient continuity, resources needed but not received, and difficulty filling prescriptions.

CONCLUSIONS

Parents identified multiple challenges associated with chronicity of medical management and transitions of care for CMC. Future interventions aiming to improve continuity and communication between admissions, ensure that home services are provided when applicable and prescriptions are filled, and provide comprehensive support for families in both the short- and long-term may help improve patient and family experiences while potentially decreasing readmissions.

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.

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.

Key Population Health Outcomes for Children with Medical Complexity: A Systematic Review

INTRODUCTION

Despite the significant healthcare policy and program implications, a summary measure of health for children with medical complexity (CMC) has not been identified. It is unclear whether existing population health approaches apply to CMC. We conducted a systematic review of the existing peer-reviewed research literature on CMC to describe the health outcomes currently measured for CMC.

METHODS

We searched MEDLINE and PsycINFO by linking combinations of key words from three groups of concepts: (1) pediatric, (2) medical complexity, and (3) chronicity or severity. Study eligibility criteria were research studies including CMC with any outcome reported. Data on the outcomes were systematically extracted. Iterative content analysis organized outcomes into conceptual domains and sub-domains.

RESULTS

Our search yielded 3853 articles. After exclusion criteria were applied, 517 articles remained for data extraction. Five distinct outcome domains and twenty-four sub-domains emerged. Specifically, 50% of the articles studied healthcare access and use; 43% family well-being; 39% child health and well-being; 38% healthcare quality; and 25% adaptive functioning. Notably lacking were articles examining routine child health promotion as well as child mental health and outcomes related to family functioning.

CONCLUSIONS

Key health domains for CMC exist. Adaptations of existing sets of metrics and additional tools are needed to fully represent and measure population health for CMC. This approach may guide policies and programs to improve care for CMC.

Parental anxiety regarding premature infants and factors affecting parental concern

PURPOSE

Premature births have a great impact on the parents. The purpose of this study was to investigate the anxieties of parents of premature infants regarding infantile diseases and to help medical staff better communicate with parents of premature infants.

DESIGN AND METHODS

This study included premature infants <37 weeks of age who were admitted to the Neonatal Intensive Care Unit of Kosin University Gospel Hospital between August 1, 2017, and December 31, 2017. The eligible subjects included 51 premature infants with their 75 parents (45 mothers and 30 fathers) listed in the children's medical records. Parental anxieties regarding the infants were determined by retrospective interviews at various time points as follows: before and after the birth, on postnatal Days 3 and 7, before discharge, in the first week after discharge, and at "whenever" time point.

RESULTS

The highest parental anxiety during all time points was regarding the respiratory system of the premature infants. Parental concerns regarding the metabolic-endocrine system of their infants significantly correlated with the presence of maternal diabetes mellitus. Parental anxiety significantly differed depending on the use of resuscitation after birth. A statistically significant difference in parental anxiety was observed in relation to the birth weight before discharge. The premature infants with bronchopulmonary dysplasia showed a significant difference in the level of parental anxiety concerning the infant's illness in the first week after discharge.

CONCLUSIONS

The parents of the premature infants were greatly concerned about their infants' respiratory system. Careful prenatal counseling and support are needed for mothers with diabetes.