Neonatal Intensive Care Unit discharge preparedness among families with limited english proficiency

Experiences of communication in the neonatal intensive care unit for mothers with a preferred language other than English

OBJECTIVE

To understand the experiences of mothers with a preferred language other than English (PLOE) in communicating with staff and engaging in the care of their hospitalized infant.

DESIGN

We qualitatively analyzed a previously collected and a prospective dataset comprised of transcripts of 36 interviews with Spanish-, Haitian Creole-, and Brazilian Portuguese-speaking mothers of preterm infants from 3 NICUs. We applied the constant comparative method to develop codes and themes, which were inductively structured using the socio-ecological framework.

RESULTS

We identified themes across socio-ecological levels: Individual (unaddressed language barriers, varied maternal empowerment, and justification of suboptimal interpreter use); Interpersonal (family-staff language concordance facilitating engagement, positive impact of non-interpreted informal interactions, and differential treatment based on maternal language status); Institutional (system-level interpretation barriers and varied interpreter service quality).

CONCLUSION

Mothers with PLOE face multilevel communication and engagement barriers in the NICU; we discuss potential interventions to improve equity in these areas.

Equity-Focused Interventions Improve Interpreter Use in the Pediatric Intensive Care Unit

BACKGROUND

Federal guidelines and equitable care mandate that patients who use a language other than English receive interpretation in their preferred language. Substantial variability exists in interpreter use in intensive care settings. We aimed to increase the rate of interpretations in our pediatric intensive care unit (PICU) through a series of targeted interventions.

METHODS

A multidisciplinary team developed a key driver diagram to identify areas for focused intervention. Each plan-do-study-act cycle informed the next cycle of interventions, targeting increasing interpreter (video, phone, and in-person) use. Interventions included standardizing technology, standardizing placement of interpretation devices in patient rooms, provider education, and creating accountability systems of interpreter use by care providers. We reviewed data from PICU encounters between January 2018 and January 2022 and used summary statistics and statistical process control methods to measure the impact of our interventions.

RESULTS

We analyzed 882 patient encounters over the 4-year study period. Demographic characteristics were similar in the preintervention and postintervention periods. The total interpretation rate increased to 2.7 interpretations per patient per day from a baseline rate of 1.4. Each individual interpretation modality demonstrated increases in use. Average time spent interpreting via phone increased from 8 to 10.5 minutes per patient per day, and average time spent interpreting via video went from 9.5 to 22 minutes per patient per day.

CONCLUSIONS

Iterative quality improvement methodology effectively identified barriers to equitable care, guided development of focused interventions, and improved interpreter use among pediatric patients who were critically ill.

Communication Practices for Families With Languages Other Than English in US Neonatal Care Units

BACKGROUND AND OBJECTIVES

The lack of provision of culturally and linguistically appropriate services (CLAS) to families with languages other than English (LOE) is a highly modifiable driver of health care inequities. In a nationally representative sample of level 2 to 4 US NICUs, we examined patterns and predictors of communication practices for families with LOE and ascertained clinical leaders' beliefs about barriers to CLAS provision.

METHODS

We surveyed clinical leaders from 500 randomly selected US NICUs. Responses were weighted by the number of eligible NICUs per region and nonresponse rates. Outcomes included: consistent parental language documentation (≥75% of the time versus <75%) and consistent professional interpreter use (in-person or remote interpretation ≥75% of the time versus <75%). We used logistic regression to examine the associations of predictors (region, hospital characteristics, and the proportion of racial and ethnic minority and families with LOE served) with outcomes.

RESULTS

The overall response rate was 34%. A total of 63% of NICUs collected parental language data consistently, and 41% used interpreters consistently. Patterns of interpreter use varied by service hours and type of communication event. Teaching status, highest level of neonatal care, and larger NICU size were associated with consistent language documentation. Only a larger NICU size was associated with consistent interpreter use. Barriers to CLAS provision included untimely access to interpreter services and suboptimal quality of certain interpretation modalities.

CONCLUSIONS

Implementation guidance, accountability for compliance with existing mandates, and interventions tailored to the NICU context are needed to reduce linguistic disparities.

Limited English Proficiency and Outcomes in the Intensive Care Unit: An Integrated Review

INTRODUCTION

Language barriers place patients at risk of substandard care. Hospitalized patients with limited English proficiency (LEP) face unique challenges, especially in the intensive care unit (ICU). The purpose of this review is to critique and synthesize quantitative evidence on LEP and ICU outcomes.

METHODOLOGY

Quantitative studies published in English between 1999 and 2022 were queried using intentional terminology.

RESULTS

Searches yielded 138 results, with 12 meeting inclusion criteria. The analysis resulted in the extrapolation of five themes pertinent to outcomes of ICU patients or families with LEP: (a) knowledge deficit relating to conditions and care; (b) lack of language-appropriate care; (c) alienation from care process; (d) decreased confidence and ownership of care; and (e) relationship to clinical quality indicators.

DISCUSSION

Outcomes associated with LEP were largely negative and revealed unmet needs for ICU patients with LEP. More research is needed to improve linguistically and culturally congruent care in the ICU.

Association of Primary Language with Very Low Birth Weight Outcomes in Hispanic Infants in California

OBJECTIVE

To determine the association of Spanish as a primary language for a family with the health outcomes of Hispanic infants with very low birth weight (VLBW, <1500g).

STUDY DESIGN

Data from the California Perinatal Quality Care Collaborative (CPQCC) linked to hospital discharge records were analyzed. Hispanic infants with VLBW born between 2009 and 2018 with a primary language of English or Spanish were included. Outcomes selected were hypothesized to be sensitive to language barriers. Multivariable logistic regression models and mixed models estimated associations between language and outcomes.

RESULTS

Of 18 364 infants meeting inclusion criteria, 27% (n = 4976) were born to families with Spanish as a primary language. In unadjusted analyses, compared with infants of primarily English-speaking families, these infants had higher odds of hospital readmission within 1 year (OR 1.11 [95% CI 1.02-1.21]), higher odds to receive human milk at discharge (OR 1.32 [95% CI 1.23-1.42]), and lower odds of discharge home with oxygen (OR 0.83 [95% CI 0.73-0.94]). In multivariable analyses, odds of readmission and home oxygen remained significant when adjusting for infant but not maternal and hospital characteristics. Higher odds for receipt of any human milk at discharge were significant in all models. Remaining outcomes did not differ between groups.

CONCLUSIONS

Significant differences exist between Hispanic infants with VLBW of primarily Spanish-vs English-speaking families. Exploration of strategies to prevent readmissions of infants of families with Spanish as a primary language is warranted.

Communication in the neonatal ICU for Spanish speaking parents: a qualitative interview study

BACKGROUND

In the neonatal intensive care unit (NICU), health outcome disparities exist between patients with limited English proficiency (LEP) and those proficient in English. Our objective was to investigate the communication experience of parents with LEP in the NICU to learn how to mitigate such health disparities.

METHODS

A certified bilingual provider conducted seventeen interviews of parents who identified Spanish as their preferred language and whose newborn was admitted to the NICU for ≥ 1 week. Interviews were conducted August 2020 - December 2021. Conventional content analysis utilizing an inductive open coding process was performed.

RESULTS

The experiences of Spanish speaking parents with LEP in the NICU can be characterized by 3 main themes: 1) Information accessibility 2) Perspectives about interpreters and 3) Emotional consequences.

CONCLUSIONS

Our findings can inform neonatal quality initiatives to facilitate timely and good communication for NICU families with LEP.

Quality improvement for neonatal resuscitation and delivery room care

Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.

Limited English proficiency in the labor and delivery unit

PURPOSE OF REVIEW

Limited English proficiency (LEP) impacts patient access to safe and comprehensive care during the antepartum, intrapartum, and postpartum periods. In this review, we explore disparities in care delivery and outcomes that LEP women experience, and discuss the importance of providing language concordant care and using interpretation services appropriately.

RECENT FINDINGS

The number of individuals with LEP is steadily increasing in the United States. Pregnant women with LEP suffer disparities in obstetric care and are at risk for postpartum depression, breastfeeding difficulties, and substandard newborn care after neonatal ICU discharge because of insufficient education. Addressing these issues requires the implementation of language concordant care and education, along with the utilization of medically trained interpreters. Although further evidence is needed, the authors support these interventions to improve patient satisfaction, decrease medical errors, and curtail misdiagnoses.

SUMMARY

The pregnant woman with limited English proficiency is at risk of receiving suboptimal care and experiencing negative outcomes during the antepartum, intrapartum, and postpartum periods. The use of medically trained interpreters and the provision of language concordant care, through workforce diversification and the creation of forms and educational materials in diverse languages, can improve patient safety, outcomes, and quality of care.

Quality Improvement for Neonatal Resuscitation and Delivery Room Care

Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.

Increasing Parent Satisfaction With Discharge Planning: An Improvement Project Using Technology in a Level 3 NICU

BACKGROUND

Neonatal intensive care unit (NICU) families are often overwhelmed by the discharge process. Their anxiety can inhibit learning and contribute to poor infant outcomes and increased healthcare utilization after discharge. Quality of the discharge teaching is the strongest predictor of discharge readiness, so NICUs must develop excellent discharge preparation programs.

PURPOSE

This improvement project enhances NICU discharge preparedness by providing consistent, early discharge teaching using technology as a supplemental resource and raises parental satisfaction with the process.

METHODS

Neonatal intensive care unit staff and former NICU parents developed a task force to create technology-based discharge education content. The content was originally uploaded to an e-book and later transferred to the electronic health record inpatient portal. Families were able to view discharge teaching content at their own convenience and pace and review topics as needed with the NICU staff. Postdischarge follow-up phone calls provided insight into parental reaction to the new education format.

RESULTS

Parent satisfaction top-box scores, reflecting the highest rating in the "Prepared for Discharge" category of the patient satisfaction survey, improved from a baseline of 47% in 2017 to 70% in 2019. Overwhelmingly, 92% of families highly rated the tablet-based discharge teaching during postdischarge phone calls.

IMPLICATIONS FOR PRACTICE

A comprehensive, consistent, and early discharge program using technology can lead to more effective and efficient NICU discharge education and improved parent satisfaction.

IMPLICATIONS FOR RESEARCH

Further studies are needed to generalize hospital-based inpatient portal teaching as an additional resource for parental education in the NICU.

Parental mental health screening in the NICU: a psychosocial team initiative

OBJECTIVE

About 40-50% of parents with children admitted to Neonatal Intensive Care Units (NICU) experience clinically significant levels of depression, anxiety, and trauma. Poor parental mental health can negatively influence parent-child interactions and child development. Therefore, early identification of parents at-risk for clinical distress is of paramount importance.

METHODS

To address this need, the psychosocial team, including psychology and psychiatry, at a large, level 4 Neonatal Intensive Care Unit (NICU) developed a quality-improvement initiative to assess the feasibility of screening parents and to determine rates of depression and trauma in the unit.

RESULTS

About 40% of mothers and 20% of fathers were screened between 2 weeks of their child's hospitalization. About 40-45% of those parents endorsed clinically significant levels of depression and anxiety symptoms.

CONCLUSIONS

Recommendations for enhancing the feasibility and effectiveness of this process are discussed and considerations for future clinical and research endeavors are introduced.

NICU discharge preparation and transition planning: guidelines and recommendations

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

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.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

IMPLICATIONS FOR PRACTICE

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

Using rising tides to lift all boats: Equity-focused quality improvement as a tool to reduce neonatal health disparities

Evidence of health disparities affecting newborns abounds. Although quality improvement (QI) methodology is often suggested as a tool to advance health equity, the impact of QI initiatives on disparities is variable. QI work may mitigate, worsen, or perpetuate existing disparities. QI projects designed without an intentional focus on equity promotion may foster intervention-generated inequalities that further disadvantage vulnerable groups. This article reviews disparities in perinatal and neonatal care, the impact of QI on health disparities, and the concept of "Equity-Focused Quality Improvement" (EF-QI). EF-QI differs from QI with an equity lens in that it is action-oriented and centered around equity. EF-QI initiatives purposely integrate equity throughout the fabric of the project and are inclusive, collaborative efforts that foreground and address the needs of disadvantaged populations. EF-QI principles are applicable at every stage of project conception, execution, analysis, and dissemination, and may provide opportunities for reducing disparities in neonatal care.

Health literacy of parents of very preterm infants at NICU admission and discharge: a prospective cohort study

OBJECTIVE

To determine the prevalence of limited health literacy in parents of infants born ≤32 and 0/7 weeks and if health literacy changes during hospitalization.

STUDY DESIGN

Multi-site, prospective cohort study measuring health literacy using the Parent Health Literacy Activities Test, which estimates caregivers' ability to complete tasks such as reading prescription labels and preparing bottles. Data were analyzed using parametric and nonparametric comparison tests and multivariable regression to control for confounders.

RESULT

Of the 137 participants, 31% missed ≥3 questions of 8. Scores were not associated with admission characteristics or NICU complications. Lower scores were associated with lower nurses' (rho 0.20, p = 0.04) but not parents' (rho -0.12, p = 0.22) ratings of discharge readiness. Scores improved slightly from admission to discharge (p = 0.049).

CONCLUSION

Many parents have difficulty answering questions related to basic infant care tasks. NICUs should ensure that communication and discharge planning are mindful of health literacy.