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Nummedal MA, King S, Uleberg O, Pedersen SA, Bjørnsen LP. Non-emergency department (ED) interventions to reduce ED utilization: a scoping review. BMC Emerg Med 2024; 24:117. [PMID: 38997631 PMCID: PMC11242019 DOI: 10.1186/s12873-024-01028-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 06/20/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Emergency department (ED) crowding is a global burden. Interventions to reduce ED utilization have been widely discussed in the literature, but previous reviews have mainly focused on specific interventions or patient groups within the EDs. The purpose of this scoping review was to identify, summarize, and categorize the various types of non-ED-based interventions designed to reduce unnecessary visits to EDs. METHODS This scoping review followed the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive structured literature search was performed in the databases MEDLINE and Embase from 2008 to March 2024. The inclusion criteria covered studies reporting on interventions outside the ED that aimed to reduce ED visits. Two reviewers independently screened the records and categorized the included articles by intervention type, location, and population. RESULTS Among the 15,324 screened records, we included 210 studies, comprising 183 intervention studies and 27 systematic reviews. In the primary studies, care coordination/case management or other care programs were the most commonly examined out of 15 different intervention categories. The majority of interventions took place in clinics or medical centers, in patients' homes, followed by hospitals and primary care settings - and targeted patients with specific medical conditions. CONCLUSION A large number of studies have been published investigating interventions to mitigate the influx of patients to EDs. Many of these targeted patients with specific medical conditions, frequent users and high-risk patients. Further research is needed to address other high prevalent groups in the ED - including older adults and mental health patients (who are ill but may not need the ED). There is also room for further research on new interventions to reduce ED utilization in low-acuity patients and in the general patient population.
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Affiliation(s)
- Målfrid A Nummedal
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Sarah King
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Oddvar Uleberg
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Sindre A Pedersen
- The Medicine and Health Library, Library Section for Research Support, Data and Analysis, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Lars Petter Bjørnsen
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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Hama Diallo A, Shahid ASMSB, Khan AF, Saleem AF, Singa BO, Gnoumou BS, Tigoi C, Achieng C, Bourdon C, Oduol C, Lancioni CL, Manyasi C, McGrath CJ, Maronga C, Lwanga C, Brals D, Ahmed D, Mondal D, Denno DM, Mangale DI, Chimezi E, Mbale E, Mupere E, Salauddin Mamun GM, Ouédraogo I, Berkley JA, Njirammadzi J, Mukisa J, Thitiri J, Walson JL, Jemutai J, Tickell KD, Shahrin L, Mallewa M, Hossain MI, Chisti MJ, Timbwa M, Mburu M, Ngari MM, Ngao N, Aber P, Harawa PP, Sukhtankar P, Bandsma RH, Bamouni RM, Molyneux S, Mwaringa S, Shaima SN, Ali SA, Afsana SM, Banu S, Ahmed T, Voskuijl WP, Kazi Z. Hospital readmission following acute illness among children 2-23 months old in sub-Saharan Africa and South Asia: a secondary analysis of CHAIN cohort. EClinicalMedicine 2024; 73:102676. [PMID: 38933099 PMCID: PMC11200276 DOI: 10.1016/j.eclinm.2024.102676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/13/2024] [Accepted: 05/20/2024] [Indexed: 06/28/2024] Open
Abstract
Background Children in low and middle-income countries remain vulnerable following hospital-discharge. We estimated the incidence and correlates of hospital readmission among young children admitted to nine hospitals in sub-Saharan Africa and South Asia. Methods This was a secondary analysis of the CHAIN Network prospective cohort enrolled between 20th November 2016 and 31st January 2019. Children aged 2-23 months were eligible for enrolment, if admitted for an acute illness to one of the study hospitals. Exclusions were requiring immediate resuscitation, inability to tolerate oral feeds in their normal state of health, had suspected terminal illness, suspected chromosomal abnormality, trauma, admission for surgery, or their parent/caregiver was unwilling to participate and attend follow-up visits. Data from children discharged alive from the index admission were analysed for hospital readmission within 180-days from discharge. We examined ratios of readmission to post-discharge mortality rates. Using models with death as the competing event, we evaluated demographic, nutritional, clinical, and socioeconomic associations with readmission. Findings Of 2874 children (1239 (43%) girls, median (IQR) age 10.8 (6.8-15.6) months), 655 readmission episodes occurred among 506 (18%) children (198 (39%) girls): 391 (14%) with one, and 115 (4%) with multiple readmissions, with a rate of: 41.0 (95% CI 38.0-44.3) readmissions/1000 child-months. Median time to readmission was 42 (IQR 15-93) days. 460/655 (70%) and 195/655 (30%) readmissions occurred at index study hospital and non-study hospitals respectively. One-third (N = 213/655, 33%) of readmissions occurred within 30 days of index discharge. Sites with fewest readmissions had the highest post-discharge mortality. Most readmissions to study hospitals (371/450, 81%) were for the same illness as the index admission. Age, prior hospitalisation, chronic conditions, illness severity, and maternal mental health score, but not sex, nutritional status, or physical access to healthcare, were associated with readmission. Interpretation Readmissions may be appropriate and necessary to reduce post-discharge mortality in high mortality settings. Social and financial support, training on recognition of serious illness for caregivers, and improving discharge procedures, continuity of care and facilitation of readmission need to be tested in intervention studies. We propose the ratio of readmission to post-discharge mortality rates as a marker of overall post-discharge access and care. Funding The Bill & Melinda Gates Foundation (OPP1131320).
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Coon ER, Greene T, Fritz J, Desai AD, Ray KN, Hersh AL, Bardsley T, Bonafide CP, Brady PW, Wallace SS, Schroeder AR. A multicenter randomized trial to compare automatic versus as-needed follow-up for children hospitalized with common infections: The FAAN-C trial protocol. J Hosp Med 2024. [PMID: 38840329 DOI: 10.1002/jhm.13425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Physicians commonly recommend automatic primary care follow-up visits to children being discharged from the hospital. While automatic follow-up provides an opportunity to address postdischarge needs, the alternative is as-needed follow-up. With this strategy, families monitor their child's symptoms and decide if they need a follow-up visit in the days after discharge. In addition to being family centered, as-needed follow-up has the potential to reduce time and financial burdens on both families and the healthcare system. As-needed follow-up has been shown to be safe and effective for children hospitalized with bronchiolitis, but the extent to which hospitalized children with other common conditions might benefit from as-needed follow-up is unclear. METHODS The Follow-up Automatically versus As-Needed Comparison (FAAN-C, or "fancy") trial is a multicenter randomized controlled trial. Children who are hospitalized for pneumonia, urinary tract infection, skin and soft tissue infection, or acute gastroenteritis are eligible to participate. Participants are randomized to an as-needed versus automatic posthospitalization follow-up recommendation. The sample size estimate is 2674 participants and the primary outcome is all-cause hospital readmission within 14 days of discharge. Secondary outcomes are medical interventions and child health-related quality of life. Analyses will be conducted in an intention-to-treat manner, testing noninferiority of as-needed follow-up compared with automatic follow-up. DISCUSSION FAAN-C will elucidate the relative benefits of an as-needed versus automatic follow-up recommendation, informing one of the most common decisions faced by families of hospitalized children and their medical providers. Findings from FAAN-C will also have implications for national quality metrics and guidelines.
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Affiliation(s)
- Eric R Coon
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Tom Greene
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Julie Fritz
- Department of Physical Therapy & Athletic Training, College of Health, University of Utah, Salt Lake City, Utah, USA
| | - Arti D Desai
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adam L Hersh
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Tyler Bardsley
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Christopher P Bonafide
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Patrick W Brady
- Division of Hospital Medicine, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | | | - Alan R Schroeder
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
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Taylor JA, McDaniel CE, Stevens CA, Jacob-Files E, Acquilano SC, Freyleue SD, Bode R, Erdem G, Felman K, Lauden S, Bruce ML, Leyenaar JK. Direct Admission Program Implementation: A Qualitative Analysis of Variation Across Health Systems. Pediatrics 2024; 153:e2023063569. [PMID: 38533563 DOI: 10.1542/peds.2023-063569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 03/28/2024] Open
Abstract
OBJECTIVES Direct admission (DA) to the hospital has the potential to improve family satisfaction and timeliness of care by bypassing the emergency department. Using the RE-AIM implementation framework, we sought to characterize variation across health systems in the reach, effectiveness, adoption, and implementation of a DA program from the perspectives of parents and multidisciplinary clinicians. METHODS As part of a stepped-wedge cluster randomized trial to compare the effectiveness of DA to admission through the emergency department, we evaluated DA rates across 69 clinics and 3 health systems and conducted semi-structured interviews with parents and clinicians. We used thematic analysis to identify themes related to the reach, effectiveness, adoption, and implementation of the DA program and applied axial coding to characterize thematic differences across sites. RESULTS Of 2599 hospitalizations, 171 (6.6%) occurred via DA, with DA rates varying 10-fold across health systems from 0.9% to 9.3%. Through the analysis of 137 interviews, including 84 with clinicians and 53 with parents, we identified similarities across health systems in themes related to perceived program effectiveness and patient and family engagement. Thematic differences across sites in the domains of program implementation and clinician adoption included variation in transfer center efficiency, trust between referring and accepting clinicians, and the culture of change within the health system. CONCLUSIONS The DA program was adopted variably, highlighting unique challenges and opportunities for implementation in different hospital systems. These findings can inform future quality improvement efforts to improve transitions to the hospital.
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Affiliation(s)
- Jordan A Taylor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Corrie E McDaniel
- Seattle Children's Hospital, Seattle, Washington
- University of Washington, Seattle, Washington
| | | | | | - Stephanie C Acquilano
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Seneca D Freyleue
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Ryan Bode
- Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State College of Medicine, Columbus, Ohio
| | - Guliz Erdem
- Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State College of Medicine, Columbus, Ohio
| | - Kristyn Felman
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephanie Lauden
- Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State College of Medicine, Columbus, Ohio
- University of Colorado, Department of Pediatrics, Denver, Colorado
| | - Martha L Bruce
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Dartmouth Health Children's, Lebanon, New Hampshire
| | - JoAnna K Leyenaar
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Dartmouth Health Children's, Lebanon, New Hampshire
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Basso D, Bermúdez C, Carpio V, Tonini F, Ferrero F, Ibarra ME. Thirty-day readmissions in children with complex chronic conditions. An Pediatr (Barc) 2024; 100:188-194. [PMID: 38368139 DOI: 10.1016/j.anpede.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/07/2024] [Indexed: 02/19/2024] Open
Abstract
INTRODUCTION The rate of hospital readmission within 30 days of discharge is a quality indicator in health care. Paediatric patients with complex chronic conditions have high readmission rates. Failure in the transition between hospital and home care could explain this phenomenon. OBJECTIVES To estimate the incidence rate of 30-day hospital readmission in paediatric patients with complex chronic conditions, estimate how many are potentially preventable and explore factors associated with readmission. MATERIALS AND METHOD Cohort study including hospitalised patients with complex chronic conditions aged 1 month to 18 years. Patients with cancer or with congenital heart disease requiring surgical correction were excluded. The outcomes assessed were 30-day readmission rate and potentially preventable readmissions. We analysed sociodemographic, geographic, clinical and transition to home care characteristics as factors potentially associated with readmission. RESULTS The study included 171 hospitalizations, and 28 patients were readmitted within 30 days (16.4%; 95% CI, 11.6%-22.7%). Of the 28 readmissions, 23 were potentially preventable (82.1%; 95% CI, 64.4%-92.1%). Respiratory disease was associated with a higher probability of readmission. There was no association between 30-day readmission and the characteristics of the transition to home care. CONCLUSIONS The 30-day readmission rate in patients with complex chronic disease was 16.4%, and 82.1% of readmissions were potentially preventable. Respiratory disease was the only identified risk factor for 30-day readmission.
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Affiliation(s)
- Daiana Basso
- Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Carolina Bermúdez
- Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Vanessa Carpio
- Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Francisco Tonini
- Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Fernando Ferrero
- Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Mariano Esteban Ibarra
- Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina.
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Zhang R, Wang D, Zhu L, He Y, Cheng L, Ma J, Zhang T, Zhang J, Li L. Research trends in readiness for hospital discharge between 2002 and 2021: A bibliometric analysis. Nurs Open 2023; 10:7676-7693. [PMID: 37775985 PMCID: PMC10643845 DOI: 10.1002/nop2.2009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 06/16/2023] [Accepted: 09/17/2023] [Indexed: 10/01/2023] Open
Abstract
AIM This study aimed to undertake a bibliometric analysis to provide comprehensive information in demonstrating the current status and outline the overall trends in the area of readiness for hospital discharge (RHD). DESIGN A bibliometric and visual analysis of RHD literature was undertaken. METHODS Articles were retrieved from the Web of Science network from 2002 to 2021. VOSviewer was used to identify the co-authorship network of countries/institutions, co-authorship and co-citation analysis of authors, and co-citation analysis of references and citation analysis of documents. CiteSpace was used to identify the keyword co-occurrence network and perform cluster analysis, detecting the keywords with citation bursts and speculated frontiers in this research field. RESULTS A total of 512 articles were included in the final analysis. Key findings are: (1) There has been a continuous but somewhat fluctuating rise in the number of publications. (2) 56.05% of publications come from the USA with Marquette University making the highest contribution. (3) Most publications (17, 3.32%) in RHD research were from the Journal of Clinical Nursing, and Anaesthesia and Analgesia had the highest number of citations (584 citations). (4) Weiss ME (25, 4.88%) was the most productive author whose articles have been the most highly cited (646 citations). (5) Cited references from Weiss ME (2007) also made the largest contribution to co-citations, and the most cited reference was from Jack BW (2009) (1022 citations). (6) The 20 most frequent keywords and keywords with the strongest citation bursts were retrieved. There were seven research hotspots, and three emerging research frontiers were explored. CONCLUSIONS The bibliometric analysis of material published in the last 20 years indicates that there have been statistically significant gains in comprehensive information on RHD, including the knowledge mapping of the countries, institutions, authors, references and keywords. The hotspots and frontiers, which have been explored can give guidance to researchers as to new angles and directions to take. IMPLICATIONS FOR NURSING MANAGEMENT The effects of the implementation of ERAS on RHD-related risk for adverse post-discharge outcomes in surgical patients will be of increasing concern for healthcare professionals. It is important for patients and their relatives to be confident that on discharge they are sufficiently ready for hospital discharge to enable them to safely and smoothly make the transition to home. Improving the level of RHD in discharged patients can help nurse managers and researchers measure the effectiveness of discharge planning services.
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Affiliation(s)
- Rong Zhang
- Department of Neuro‐Oncology Center, Taihe HospitalHubei University of MedicineShiyanChina
| | - Dongmei Wang
- Department of Neuro‐Oncology Center, Taihe HospitalHubei University of MedicineShiyanChina
| | - Ling Zhu
- Department of Neuro‐Oncology Center, Taihe HospitalHubei University of MedicineShiyanChina
| | - Yongdong He
- Department of Neuro‐Oncology Center, Taihe HospitalHubei University of MedicineShiyanChina
| | - Ling Cheng
- Department of Neuro‐Oncology Center, Taihe HospitalHubei University of MedicineShiyanChina
| | - Jifen Ma
- Department of Neuro‐Oncology Center, Taihe HospitalHubei University of MedicineShiyanChina
| | - Ting Zhang
- Department of Thoracic, Cardiac, and Great Vascular Surgery, Taihe HospitalHubei University of MedicineShiyanChina
| | - Jun Zhang
- School of NursingWuhan UniversityWuhanChina
| | - Longti Li
- Nursing Department, Taihe HospitalHubei University of MedicineShiyanChina
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Warniment A, Sauers-Ford H, Brady PW, Beck AF, Callahan SR, Giambra BK, Herzog D, Huang B, Loechtenfeldt A, Loechtenfeldt L, Miller CL, Perez E, Riddle SW, Shah SS, Shepard M, Sucharew HJ, Tegtmeyer K, Thomson JE, Auger KA. Garnering effective telehealth to help optimize multidisciplinary team engagement (GET2HOME) for children with medical complexity: Protocol for a pragmatic randomized control trial. J Hosp Med 2023; 18:877-887. [PMID: 37602537 DOI: 10.1002/jhm.13192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023]
Abstract
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.
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Affiliation(s)
- Amanda Warniment
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Hadley Sauers-Ford
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Patrick W Brady
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Andrew F Beck
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Cincinnati Children's HealthVine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Michael Fisher Child Health Equity Center Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Scott R Callahan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Barbara K Giambra
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- College of Nursing, University of Cincinnati, Cincinnati, Ohio, USA
| | - Diane Herzog
- Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Bin Huang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Allison Loechtenfeldt
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Chelsey L Miller
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Combined Pediatrics/Medicine House Staff, Cincinnati Children's Hospital Medical Center and University of Cincinnati Hospital, Cincinnati, Ohio, USA
| | | | - Sarah W Riddle
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Heidi J Sucharew
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ken Tegtmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Center for Telehealth, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Joanna E Thomson
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Katherine A Auger
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Nelson A, Stuckey H, Snyder B, Van Scoy LJ, Daymont C, Irvin C, Wasserman E, Beck M. Provider Perspectives of Transitions of Care at a Tertiary Care Children's Hospital With a Hospitalist-Run Discharge Clinic. Clin Pediatr (Phila) 2023; 62:926-934. [PMID: 36726290 PMCID: PMC10986183 DOI: 10.1177/00099228221149279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Children's hospitals are discharging patients to home with increasingly complex outpatient needs, making safe transitions of care (ToCs) of vital importance. Our study involved a survey of both outpatient providers and pediatric hospitalists associated with our medical center to better describe providers' views on the ToC process. The survey included questions assessing views on patient care responsibilities, resource availability, our hospitalist-run postdischarge clinic (PDC), and comfort with telemedicine. Our hospitalists generally believed that primary care providers (PCPs) did not have adequate access to important ToC elements, whereas PCPs felt their access was adequate. Both provider types felt it was the inpatient team's responsibility to manage patient events between discharge and PCP follow-up and that a hospitalist-run PDC may reduce interim emergency room visits. This study challenges perceptions about the ToC process in children and describes a generalizable approach to assessing provider perceptions surrounding the ToC within individual health systems.
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Affiliation(s)
- Abigail Nelson
- Penn State Children’s Hospital, Department of Pediatrics
| | - Heather Stuckey
- Penn State Hershey College of Medicine; Department of Medicine
| | - Bethany Snyder
- Penn State Hershey College of Medicine; Department of Medicine
| | | | - Carrie Daymont
- Penn State Children’s Hospital, Department of Pediatrics
- Penn State Hershey College of Medicine, Department of Public Health Sciences
| | | | - Emily Wasserman
- Penn State Hershey College of Medicine, Department of Public Health Sciences
| | - Michael Beck
- Penn State Children’s Hospital, Department of Pediatrics
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Oliveira PV, Brocchi BS, Enes CC, Nucci LB. Hospitalizations of children and adolescents with complex chronic conditions in Brazil: a temporal analysis from 2009 to 2020. Eur J Pediatr 2023; 182:4153-4161. [PMID: 37434077 DOI: 10.1007/s00431-023-05071-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/26/2023] [Accepted: 06/17/2023] [Indexed: 07/13/2023]
Abstract
Access to advanced and sophisticated health technologies made it possible to increase the survival of children with complex chronic conditions. Thus, the profile of pediatric patients admitted to hospitals has changed in recent decades. In Brazil, there are few epidemiological studies on this subject. This study aims to evaluate the main characteristics and temporal trend of hospital admissions of children and adolescents with complex chronic conditions in Brazil, 2009-2020. This is a cross-sectional study with data on hospitalizations of children and adolescents with complex chronic conditions, extracted from the Hospital Information System of the Unified Health System, 2009-2020, in the 26 Brazilian states and the Federal District. The analysis included descriptive statistics and a generalized linear model. From 2009 to 2020, there were 1,337,120 hospitalizations of children and adolescents with complex chronic conditions, and of these, 735,820 (55.0%) were male. The percentage of hospital deaths during the analyzed period was 4.0%. The most recurrent diagnostic category was malignancy (41.0%), with an annual incidence increase of 2.61 (95% CI: 1.16-4.05). Between 2009 and 2019, the increase in hospitalizations for complex chronic conditions was 27.4% for boys and 25.2% for girls, and the reductions in the number of hospitalizations for other causes were 15.4% and 11.9% for boys and girls, respectively. Conclusions: Hospitalizations for complex chronic conditions in pediatrics are increasing in Brazil. This increase is a new challenge for the Brazilian public health system. What is Known: • The profile of pediatric patients admitted to hospitals has changed in recent decades, with a reduction in the total number of hospitalizations, but with an increase in the complexity and costs of these hospitalizations. • The world's scientific production on CCC is concentrated in the United States health care system. Epidemiological studies on the topic in universal health care systems are scarce. What is New: • This is the first study that evaluated the temporal trend of hospitalizations of children and adolescents with CCC in Brazil. • Hospitalizations for CCC in pediatrics are increasing in Brazil, with emphasis on the condition of malignancy, higher incidence in males and in children under one year of age. Furthermore, our study found a decrease in hospitalizations for other pediatric causes.
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Affiliation(s)
- Patrícia V Oliveira
- School of Life Sciences, Postgraduate Program in Health Sciences, Pontifical Catholic University of Campinas, São Paulo, Brazil.
| | - Beatriz S Brocchi
- School of Life Sciences, Department of Speech, Language, and Hearing Sciences, Pontifical Catholic University of Campinas, São Paulo, Brazil
| | - Carla C Enes
- School of Life Sciences, Postgraduate Program in Health Sciences, Pontifical Catholic University of Campinas, São Paulo, Brazil
| | - Luciana B Nucci
- School of Life Sciences, Postgraduate Program in Health Sciences, Pontifical Catholic University of Campinas, São Paulo, Brazil
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10
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Gross I, Berkun L, Egbaria D, Hashavya S, Rief S. Parents' Adherence to Follow-up Testing Instructions Following Hospital Discharge. Clin Pediatr (Phila) 2023; 62:571-575. [PMID: 36433632 DOI: 10.1177/00099228221139979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The adherence to follow-up testing instructions post-hospitalization is influenced by a variety of factors. Our aim was to assess the parental adherence to follow-up instructions and identify the factors that influence it. Parents of 200 children were asked about their adherence with these instructions; responses were obtained from 184 of 200. Parents did not adhere in 20 of 194 (10.9%) of cases. Families of infants under 12 months and children older than 10 years had lower adherence rates. Test completion was more frequent for children discharged with a test appointment compared with those discharged without an appointment (96% vs 86.6%; P = .07). The main reasons for non-adherence were disagreement as to the value of the testing (45%) or parental misunderstanding (30%). In conclusion, in order to increase adherence with post-hospitalization follow-up testing, physicians should focus on explaining the need and importance of the test and schedule an appointment prior to discharge.
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Affiliation(s)
- Itai Gross
- Department of Pediatric Emergency Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Lina Berkun
- Department of Pediatrics, Hadassah Medical Center, Jerusalem, Israel
| | - Dema Egbaria
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Saar Hashavya
- Department of Pediatric Emergency Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Shimon Rief
- Department of Pediatrics, Hadassah Medical Center, Jerusalem, Israel
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11
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Developing the Key Driver Diagram by Analyzing Home Central Line Caregiver Proficiency Factors. Pediatr Qual Saf 2023; 8:e638. [PMID: 36926216 PMCID: PMC10013623 DOI: 10.1097/pq9.0000000000000638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/10/2023] [Indexed: 03/16/2023] Open
Abstract
Caregivers of pediatric oncology and stem cell transplant patients often care for central lines (CLs) at home. Methods to achieve caregiver CL care proficiency, and interventions designed with caregiver input are lacking. Methods Caregivers of pediatric oncology and stem cell transplant patients patients with an external CL or removed within 2 weeks were eligible for a survey assessing knowledge, the value of training strategies, and comfort. We mapped responses (n = 79) and acceptability/challenges of introducing a pilot caregiver CL teach-back clinic program onto the capability, opportunity, motivation behavioral (COM-B) model of change to identify drivers of caregiver CL care proficiency. A working group, including caregivers, refined and approved a final driver diagram. Results Survey: Ninety-four percent of caregivers answered knowledge questions correctly (capability); 95% considered hands-on training helpful (opportunity); 53% were not very comfortable with CL care (motivation). Teach-back: Seventy-nine percent of caregivers were interested in a teach-back as additional training; 38% participated (opportunity); 20% refused participation due to being overwhelmed/not having time (motivation). Thirty-three percent of participants had a CL proficiency assessment (capability). Drivers of home caregiver CL care proficiency included: support for the caregiver's physical capability to perform CL care; enabling the CL care nurse trainer role; facilitating and increasing training opportunities, and engaging caregivers early and continuously to motivate proficiency development appropriately. Conclusions An approach centered on caregivers as main stakeholders can identify drivers to co-design an intervention for improved home CL care delivery. A standardized process to train and evaluate caregivers with multiple hands-on opportunities might be beneficial.
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12
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DiFazio RL, Miller PJ, Geyer D, Shore BJ, Snyder BD, Vessey JA. Parental caregivers' perception of their transition from hospital to home in children with cerebral palsy who have undergone orthopedic surgery. J Pediatr Nurs 2023; 69:47-55. [PMID: 36640526 DOI: 10.1016/j.pedn.2022.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/29/2022] [Accepted: 12/22/2022] [Indexed: 01/14/2023]
Abstract
PURPOSE Evaluate parental perception of the quality of discharge teaching, readiness for discharge, and the impact of these on post discharge coping difficulty and resource utilization in children with cerebral palsy (CP) following surgery. DESIGN AND METHODS Prospective cohort study conducted from September 2017-March 2021 at a pediatric academic medical center. Demographics were collected pre-operatively. Parents completed the Readiness for Hospital Discharge Scale (RHDS) and Quality of Discharge Teaching Scale (QDTS) within four hours of discharge. Four weeks post-discharge, parents completed the Post-discharge Coping Difficulty Scale (PDCDS). Utilization of healthcare resources were extracted from the electronic health record for 90 days post-operatively. Associations among demographics, RHDS, QDTS, PDCDS and resource utilization were assessed using general linear models; PDCDS's open-ended questions were analyzed using directed content analysis. RESULTS 114 parental caregivers participated. Post discharge coping was significantly associated with additional resource utilization: length of stay (p = 0.046), readmissions (p = 0.001), emergency department visits (p = 0.001), clinic calls (p = 0.001) and unplanned clinic visits (p = 0.006). PDCDS was negatively correlated with the QDTS Quality of Teaching Delivered subscale (r = -0.32; p = 0.004) and three of five RHDS subscales: 1) Child's Personal Status (r = -0.24; p = 0.02); 2) Knowledge (r = -0.30; p = 0.005); and 3) Coping Ability (r = -0.39; p < 0.001). Four themes explicated parental coping difficulties. CONCLUSION Parents experiencing coping difficulties were more likely to have difficulty managing their child's care needs at home and required additional health care resources. PRACTICE IMPLICATIONS Recognizing that parents' readiness for discharge may not reflect their coping abilities post-discharge requiring nurses to coordinate pre- and post-discharge education and support services.
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Affiliation(s)
- Rachel L DiFazio
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA 02115, United States of America.
| | - Patricia J Miller
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Boston, MA, United States of America
| | - David Geyer
- Boston College, Connell School of Nursing, Chestnut Hill, MA, United States of America.
| | - Benjamin J Shore
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA 02115, United States of America
| | - Brian D Snyder
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA 02115, United States of America
| | - Judith A Vessey
- Medical, Surgical, and Behavioral Health Programs, Boston Children's Hospital, Boston, MA 02115, United States of America
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13
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Forster EM, Kotzur C, Richards J, Gilmour J. Paediatric post-discharge pain and parent perceptions of support from an Australian nurse practitioner led acute pain service. J Child Health Care 2022; 26:394-406. [PMID: 33940942 DOI: 10.1177/13674935211014742] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Poorly managed post-operative pain remains an issue for paediatric patients. Post-discharge telephone follow-up is used by an Australian Nurse Practitioner Acute Pain Service (NpAPS) to provide access to effective pain management post-discharge from hospital. This cross-sectional survey design study aimed to determine the pain levels of children following discharge and parent views on participation in their child's pain management and perceptions of support from the NpAPS. Parents completed the Parents' Postoperative Pain Measure-Short Form (PPPM-SF) and factors affecting parents' participation in children's pain management questionnaire (FPMQ). Results indicated that pain score was high, especially on the day of discharge and 24 hours post-discharge. Parents, despite feeling supported by the NpAPS, experienced uncertainty, emotional responses and expressed concerns about communication and coordination of care. The clinically significant pain levels of the majority of children on the day of discharge and day post-discharge from hospital are a concern. Worry and uncertainty among parents, particularly on the day and first night of discharge, suggest this transition period where responsibility of clinical management of pain is handed over to parents may require greater focus for parental support.
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Affiliation(s)
| | - Catherine Kotzur
- Department of Anaesthetics, 94273Queensland Children's Hospital, Brisbane
| | - Julianne Richards
- Department of Anaesthetics, 94273Queensland Children's Hospital, Brisbane
| | - John Gilmour
- School of Psychology, University of Southern Queensland, Australia
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14
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van der Perk CJ, van de Riet L, Alsem M, van Goudoever JB, Maaskant J. Prognostic factors influencing parental empowerment after discharge of their hospitalized child: A cross-sectional study. J Pediatr Nurs 2022; 66:e145-e151. [PMID: 35537978 DOI: 10.1016/j.pedn.2022.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE There is a growing number of children with medical complexity (CMC). After hospitalization, care often has to be continued at home, making transitional care very important. However, many parents do not feel empowered in their role as caregiver for the child. To move forward in this field, we explored prognostic factors associated with parental empowerment after discharge of hospitalized children. DESIGN AND METHODS In a cross-sectional study, we collected data on potential prognostic factors found in the literature and on parental empowerment by means of the Family Empowerment Scale (FES). Linear regression analyses were performed to explore the associations between the prognostic factors and the FES. RESULTS Data from 228 patients and their parents were analyzed. Out of twelve factors included in the study, three showed significant associations with parental empowerment. Parents of CMC felt more empowered compared to parents of children with less complex conditions (β = 0.20, p = 0.00). We found a positive association between the age of the child and parental empowerment (β = 0.01, p = 0.00). Employed couples felt more empowered compared to unemployed couples (β = 0.30, p = 0.00). These three variables explained 11% of variance in the FES scores. CONCLUSIONS Parental empowerment is associated with the patient's age, child's medical complexity, and parental employment status. PRACTICE IMPLICATIONS Attention should be paid to the discharge preparation of parents of children with less medical complexity. Awareness is required for parents of younger children and parental employment status, because they are at risk for lower parental empowerment.
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Affiliation(s)
- Cor-Jan van der Perk
- Amsterdam University Medical Center, University of Amsterdam, Emma Children's Hospital, Amsterdam, the Netherlands.
| | - Liz van de Riet
- Amsterdam University Medical Center, University of Amsterdam, Emma Children's Hospital, Amsterdam, the Netherlands
| | - Mattijs Alsem
- Amsterdam University Medical Center, University of Amsterdam, Emma Children's Hospital, Amsterdam, the Netherlands; Amsterdam University Medical Center Department of Rehabilitation Medicine, Amsterdam, the Netherlands
| | - Johannes B van Goudoever
- Amsterdam University Medical Center, University of Amsterdam, Emma Children's Hospital, Amsterdam, the Netherlands
| | - Jolanda Maaskant
- Amsterdam University Medical Center, University of Amsterdam, Emma Children's Hospital, Amsterdam, the Netherlands; Amsterdam University Medical Center, University of Amsterdam Department of Data Science and Epidemiology, Amsterdam, the Netherlands
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15
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Gay JC, Teufel RJ, Peltz A, Auger KA, Harris JM, Hall M, Neuman MI, Simon HK, Morse R, Eghtesady P, McClead R, Shah SS. Variation in Condition-Specific Readmission Rates Across US Children's Hospitals. Acad Pediatr 2022; 22:797-805. [PMID: 35081468 DOI: 10.1016/j.acap.2022.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 01/14/2022] [Accepted: 01/16/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Despite extensive efforts, overall readmission rates at US children's hospitals have not materially declined over the past decade, raising questions about how to direct future efforts. Using measures of prevalence and performance variation we describe readmission rates by condition and identify priority conditions for future intervention. METHODS Retrospective cohort study of 49 US children's hospitals in the Pediatric Health Information System in 2017. Conditions were classified using All Patients Refined Diagnosis Related Groups. 30-day unadjusted and risk-adjusted readmission rates were calculated for each hospital/condition using the Pediatric All Cause Readmission measure. We ranked the highest volume conditions by rate variation (RV, interquartile range divided by the median) for each condition across hospitals. RESULTS The sample included 811,434 index hospitalizations with 50,196 (6.2%) 30-day readmissions. The RV across hospitals/conditions was between 0 and 2.8 (median = 0.7). Common reasons for admission had low RVs across hospitals, for example, bronchiolitis (readmission rate = 5.6%, RV = 0.4), seizure (readmission rate = 6.6%, RV = 0.3), and asthma (readmission rate = 3.1%, RV = 0.4). We identified 33 conditions with high variation in readmission rates across hospitals, which accounted for 18% of all discharges and 11% of all pediatric readmissions. These conditions may serve as candidates for future readmission reduction activities. CONCLUSIONS Many common childhood conditions have little variation in readmission rates across children's hospitals, suggesting limited future improvement opportunities. Conditions with high rate variation may provide opportunities for quality improvement; however, these conditions account for a relatively small share of total discharges suggesting modest potential impacts on national rates.
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Affiliation(s)
- James C Gay
- Department of Pediatrics (JC Gay), Vanderbilt University Medical Center, Nashville, Tenn
| | - Ronald J Teufel
- Department of Pediatrics (RJ Teufel), Medical University of South Carolina, College of Medicine, Charleston, SC
| | - Alon Peltz
- Department of Population Medicine (A Peltz), Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Mass.
| | - Katherine A Auger
- Division of Hospital Medicine and James M. Anderson Center for Healthcare Improvement, Cincinnati Children's Hospital Medical Center; Department of Pediatrics (KA Auger), University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Hospital Medicine (SS Shah), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Matthew Hall
- Children's Hospital Association (M Hall), Lenexa, Kans
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Department of Pediatrics (MI Neuman), Harvard Medical School, Boston, Mass
| | - Harold K Simon
- Department of Pediatrics and Emergency Medicine (HK Simon), Emory University School of Medicine; Children's Healthcare of Atlanta, Atlanta, Ga
| | - Rustin Morse
- Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, The Ohio State College of Medicine (R Morse), Columbus, Ohio
| | | | - Richard McClead
- Office of the Chief Medical Officer (R McClead), Nationwide Children's Hospital, Columbus, Ohio
| | - Samir S Shah
- Division of Hospital Medicine (SS Shah), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Discharge interventions from inpatient child and adolescent mental health care: a scoping review. Eur Child Adolesc Psychiatry 2022; 31:857-878. [PMID: 32886222 PMCID: PMC9209379 DOI: 10.1007/s00787-020-01634-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 08/26/2020] [Indexed: 11/26/2022]
Abstract
The post-discharge period is an extremely vulnerable period for patients, particularly for those discharged from inpatient children and adolescent mental health services (CAMHS). Poor discharge practices and discontinuity of care can put children and youth at heightened risk for readmission, among other adverse outcomes. However, there is limited understanding of the structure and effectiveness of interventions to facilitate discharges from CAMHS. As such, a scoping review was conducted to identify the literature on discharge interventions. This scoping review aimed to describe key components, designs, and outcomes of existing discharge interventions from CAMHS. Nineteen documents were included in the final review. Discharge interventions were extracted and summarized for pre-discharge, post-discharge, and bridging elements. Results of this scoping review found that intervention elements included aspects of risk assessment, individualized care, discharge preparation, community linkage, psychoeducation, and follow-up support. Reported outcomes of discharge interventions were also extracted and included positive patient and caregiver satisfaction, improved patient health outcomes, and increased cost effectiveness. Literature on discharge interventions from inpatient CAMHS, while variable in structure, consistently underscore the role of such interventions in minimizing patient and family vulnerability post-discharge. However, findings are limited by inadequate reporting and heterogeneity across studies. There is a need for further research into the design, implementation, and evaluation of interventions to support successful discharges from inpatient child and adolescent mental health care.
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17
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Identifying Children at Readmission Risk: At-Admission versus Traditional At-Discharge Readmission Prediction Model. Healthcare (Basel) 2021; 9:healthcare9101334. [PMID: 34683014 PMCID: PMC8544577 DOI: 10.3390/healthcare9101334] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 09/24/2021] [Accepted: 09/27/2021] [Indexed: 11/16/2022] Open
Abstract
The timing of 30-day pediatric readmissions is skewed with approximately 40% of the incidents occurring within the first week of hospital discharges. The skewed readmission time distribution coupled with delay in health information exchange among healthcare providers might offer a limited time to devise a comprehensive intervention plan. However, pediatric readmission studies are thus far limited to the development of the prediction model after hospital discharges. In this study, we proposed a novel pediatric readmission prediction model at the time of hospital admission which can improve the high-risk patient selection process. We also compared proposed models with the standard at-discharge readmission prediction model. Using the Hospital Cost and Utilization Project database, this prognostic study included pediatric hospital discharges in Florida from January 2016 through September 2017. Four machine learning algorithms—logistic regression with backward stepwise selection, decision tree, Support Vector machines (SVM) with the polynomial kernel, and Gradient Boosting—were developed for at-admission and at-discharge models using a recursive feature elimination technique with a repeated cross-validation process. The performance of the at-admission and at-discharge model was measured by the area under the curve. The performance of the at-admission model was comparable with the at-discharge model for all four algorithms. SVM with Polynomial Kernel algorithms outperformed all other algorithms for at-admission and at-discharge models. Important features associated with increased readmission risk varied widely across the type of prediction model and were mostly related to patients’ demographics, social determinates, clinical factors, and hospital characteristics. Proposed at-admission readmission risk decision support model could help hospitals and providers with additional time for intervention planning, particularly for those targeting social determinants of children’s overall health.
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18
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Osorio SN, Gage S, Mallory L, Soung P, Satty A, Abramson EL, Provost L, Cooperberg D. Factorial Analysis Quantifies the Effects of Pediatric Discharge Bundle on Hospital Readmission. Pediatrics 2021; 148:peds.2021-049926. [PMID: 34593650 DOI: 10.1542/peds.2021-049926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Snezana Nena Osorio
- Department of Pediatrics, Weill Cornell Medical College and New York Presbyterian Hospital, New York, New York
| | - Sandra Gage
- Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin.,Department of Child Health, College of Medicine-Phoenix, University of Arizona and Phoenix Children's Hospital, Phoenix, Arizona
| | - Leah Mallory
- Department of Pediatrics, School of Medicine, Tufts University and The Barbara Bush Children's Hospital, Portland, Maine
| | - Paula Soung
- Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Alexandra Satty
- Department of Pediatrics, Weill Cornell Medical College and New York Presbyterian Hospital, New York, New York
| | - Erika L Abramson
- Department of Pediatrics, Weill Cornell Medical College and New York Presbyterian Hospital, New York, New York
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Uong A, Philips K, Hametz P, Dunbar J, Jain P, O’Connor K, Offenbacher R, Eliezer K, Pilnick C, Kiely V, Rinke ML. SAFER Care: Improving Caregiver Comprehension of Discharge Instructions. Pediatrics 2021; 147:peds.2020-0031. [PMID: 33707198 PMCID: PMC8015156 DOI: 10.1542/peds.2020-0031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND One in five pediatric patients suffers from adverse events related to hospital discharge. Current literature lacks evidence on effective interventions to improve caregiver comprehension (CC) of discharge instructions. We examined if a standardized framework for written and verbal discharge counseling was associated with increased CC of key discharge instructions after discharge from a general pediatric inpatient unit. METHODS An interprofessional team created the SAFER Care framework to encourage standard, comprehensive discharge counseling. Plan-do-study-act cycles included electronic health record smartphrases, educational initiatives, data feedback, visual aids, and family outreach. Caregivers were surveyed by phone within 4 days of discharge. Our primary outcome was the proportion of caregivers correctly responding to all questions related to discharge care, comparing pre- and postintervention periods. Data were plotted on a statistical process control chart to assess the effectiveness of interventions. RESULTS A total of 171 surveys were analyzed in the preintervention period, and 262 surveys were analyzed in the postintervention period. A total of 37% of caregivers correctly responded to all questions in the preintervention period, compared with 62% of caregivers in the postintervention period, meeting rules for special cause variation. CONCLUSIONS Development of the SAFER Care framework and its use in written and verbal discharge counseling was associated with significantly improved CC of discharge instructions in a general pediatric inpatient unit. Further studies should be focused on expanding this to other populations, particularly limited-English-proficiency families.
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Affiliation(s)
- Audrey Uong
- Children's Hospital at Montefiore, Bronx, New York; and .,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Kaitlyn Philips
- Children’s Hospital at Montefiore, Bronx, New York; and,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Patricia Hametz
- Children’s Hospital at Montefiore, Bronx, New York; and,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Julie Dunbar
- Children’s Hospital at Montefiore, Bronx, New York; and,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Priya Jain
- Children’s Hospital at Montefiore, Bronx, New York; and,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Katherine O’Connor
- Children’s Hospital at Montefiore, Bronx, New York; and,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | | | | | | | | | - Michael L. Rinke
- Children’s Hospital at Montefiore, Bronx, New York; and,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
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20
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Holbrook A, Benipal H, Paterson JM, Martins D, Greaves S, Lee M, Gomes T. Adverse event rates associated with oral anticoagulant treatment early versus later after hospital discharge in older adults: a retrospective population-based cohort study. CMAJ Open 2021; 9:E364-E375. [PMID: 33863794 PMCID: PMC8084547 DOI: 10.9778/cmajo.20200138] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Oral anticoagulants are commonly used high-risk medications, but little is known about their safety in transition from hospital to home. Our objective was to measure the rates of hemorrhage and thromboembolic events among older adults receiving oral anticoagulant treatment early after hospital discharge compared to later. METHODS We conducted a retrospective population-based cohort study among Ontario residents aged 66 years or more who started, continued or resumed oral anticoagulant therapy at hospital discharge between September 2010 and March 2015. We calculated the rates of hemorrhage and thromboembolic events requiring hospital admission or an emergency department visit over a 1-year follow-up period, stratified by the first 30 days after discharge and the remainder of the year. We used multivariable regression models, adjusting for covariates, to estimate the effect of sex, prevalent versus incident use, and switching anticoagulants on events. RESULTS A total of 123 139 patients (68 408 women [55.6%]; mean age 78.2 yr) were included. About one-quarter (32 563 [26.4%]) had a Charlson Comorbidity Index score of 2 or higher. The rates of hemorrhage and thromboembolic events per 100 person-years were highest during the first 30 days after hospital discharge (25.8, 95% CI 24.8-26.8 and 19.3, 95% CI 18.4-20.2, respectively), falling to 15.7 (95% CI 15.3-16.1) and 6.9 (95% CI 6.6-7.1), respectively, during the subsequent 11 months. Multivariable analysis showed that patients whose anticoagulant was switched in hospital and men had more hemorrhages and thromboembolic events in follow-up. INTERPRETATION The first few weeks following hospital discharge represent a very high-risk period for adverse events related to oral anticoagulant treatment among older adults. The results support an intervention trial addressing anticoagulation management in the early postdischarge period.
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Affiliation(s)
- Anne Holbrook
- Division of Clinical Pharmacology & Toxicology (Holbrook), Department of Medicine and Department of Health Research Methods, Evidence, and Impact (Holbrook, Benipal, Greaves), McMaster University, Hamilton, Ont.; ICES (Paterson, Gomes); Institute of Health Policy, Management and Evaluation (Paterson), University of Toronto, Toronto, Ont.; Schulich School of Medicine and Dentistry (Lee), Western University, London, Ont.; Li Ka Shing Knowledge Institute (Martins, Gomes), St. Michael's Hospital, Toronto, Ont.
| | - Harsukh Benipal
- Division of Clinical Pharmacology & Toxicology (Holbrook), Department of Medicine and Department of Health Research Methods, Evidence, and Impact (Holbrook, Benipal, Greaves), McMaster University, Hamilton, Ont.; ICES (Paterson, Gomes); Institute of Health Policy, Management and Evaluation (Paterson), University of Toronto, Toronto, Ont.; Schulich School of Medicine and Dentistry (Lee), Western University, London, Ont.; Li Ka Shing Knowledge Institute (Martins, Gomes), St. Michael's Hospital, Toronto, Ont
| | - J Michael Paterson
- Division of Clinical Pharmacology & Toxicology (Holbrook), Department of Medicine and Department of Health Research Methods, Evidence, and Impact (Holbrook, Benipal, Greaves), McMaster University, Hamilton, Ont.; ICES (Paterson, Gomes); Institute of Health Policy, Management and Evaluation (Paterson), University of Toronto, Toronto, Ont.; Schulich School of Medicine and Dentistry (Lee), Western University, London, Ont.; Li Ka Shing Knowledge Institute (Martins, Gomes), St. Michael's Hospital, Toronto, Ont
| | - Diana Martins
- Division of Clinical Pharmacology & Toxicology (Holbrook), Department of Medicine and Department of Health Research Methods, Evidence, and Impact (Holbrook, Benipal, Greaves), McMaster University, Hamilton, Ont.; ICES (Paterson, Gomes); Institute of Health Policy, Management and Evaluation (Paterson), University of Toronto, Toronto, Ont.; Schulich School of Medicine and Dentistry (Lee), Western University, London, Ont.; Li Ka Shing Knowledge Institute (Martins, Gomes), St. Michael's Hospital, Toronto, Ont
| | - Simon Greaves
- Division of Clinical Pharmacology & Toxicology (Holbrook), Department of Medicine and Department of Health Research Methods, Evidence, and Impact (Holbrook, Benipal, Greaves), McMaster University, Hamilton, Ont.; ICES (Paterson, Gomes); Institute of Health Policy, Management and Evaluation (Paterson), University of Toronto, Toronto, Ont.; Schulich School of Medicine and Dentistry (Lee), Western University, London, Ont.; Li Ka Shing Knowledge Institute (Martins, Gomes), St. Michael's Hospital, Toronto, Ont
| | - Munil Lee
- Division of Clinical Pharmacology & Toxicology (Holbrook), Department of Medicine and Department of Health Research Methods, Evidence, and Impact (Holbrook, Benipal, Greaves), McMaster University, Hamilton, Ont.; ICES (Paterson, Gomes); Institute of Health Policy, Management and Evaluation (Paterson), University of Toronto, Toronto, Ont.; Schulich School of Medicine and Dentistry (Lee), Western University, London, Ont.; Li Ka Shing Knowledge Institute (Martins, Gomes), St. Michael's Hospital, Toronto, Ont
| | - Tara Gomes
- Division of Clinical Pharmacology & Toxicology (Holbrook), Department of Medicine and Department of Health Research Methods, Evidence, and Impact (Holbrook, Benipal, Greaves), McMaster University, Hamilton, Ont.; ICES (Paterson, Gomes); Institute of Health Policy, Management and Evaluation (Paterson), University of Toronto, Toronto, Ont.; Schulich School of Medicine and Dentistry (Lee), Western University, London, Ont.; Li Ka Shing Knowledge Institute (Martins, Gomes), St. Michael's Hospital, Toronto, Ont
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21
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Choe AY, Thomson JE, Unaka NI, Wagner V, Durling M, Moeller D, Ampomah E, Mangeot C, Schondelmeyer AC. Disparity in Nurse Discharge Communication for Hospitalized Families Based on English Proficiency. Hosp Pediatr 2021; 11:245-253. [PMID: 33531376 DOI: 10.1542/hpeds.2020-000745] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Effective communication is critical for safely discharging hospitalized children, including those with limited English proficiency (LEP), who are at high risk of reuse. Our objective was to describe and compare the safety and family centeredness of nurse communication at hospital discharge for English-proficient (EP) and LEP families. METHODS In this single-center, cross-sectional study, we used direct observation of hospital discharges for EP and LEP children. Observers recorded quantitative and qualitative details of nurse-family communication, focusing on 3 domains: safe discharge, family centeredness, and family engagement. Patient characteristics and percentages of encounters in which all components were discussed within each domain were compared between EP and LEP encounters by using Fisher's exact tests. We used field notes to supplement quantitative findings. RESULTS We observed 140 discharge encounters; 49% were with LEP families. Nurses discussed all safe discharge components in 31% of all encounters, most frequently omitting emergency department return precautions. Nurses used all family-centered communication components in 11% and family-engagement components in 89% of all encounters. Nurses were more likely to discuss all components of safe discharge in EP encounters when compared with LEP encounters (53% vs 9%; P < .001; odds ratio: 11.5 [95% confidence interval 4.4-30.1]). There were no differences in family centeredness or family engagement between LEP and EP encounters. CONCLUSIONS Discharge encounters of LEP patients were less likely to include all safe discharge communication components, compared with EP encounters. Opportunities to improve nurse-family discharge communication include providing written discharge instructions in families' primary language, ensuring discussion of return precautions, and using teach-back to optimize family engagement and understanding.
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Affiliation(s)
- Angela Y Choe
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California; .,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | | | - Vanessa Wagner
- College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | | | | | - Colleen Mangeot
- Division of Epidemiology, Departments of Environmental and Public Health Sciences and
| | - Amanda C Schondelmeyer
- Division of Hospital Medicine and.,Pediatrics and.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
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22
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Better Outcomes for Hospitalized Children through Safe Transitions: A Quality Improvement Project. Pediatr Qual Saf 2020; 6:e378. [PMID: 33409430 PMCID: PMC7781294 DOI: 10.1097/pq9.0000000000000378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 08/29/2020] [Indexed: 11/27/2022] Open
Abstract
This project’s goal was to implement an already validated pediatric discharge toolkit to enhance the effectiveness of transition from hospital to home, thus reducing 30-day readmission rates.
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23
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Kenyon CC, Strane D, Floyd GC, Jacobi EG, Penrose TJ, Ewig JM, DaVeiga SP, Zorc JJ, Rubin DM, Bryant-Stephens TC. An Asthma Population Health Improvement Initiative for Children With Frequent Hospitalizations. Pediatrics 2020; 146:peds.2019-3108. [PMID: 33004429 PMCID: PMC8609917 DOI: 10.1542/peds.2019-3108] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES A relatively small proportion of children with asthma account for an outsized proportion of health care use. Our goal was to use quality improvement methodology to reduce repeat emergency department (ED) and inpatient care for patients with frequent asthma-related hospitalization. METHODS Children ages 2 to 17 with ≥3 asthma-related hospitalizations in the previous year who received primary care at 3 in-network clinics were eligible to receive a bundle of 4 services including (1) a high-risk asthma screener and tailored education, (2) referral to a clinic-based asthma community health worker program, (3) facilitated discharge medication filling, and (4) expedited follow-up with an allergy or pulmonology specialist. Statistical process control charts were used to estimate the impact of the intervention on monthly 30-day revisits to the ED or hospital. We then conducted a difference-in-differences analysis to compare changes between those receiving the intervention and a contemporaneous comparison group. RESULTS From May 1, 2016, to April 30, 2017, we enrolled 79 patients in the intervention, and 128 patients constituted the control group. Among the eligible population, the average monthly proportion of children experiencing a revisit to the ED and hospital within 30 days declined by 38%, from a historical baseline of 24% to 15%. Difference-in-differences analysis demonstrated 11.0 fewer 30-day revisits per 100 patients per month among intervention recipients relative to controls (95% confidence interval: -20.2 to -1.8; P = .02). CONCLUSIONS A multidisciplinary quality improvement intervention reduced health care use in a high-risk asthma population, which was confirmed by using quasi-experimental methodology. In this study, we provide a framework to analyze broader interventions targeted to frequently hospitalized populations.
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Affiliation(s)
- Chén C. Kenyon
- PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Douglas Strane
- PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - G. Chandler Floyd
- PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ethan G. Jacobi
- Office of Clinical Quality Improvement, Children’s Hospital of Philadelphia, Philadephia, PA USA
| | - Tina J. Penrose
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jeffrey M. Ewig
- Division of Pulmonary Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sigrid Payne DaVeiga
- Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph J. Zorc
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Emergency Department, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - David M. Rubin
- PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tyra C. Bryant-Stephens
- PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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24
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Logsdon KD, Little JM. Evaluation of Discharge Coordinators and Their Effect on Discharge Efficiency and Preparedness. J Pediatr Health Care 2020; 34:435-441. [PMID: 32593500 DOI: 10.1016/j.pedhc.2020.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION A discharge coordinator role was evaluated to determine if it resulted in more discharges before noon, decreased length of stay, and prepared families for self-care at home. METHOD This evaluation took place at a pediatric cardiac care unit. Discharges before noon, reasons for delays, and length of stay were analyzed before and after the discharge coordinator role. Parental knowledge assessments were completed a week after discharge. A nursing survey measured satisfaction with the patient discharge process. RESULTS Rates of discharge before noon increased (31.68% vs. 44.39%) and length of stay decreased (97.16 vs. 85.24 hr) with a discharge coordinator. Parental knowledge assessment revealed fewer deficits, and nurses were satisfied. DISCUSSION A dedicated person to coordinate patient discharge needs can improve discharge efficiency and increase the likelihood of successful self-care at home. Further evaluation is needed to determine how this role impacts readmission.
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25
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Riddle SW, Sherman SN, Moore MJ, Loechtenfeldt AM, Tubbs-Cooley HL, Gold JM, Wade-Murphy S, Beck AF, Statile AM, Shah SS, Simmons JM, Auger KA. A Qualitative Study of Increased Pediatric Reutilization After a Postdischarge Home Nurse Visit. J Hosp Med 2020; 15:518-525. [PMID: 32195655 PMCID: PMC7489800 DOI: 10.12788/jhm.3370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 12/07/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND The Hospital to Home Outcomes (H2O) trial was a 2-arm, randomized controlled trial that assessed the effects of a nurse home visit after a pediatric hospital discharge. Children randomized to the intervention had higher 30-day postdischarge reutilization rates compared with those with standard discharge. We sought to understand perspectives on why postdischarge home nurse visits resulted in higher reutilization rates and to elicit suggestions on how to improve future interventions. METHODS We sought qualitative input using focus groups and interviews from stakeholder groups: parents, primary care physicians (PCP), hospital medicine physicians, and home care registered nurses (RNs). A multidisciplinary team coded and analyzed transcripts using an inductive, iterative approach. RESULTS Thirty-three parents participated in interviews. Three focus groups were completed with PCPs (n = 7), 2 with hospital medicine physicians (n = 12), and 2 with RNs (n = 10). Major themes in the explanation of increased reutilization included: appropriateness of patient reutilization; impact of red flags/warning sign instructions on family's reutilization decisions; hospital-affiliated RNs "directing traffic" back to hospital; and home visit RNs had a low threshold for escalating care. Major themes for improving design of the intervention included: need for improved postdischarge communication; individualizing home visits-one size does not fit all; and providing context and framing of red flags. CONCLUSION Stakeholders questioned whether hospital reutilization was appropriate and whether the intervention unintentionally directed patients back to the hospital. Future interventions could individualize the visit to specific needs or diagnoses, enhance postdischarge communication, and better connect patients and home nurses to primary care.
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Affiliation(s)
- Sarah W Riddle
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Corresponding Author: Sarah W Riddle, MD, IBCLC; ; Telephone: 513-636-1003
| | | | - Margo J Moore
- Division of Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Allison M Loechtenfeldt
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Heather L Tubbs-Cooley
- College of Nursing, Martha S. Pitzer Center for Women, Children and Youth, Columbus, Ohio
| | - Jennifer M Gold
- Division of Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Susan Wade-Murphy
- Division of Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Andrew F Beck
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Angela M Statile
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jeffrey M Simmons
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health System Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Katherine A Auger
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health System Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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26
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Combined Effect of Race/Ethnicity and Type of Insurance on Reuse of Urgent Hospital-Based Services in Children Discharged with Asthma. CHILDREN-BASEL 2020; 7:children7090107. [PMID: 32825507 PMCID: PMC7552762 DOI: 10.3390/children7090107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/17/2020] [Accepted: 08/19/2020] [Indexed: 11/17/2022]
Abstract
Asthma is a leading cause of health disparity in children. This study explores the joint effect of race/ethnicity and insurance type on risk for reuse of urgent services within a year of hospitalization. Data were collected from 604 children hospitalized with asthma between 2012 and 2015 and stratified with respect to combination of patients’ insurance status (public vs. private) and race/ethnicity (white vs. nonwhite). Highest rates for at least one emergency department (ED) revisit (49.5%, 95% CI 42.5, 56.5) and for average revisits (1.03, 95% CI 0.83, 1.22) were recorded in nonwhite children with public insurance. Adjusted models revealed higher chance for ED reuse in white as well as nonwhite children covered by public insurance. Hospitalization rate was not dependent on the combination of social determinants, but on the number of post-discharge ED revisits. The combined effect of race/ethnicity and health insurance are associated with post-discharge utilization of ED services, but not with hospital readmission.
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27
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Keret A, Shir Y, Schwartz S, Berliner E, Erlichman M, Weiser G. The rates of hospital admissions and return visits to a rapidly growing pediatric emergency department as measures of quality of care. Isr J Health Policy Res 2020; 9:40. [PMID: 32787928 PMCID: PMC7422502 DOI: 10.1186/s13584-020-00397-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 08/06/2020] [Indexed: 11/27/2022] Open
Abstract
Background Return visits to the emergency department are viewed as a quality measure of patient management. Avoiding unnecessary admissions to the ward can potentially cause an increase in return visits, thus effecting quality assessment. Methods After implementing an educational process the relationship between admissions and return visits was assessed over time at a rapidly growing pediatric emergency department. Results There was a 264% increase in visits from 2004 to 2017. In the study period admission rates declined from 25 to 14%. This was achieved without a rise in return visits and with a stable percentage of admissions from return visits. Conclusions Interventions aimed at decreasing unnecessary admissions do not lead to increased return visits and return visit admissions.
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Affiliation(s)
- Amit Keret
- Hebrew university medical school, Jerusalem, Israel
| | - Yakir Shir
- Pediatric emergency department, Shaare Zedek Medical Center, 12 Bait st, Jerusalem, Israel
| | - Shepard Schwartz
- Pediatric emergency department, Shaare Zedek Medical Center, 12 Bait st, Jerusalem, Israel
| | - Elihay Berliner
- Pediatric emergency department, Shaare Zedek Medical Center, 12 Bait st, Jerusalem, Israel
| | - Mattityahu Erlichman
- Pediatric emergency department, Shaare Zedek Medical Center, 12 Bait st, Jerusalem, Israel
| | - Giora Weiser
- Pediatric emergency department, Shaare Zedek Medical Center, 12 Bait st, Jerusalem, Israel.
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Balighian E, Burke M, Davis A, Chinsky J, Tschudy MM, Perin J, Serwint JR. A Posthospitalization Home Visit Curriculum for Pediatric Patients. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2020; 16:10939. [PMID: 32743065 PMCID: PMC7391452 DOI: 10.15766/mep_2374-8265.10939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 01/25/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Home visits allow physicians to develop a deeper understanding of patients' homes and community, enhance physician-patient connectedness, and improve physician treatment plans for patients. We describe a unique pediatric posthospitalization home visit curriculum to train residents about the social determinants of health (SDH). METHODS Residents participated in an interactive presentation that discussed the logistics of making home visits and a background detailing SDH. During subsequent home visits, residents got to know the family and neighborhood on a deeper level. After each home visit, residents participated in a reflection session and considered the impact of SDH. Surveys were completed to capture data about residents' knowledge and attitudes regarding SDH and connectedness with the families. Families' perspectives were captured by phone surveys. RESULTS Of residents, 23 of 31 (74%) were able to make at least one home visit. After participating in the curriculum, residents reported increased confidence in understanding SDH (p = .048) and increased consideration of SDH when developing treatment plans (p = .007). All residents who made home visits predicted they would feel more confident in understanding how SDH impact patients they will care for in the future. Ninety percent of residents felt they made a stronger connection with the family. Eight families were surveyed, and all stated that the home visit had positive effects. DISCUSSION This curriculum teaches SDH while improving connections between physicians and patients.
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Affiliation(s)
- Eric Balighian
- Assistant Professor, Department of Pediatrics, Johns Hopkins University School of Medicine
| | - Michael Burke
- Associate Professor, Department of Pediatrics, Johns Hopkins University School of Medicine
| | - Amy Davis
- Clinical Associate, Department of Pediatrics, Johns Hopkins University School of Medicine
| | - Jeffrey Chinsky
- Associate Professor, Department of Pediatrics, Johns Hopkins University School of Medicine
| | - Megan M. Tschudy
- Assistant Professor, Department of Pediatrics, Johns Hopkins University School of Medicine
| | - Jamie Perin
- Associate Scientist, International Health, Johns Hopkins Bloomberg School of Public Health
| | - Janet R. Serwint
- Professor, Department of Pediatrics, Johns Hopkins University School of Medicine
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Lerret SM, Johnson NL, Polfuss M, Weiss M, Gralton K, Klingbeil CG, Gibson C, Garnier-Villarreal M, Ahamed SI, Adib R, Unteutsch R, Pawela L, White-Traut R, Sawin K. Using the Engaging Parents in Education for Discharge (ePED) iPad Application to Improve Parent Discharge Experience. J Pediatr Nurs 2020; 52:41-48. [PMID: 32163845 PMCID: PMC10465148 DOI: 10.1016/j.pedn.2020.02.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 02/24/2020] [Accepted: 02/24/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the use of the Engaging Parents in Education for Discharge (ePED) iPad application on parent experiences of hospital discharge teaching and care coordination. Hypotheses were: parents exposed to discharge teaching using ePED will have 1) higher quality of discharge teaching and 2) better care coordination than parents exposed to usual discharge teaching. The secondary purpose examined group differences in the discharge teaching, care coordination, and 30-day readmissions for parents of children with and without a chronic condition. DESIGN/METHODS Using a quasi-experimental design, ePED was implemented on one inpatient unit (n = 211) and comparison group (n = 184) from a separate unit at a pediatric academic medical center. Patient experience outcome measures collected on day of discharge included Quality of Discharge Teaching Scale-Delivery (QDTS-D) and care coordination measured by Care Transition Measure (CTM). Thirty-day readmission was abstracted from records. RESULTS Parents taught using ePED reported higher QDTS-D scores than parents without ePED (p = .002). No differences in CTM were found between groups. Correlations between QDTS-D and CTM were small for ePED (r = 0.14, p 0.03) and non-ePED (r = 0.29, p < .001) parent groups. CTM was weakly associated with 30-day readmissions in the ePED group. CONCLUSION The use of ePED by the discharging nurse enhances parent-reported quality of discharge teaching. PRACTICE IMPLICATIONS The ePED app is a theory-based structured conversation guide to engage parents in discharge preparation. Nursing implementation of ePED contributes to optimizing the patient/family healthcare experience.
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Affiliation(s)
- Stacee M Lerret
- Medical College of Wisconsin, Milwaukee, WI, United States of America; Children's Hospital of Wisconsin, Milwaukee, WI, United States of America.
| | - Norah L Johnson
- Children's Hospital of Wisconsin, Milwaukee, WI, United States of America; College of Nursing, Marquette University, Milwaukee, WI, United States of America.
| | - Michele Polfuss
- Children's Hospital of Wisconsin, Milwaukee, WI, United States of America; College of Nursing, University of Wisconsin-Milwaukee, Milwaukee, WI, United States of America.
| | - Marianne Weiss
- College of Nursing, Marquette University, Milwaukee, WI, United States of America.
| | - Karen Gralton
- Children's Hospital of Wisconsin, Milwaukee, WI, United States of America.
| | - Carol G Klingbeil
- College of Nursing, University of Wisconsin-Milwaukee, Milwaukee, WI, United States of America.
| | - Cori Gibson
- Children's Hospital of Wisconsin, Milwaukee, WI, United States of America.
| | | | - S Iqbal Ahamed
- College of Nursing, Marquette University, Milwaukee, WI, United States of America.
| | - Riddhiman Adib
- College of Nursing, Marquette University, Milwaukee, WI, United States of America.
| | - Rachel Unteutsch
- Medical College of Wisconsin, Milwaukee, WI, United States of America.
| | - Louis Pawela
- Medical College of Wisconsin, Milwaukee, WI, United States of America.
| | | | - Kathy Sawin
- Children's Hospital of Wisconsin, Milwaukee, WI, United States of America; College of Nursing, University of Wisconsin-Milwaukee, Milwaukee, WI, United States of America.
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30
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Philips KS, Reiss DE, Silver EJ, Rastogi D. Readmission and Ambulatory Health Care Use After Asthma Hospitalization Among Urban Minority Children. Hosp Pediatr 2020; 10:338-346. [PMID: 32205397 PMCID: PMC7106775 DOI: 10.1542/hpeds.2019-0148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The role of ambulatory follow-up after pediatric asthma hospitalization in preventing long-term readmissions is not well studied among hospitalized minority children. We sought to examine the association of ambulatory visit attendance with long-term readmission as well as identify predictors of attendance at these visits among urban, minority children with asthma. METHODS This 2-year retrospective cohort study analyzed data for urban, minority children 2 to 18 years old who were hospitalized for asthma at a tertiary-care center. Using bivariate and multivariable analyses, we examined the independent associations of attending a postdischarge visit (within 14 days), a routine visit (within 3 months of discharge or postdischarge visit), and both visits with likelihood of asthma readmission within 365 days. We also identified predictors of attending each of these visits. RESULTS The study included 613 children with a median age of 5 years. Of the children, 57.4% were boys, 51.2% were Hispanic, and 36.9% were non-Hispanic African American. One-quarter of the children were readmitted within 365 days of the index hospitalization. Children who attended the postdischarge visit had lower odds of long-term readmission (odds ratio = 0.65; 95% confidence interval = 0.43-0.97). However, attending a routine or both a postdischarge and a routine visit was not significantly associated with long-term readmission. Children with previous sick visits, complicating comorbidities, or more severe exacerbation were more likely to attend visits. CONCLUSIONS Attending a postdischarge visit within 14 days of hospitalization is associated with a lower likelihood of long-term readmission. Those with a previous sick visit, more severe disease, or exacerbation are more likely to attend ambulatory visits after hospital discharge. This knowledge is important in fostering quality care transitions for children with asthma.
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Affiliation(s)
- Kaitlyn S Philips
- The Children's Hospital at Montefiore, Bronx, New York; and
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Daniel E Reiss
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Ellen J Silver
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Deepa Rastogi
- The Children's Hospital at Montefiore, Bronx, New York; and
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
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31
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Pershad J, Jones T, Harrell C, Ajayi S, Giles K, Cross C, Huang E. Factors Associated With Return Visits at 7 Days After Hospital Discharge. Hosp Pediatr 2020; 10:353-358. [PMID: 32169994 DOI: 10.1542/hpeds.2019-0207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To identify variables associated with return visits to the hospital within 7 days after discharge. METHODS We performed a retrospective study of 7-day revisits and readmissions between October 2012 and September 2015 using the Pediatric Health Information System database supplemented by electronic medical record data from a tertiary-care children's hospital. We examined factors associated with revisits among the top 10 most frequent indications for hospitalization using generalized estimating equations. RESULTS There were 736 (4.2%) revisits and 416 (2.3%) readmissions within 7 days. Predictors of 7-day revisits and readmissions included age, length of hospital stay, and presence of a chronic medical condition. In addition, insurance status was associated with risk of revisits and race was associated with risk of readmissions in the bivariate analysis. CONCLUSIONS In this study, we identified patient characteristics that may be associated with a higher risk of early return to the emergency department and/or readmissions. Early identification of this at-risk group of patients may provide opportunities for intervention and enhanced care coordination at discharge.
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Affiliation(s)
- Jay Pershad
- Departments of Pediatrics and Emergency Medicine, School of Medicine and Health Sciences, The George Washington University and Children's National Hospital, Washington, District of Columbia; and
| | - Tamekia Jones
- Department of Pediatrics, The University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Camden Harrell
- Department of Pediatrics, The University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Seun Ajayi
- Department of Pediatrics, The University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Kim Giles
- Department of Pediatrics, The University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Cynthia Cross
- Department of Pediatrics, The University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Eunice Huang
- Department of Pediatrics, The University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, Tennessee
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A Quality Improvement Intervention Bundle to Reduce 30-Day Pediatric Readmissions. Pediatr Qual Saf 2020; 5:e264. [PMID: 32426630 PMCID: PMC7190252 DOI: 10.1097/pq9.0000000000000264] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 01/30/2020] [Indexed: 02/02/2023] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: Pediatric hospital readmissions can represent gaps in care quality between discharge and follow-up, including social factors not typically addressed by hospitals. This study aimed to reduce the 30-day pediatric readmission rate on 2 general pediatric services through an intervention to enhance care spanning the hospital stay, discharge, and follow-up process. Methods: A multidisciplinary team developed an intervention bundle based on a needs assessment and evidence-based models of transitional care. The intervention included pre-discharge planning with a transition coordinator, screening and intervention for adverse social determinants of health (SDH), medication reconciliation after discharge, communication with the primary care provider, access to a hospital-based transition clinic, and access to a 24-hour direct telephone line staffed by hospital attending pediatricians. These were implemented sequentially from October 2013 to February 2017. The primary outcome was the readmission rate within 30 days of index discharge. The length of stay was a balancing measure. Results: During the intervention, the included services discharged 4,853 children. The pre-implementation readmission rate of 10.3% declined to 7.4% and remained stable during a 4-month post-intervention observation period. Among 1,394 families screened for adverse SDH, 48% reported and received assistance with ≥ 1 concern. The length of stay increased from 4.10 days in 2013 to 4.30 days in 2017. Conclusions: An intervention bundle, including SDH, was associated with a sustained reduction in readmission rates to 2 general pediatric services. Transitional care that addresses multiple domains of family need during a child’s health crisis can help reduce pediatric readmissions.
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Taylor T, Altares Sarik D, Salyakina D. Development and Validation of a Web-Based Pediatric Readmission Risk Assessment Tool. Hosp Pediatr 2020; 10:246-256. [PMID: 32075853 DOI: 10.1542/hpeds.2019-0241] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Accurately predicting and reducing risk of unplanned readmissions (URs) in pediatric care remains difficult. We sought to develop a set of accurate algorithms to predict URs within 3, 7, and 30 days of discharge from inpatient admission that can be used before the patient is discharged from a current hospital stay. METHODS We used the Children's Hospital Association Pediatric Health Information System to identify a large retrospective cohort of 1 111 323 children with 1 321 376 admissions admitted to inpatient care at least once between January 1, 2016, and December 31, 2017. We used gradient boosting trees (XGBoost) to accommodate complex interactions between these predictors. RESULTS In the full cohort, 1.6% of patients had at least 1 UR in 3 days, 2.4% had at least 1 UR in 7 days, and 4.4% had at least 1 UR within 30 days. Prediction model discrimination was strongest for URs within 30 days (area under the curve [AUC] = 0.811; 95% confidence interval [CI]: 0.808-0.814) and was nearly identical for UR risk prediction within 3 days (AUC = 0.771; 95% CI: 0.765-0.777) and 7 days (AUC = 0.778; 95% CI: 0.773-0.782), respectively. Using these prediction models, we developed a publicly available pediatric readmission risk scores prediction tool that can be used before or during discharge planning. CONCLUSIONS Risk of pediatric UR can be predicted with information known before the patient's discharge and that is easily extracted in many electronic medical record systems. This information can be used to predict risk of readmission to support hospital-discharge-planning resources.
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Affiliation(s)
- Thom Taylor
- Nicklaus Children's Research Institute, .,Nicklaus Children's Health System, Miami, Florida; and.,Research Facilitation Laboratory, Northrop Grumman, Monterey, California
| | | | - Daria Salyakina
- Nicklaus Children's Research Institute.,Nicklaus Children's Health System, Miami, Florida; and
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34
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Ehwerhemuepha L, Pugh K, Grant A, Taraman S, Chang A, Rakovski C, Feaster W. A Statistical-Learning Model for Unplanned 7-Day Readmission in Pediatrics. Hosp Pediatr 2019; 10:43-51. [PMID: 31811046 DOI: 10.1542/hpeds.2019-0122] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The rate of pediatric 7-day unplanned readmissions is often seen as a measure of quality of care, with high rates indicative of the need for improvement of quality of care. In this study, we used machine learning on electronic health records to study predictors of pediatric 7-day readmissions. We ranked predictors by clinical significance, as determined by the magnitude of the least absolute shrinkage and selection operator regression coefficients. METHODS Data consisting of 50 241 inpatient and observation encounters at a single tertiary pediatric hospital were retrieved; 50% of these patients' data were used for building a least absolute shrinkage and selection operator regression model, whereas the other half of the data were used for evaluating model performance. The categories of variables included were demographics, social determinants of health, severity of illness and acuity, resource use, diagnoses, medications, psychosocial factors, and other variables such as primary care no show. RESULTS Previous hospitalizations and readmissions, medications, multiple comorbidities, longer current and previous lengths of stay, certain diagnoses, and previous emergency department use were the most significant predictors modifying a patient's risk of 7-day pediatric readmission. The model achieved an area under the curve of 0.778 (95% confidence interval 0.763-0.793). CONCLUSIONS Predictors such as medications, previous and current health care resource use, history of readmissions, severity of illness and acuity, and certain psychosocial factors modified the risk of unplanned 7-day readmissions. These predictors are mostly unmodifiable, indicating that intervention plans on high-risk patients may be developed through discussions with patients and parents to identify underlying modifiable causal factors of readmissions.
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Affiliation(s)
- Louis Ehwerhemuepha
- CHOC Children's, Orange, California; .,School of Computational and Data Science, Chapman University, Orange, California; and
| | | | | | - Sharief Taraman
- CHOC Children's, Orange, California.,Department of Pediatrics, School of Medicine, University of California, Irvine, California
| | | | - Cyril Rakovski
- School of Computational and Data Science, Chapman University, Orange, California; and
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35
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Parikh K, Perry K, Pantor C, Gardner C. Multidisciplinary Engagement Increases Medications in-Hand for Patients Hospitalized With Asthma. Pediatrics 2019; 144:peds.2019-0674. [PMID: 31753910 DOI: 10.1542/peds.2019-0674] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Asthma exacerbations in children are a leading cause of missed school days and health care use. Patients discharged from the hospital often do not fill discharge prescriptions and are at risk for future exacerbations. METHODS A multidisciplinary team aimed to increase the percentage of patients discharged from the hospital after an asthma exacerbation with their medications in-hand from 15% to 80%. Tools from the model of improvement were used to establish a process map, key driver diagram, and iterative plan-do-study-act cycles. Statistical process control charts were used to track the proportion of patients discharged with their medications in-hand as the primary outcome. Initiating multidisciplinary daily discharge huddles on the unit was the key intervention that facilitated change in the system. RESULTS During the study period, the percentage of patients with asthma who received their medications in-hand increased from 15% to >80% for all eligible children and >90% for children with public insurance. Children had a median age of 6.7 years, 47% were female, and 83.8% identified as non-Hispanic African American. Through iterative meetings and mapping with the multidisciplinary team, a process map for bedside delivery and a key driver diagram were created. Balancing measures, specifically length of stay and discharge medications forgotten at the hospital, remained constant. CONCLUSIONS Improvements in increasing medication possession at the time of discharge for children hospitalized with asthma were facilitated by multidisciplinary engagement. Standardizing discharge initiatives may play a key role in improving discharge transitions for children with asthma.
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Affiliation(s)
- Kavita Parikh
- Children's National Hospital and the George Washington School of Medicine, Washington, District of Columbia
| | - Karen Perry
- Children's National Hospital and the George Washington School of Medicine, Washington, District of Columbia
| | - Candice Pantor
- Children's National Hospital and the George Washington School of Medicine, Washington, District of Columbia
| | - Catherine Gardner
- Children's National Hospital and the George Washington School of Medicine, Washington, District of Columbia
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36
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Byrne R, Duncan A, Pickar T, Burkhardt S, Boyd RN, Neel ML, Maitre NL. Comparing parent and provider priorities in discussions of early detection and intervention for infants with and at risk of cerebral palsy. Child Care Health Dev 2019; 45:799-807. [PMID: 31323144 DOI: 10.1111/cch.12707] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/11/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Although literature suggests that parents need support when their child is diagnosed with cerebral palsy (CP), it is unclear to what extent providers implement these supports in practice and what parental perspectives surround provider early diagnosis and management of CP. Therefore, we aimed to characterize and compare experiences of providers and parents of children with CP with regards to early detection and intervention. METHOD Seventeen parents participated in day-long world-café style workshops focused on categories extracted from the International Classification of Function framework and recent systematic reviews of early detection for CP. Thirty regional providers (generalists, specialists, and therapists) caring for infants with CP completed surveys with scaled score and open-ended questions. Quantitative and qualitative data were independently assessed by two reviewers to identify prominent themes. RESULTS All parents (100%) stated early diagnosis or high risk for CP classification was beneficial compared with only 50% of providers who often gave early CP diagnoses before 12 months. Top parent priorities were honesty and positively phrased messages. Providers most often addressed cognition, primary care need, motor, and feeding issues (80%, 62%, 54%, 54% frequently/sometimes). Matching priorities for discussion were neuroimaging timing/risk/benefit, cognition, primary care, motor, and feeding/nutrition. Discordance occurred for participation, parent well-being, pain and vision, with parents wanting more education and resources. CONCLUSIONS Receiving early diagnoses or high-risk for CP classification is a parent priority. Alignment between parents and providers exists for International Classification of Function domains of body functions/structures and activity, but less for those of environment, personal, and participation.
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Affiliation(s)
| | - Andrea Duncan
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Stephanie Burkhardt
- Department of Pediatrics & Center for Perinatal Research, Nationwide Children's Hospital, Columbus, OH
| | - Roslyn N Boyd
- Queensland Cerebral Palsy Rehabilitation and Research Center, Queensland, Australia
| | - Mary Lauren Neel
- Department of Pediatrics & Center for Perinatal Research, Nationwide Children's Hospital, Columbus, OH
| | - Nathalie L Maitre
- Department of Pediatrics & Center for Perinatal Research, Nationwide Children's Hospital, Columbus, OH
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37
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Auger KA, Harris JM, Gay JC, Teufel R, McClead RE, Neuman MI, Agrawal R, Simon HK, Peltz A, Tejedor-Sojo J, Morse RB, Beccaro MAD, Fieldston E, Shah SS. Progress (?) Toward Reducing Pediatric Readmissions. J Hosp Med 2019; 14:618-621. [PMID: 31251150 PMCID: PMC6817309 DOI: 10.12788/jhm.3210] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 03/19/2019] [Accepted: 03/21/2019] [Indexed: 11/20/2022]
Abstract
Many children's hospitals are actively working to reduce readmissions to improve care and avoid financial penalties. We sought to determine if pediatric readmission rates have changed over time. We used data from 66 hospitals in the Inpatient Essentials Database including index hospitalizations from January, 2010 through June, 2016. Seven-day all cause (AC) and potentially preventable readmission (PPR) rates were calculated using 3M PPR software. Total and condition-specific quarterly AC and PPR rates were generated for each hospital and in aggregate. We included 4.52 million hospitalizations across all study years. Readmission rates did not vary over the study period. The median seven-day PPR rate across all quarters was 2.5% (range 2.1%-2.5%); the median seven-day AC rate across all quarters was 5.1% (range 4.3%-5.3%). Readmission rates for individual conditions fluctuated. Despite significant national efforts to reduce pediatric readmissions, both AC and PPR readmission rates have remained unchanged over six years.
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Affiliation(s)
- Katherine A Auger
- Division of Hospital Medicine and James M. Anderson Center for Healthcare Improvement, Cincinnati Children’s Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - James C Gay
- Monroe Carell, Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Ronald Teufel
- Department of Pediatrics, Medical University of South Carolina, College of Medicine, Charles-ton, South Carolina
| | - Richard E McClead
- Office of the Chief Medical Officer, Nationwide Children’s Hospital, Columbus, Ohio
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Rishi Agrawal
- Division of Hospital-Based Medicine, Ann and Robert H Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Harold K Simon
- Department of Pediatrics and Emergency Medicine, Emory University School of Medicine; Children’s Healthcare of Atlanta, Atlanta,
Georgia
| | - Alon Peltz
- Yale-New Haven Hospital, New Haven, Connecticut
| | - Javier Tejedor-Sojo
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta,
Georgia
| | | | - Mark A Del Beccaro
- Division of Emergency Medicine, Seattle Children’s Hospital; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Evan Fieldston
- Division of General Pediatrics, Children’s Hospital of Philadelphia; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Samir S Shah
- Division of Hospital Medicine and James M. Anderson Center for Healthcare Improvement, Cincinnati Children’s Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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38
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Leyenaar JK, Lagu T, Lindenauer PK. Are Pediatric Readmission Reduction Efforts Falling Flat? J Hosp Med 2019; 14:644-645. [PMID: 31577224 PMCID: PMC6817308 DOI: 10.12788/jhm.3269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/17/2019] [Indexed: 11/20/2022]
Affiliation(s)
- JoAnna K Leyenaar
- Department of Pediatrics and the Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth Hitchcock Medical Center,
Lebanon, New Hampshire
| | - Tara Lagu
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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39
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Pinto JM, Navallo LJ, Petrova A. Does participation in the community outreach for asthma care and healthy lifestyles (COACH) program alter subsequent use of hospital services for children discharged with asthma? J Asthma 2019; 58:231-239. [PMID: 31566040 DOI: 10.1080/02770903.2019.1672719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Transition from hospital to home is a challenging time for children with asthma and their caregivers because of the high risk for reutilization of acute hospital services. Detecting effective quality improvement initiatives to reduce utilization of urgent services in children discharged with asthma is an important clinical and public health question. This study was designed to identify the role of a multimodal, nurse-driven, inpatient initiated Community Outreach for Asthma Care and Healthy lifestyles (COACH) program on subsequent use of hospital services for pediatric patients with asthma.Methods: We utilized comparative effectiveness design to identify the difference in recurrent emergency department (ED) visits and/or admissions within 12-months after discharge between patients with asthma who engaged in the COACH program (Intervention group) and those who did not (Comparison group). We used administrative databases of hospitals included in the Meridian Health system to identify the number of and time to asthma-related readmissions and ED re-attendances.Results: We found no difference in the rate or number of recurrent hospital-based services used within 12 months, but found a reduction in ED re-visitation and/or readmission within 30 days for COACH program participants prior to and after adjustment for age, race/ethnicity, insurance status, and clinical presentation (Odd Ratio 0.44, 95% Confidence Interval 0.20, 0.93).Conclusion: Participation in the COACH program decreases the likelihood for subsequent use of hospital services within a month of discharge for children with asthma. Enhanced post-discharge interactions with families may reduce long-term reuse of hospital-based services for COACH program participants.
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Affiliation(s)
- Jamie M Pinto
- Hackensack-Meridian Health, Jersey Shore University Medical Center, Neptune, NJ, USA.,Hackensack-Meridian Health School of Medicine, Nutley, NJ, USA
| | - Lauren J Navallo
- Hackensack-Meridian Health, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Anna Petrova
- Hackensack-Meridian Health, Jersey Shore University Medical Center, Neptune, NJ, USA.,Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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40
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Auger KA, Shah SS, Huang B, Brady PW, Weinberg SH, Reamer E, Tanager KS, Zahn K, Davis MM. Discharge Medical Complexity, Change in Medical Complexity and Pediatric 30-day Readmission. J Hosp Med 2019; 14:474-481. [PMID: 31386613 PMCID: PMC6686738 DOI: 10.12788/jhm.3222] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 04/04/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND While medical complexity is associated with pediatric readmission risk, less is known about how increases in medical complexity during hospitalization affect readmission risk. METHODS We conducted a five-year retrospective, case-control study of pediatric hospitalizations at a tertiary care children's hospital. Cases with a 30-day unplanned readmission were matched to controls based on admission seasonality and distance from the hospital. Complexity variables included the number of medications prescribed at discharge, medical technology, and the need for home healthcare services. Change in medical complexity variables included new complex chronic conditions and new medical technology. We estimated odds of 30-day unplanned readmission using adjusted conditional logistic regression. RESULTS Of 41,422 eligible index hospitalizations, we included 595 case and 595 control hospitalizations. Complexity: Polypharmacy after discharge was common. In adjusted analyses, being discharged with ≥2 medications was associated with higher odds of readmission compared with being discharged without medication; children with ≥5 discharge medications had a greater than four-fold higher odds of readmission. Children assisted by technology had higher odds of readmission compared with children without technology assistance. Change in complexity: New diagnosis of a complex chronic condition (Adjusted Odds Ratio (AOR) = 1.75; 1.11-2.75) and new technology (AOR = 1.84; 1.09-3.10) were associated with higher risk of readmission when adjusting for patient characteristics. However, these associations were not statistically significant when adjusting for length of stay. CONCLUSION Polypharmacy and use of technology at discharge pose a substantial readmission risk for children. However, added technology and new complex chronic conditions do not increase risk when accounting for length of stay.
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Affiliation(s)
- Katherine A Auger
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Healthcare Improvement, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Corresponding Author: Katherine A Auger, MD, MSc; E-mail: Katherine. ; Telephone: 513-636-0409; Twitter: @KathyAugerpeds
| | - Samir S Shah
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Healthcare Improvement, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Bin Huang
- University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Patrick W Brady
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Healthcare Improvement, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Steven H Weinberg
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Elyse Reamer
- Division of Epidemiology, The Ohio State University College of Public Health, Columbus, Ohio
| | - Kevin S Tanager
- Department of Pathology, University of Chicago Medicine, Chicago, Illinois
| | - Katelin Zahn
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Matthew M Davis
- Departments of Pediatrics, Medicine, Medical Social Sciences and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Academic General Pediatrics and Mary Ann & J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Stanley Manne Children’s Research Institute, Ann and Robert H. Lurie Children’s Hospital, Chicago, Illinois
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Khan A, Wallace SS, Sampayo EM, Falco C. Caregivers' Perceptions and Hospital Experience After a Brief Resolved Unexplained Event: A Qualitative Study. Hosp Pediatr 2019; 9:508-515. [PMID: 31235529 DOI: 10.1542/hpeds.2018-0220] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES The American Academy of Pediatrics published guidelines for evaluation and management of lower-risk infants for a brief resolved unexplained event (BRUE). The guideline identified gaps in knowledge related to caregiver satisfaction, anxiety, and family-centered educational strategies to improve caregiver experience and patient outcomes. The objective of this study was to understand caregivers' experience with hospitalization for infants with BRUE, including their perception of the hospital stay, the diagnosis of BRUE, and their feelings toward the upcoming discharge from the hospital. METHODS We conducted a qualitative study using semistructured interviews with caregivers of infants aged 0 to 12 months who were admitted to a quaternary care children's hospital for a BRUE. Interviews were conducted within 24 hours of discharge. Two investigators coded transcripts and identified themes using consensus. RESULTS Eighteen caregivers of 13 infants were interviewed. No infants met criteria for being low risk according to the American Academy of Pediatrics guidelines. The coding scheme produced 3 major themes. First, parents felt reassured by hospital monitoring, diagnostic evaluation, and staff support in the hospital. Second, parents felt unsettled by the uncertainty of the child's condition and whether BRUE's "unexplainable" quality is understood as being part of normal infant behavior. Third, these themes manifested as conflicting emotions about caregivers' readiness for discharge. CONCLUSIONS Although hospital monitoring may provide reassurance for some caregivers, they continue to struggle with the uncertainty of the diagnosis. Caregiver perspectives can inform physicians' strategies to improve hospital experience and discharge readiness.
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Affiliation(s)
| | | | - Esther M Sampayo
- Pediatric Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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42
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Foster CC, Kwon S, Whitlow L, Cullen JP, Agrawal RK, Goodman D, Davis MM. Connecting Hospital to Home: Characteristics of and Rehospitalization Rates in Hospitalized Children With Private-Duty Nursing. Hosp Pediatr 2019; 9:530-537. [PMID: 31189643 DOI: 10.1542/hpeds.2018-0282] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Children with medical complexity are frequently hospitalized and have extensive health care needs. Private-duty nursing (PDN) is a service on which some children with medical complexity rely to live at home, but little is known about patients discharged with PDN. Our objective for this study was to describe the characteristics and longitudinal outcomes of patients with PDN who are hospitalized. METHODS This study was a 1-year retrospective study of patients receiving PDN who were hospitalized at a quaternary freestanding children's hospital; there was an additional 2-year follow-up. Patient characteristics, rehospitalization rates, length of stay, mortality, and hospital charges were identified. Descriptive statistics were performed to characterize trends, and a time-to-event analysis was used to characterize unplanned rehospitalization. RESULTS Among 8187 unique patients who were hospitalized in the initial study year (June 1, 2014 to -May 31, 2015), 188 patients (2%) used PDN. Of patients using PDN, 94% used gastrointestinal devices. The median index length of stay was 4 days (interquartile range 2-6). Two-year mortality was 12%. Cumulative all-cause rehospitalization rates were 18% by 30 days, 62% by 365 days, and 87% within 2 years; the median rehospitalization frequency was 3 per patient. The most common reasons for unplanned rehospitalization were infection (41%) and device complication (10%). During the study period, 11% of both rehospitalizations and total hospital days were attributed to patients with PDN. Unplanned rehospitalizations of patients with PDN accounted for $117 million in hospital charges. CONCLUSIONS One in 50 patients hospitalized at a single center were discharged with PDN, which accounted for a disproportionate level of hospital use. Future research should be used to address whether the access and quality of PDN may impact rehospitalization.
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Affiliation(s)
- Carolyn C Foster
- Departments of Pediatrics, .,Mary Ann and J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, and.,Divisions of Academic General Pediatrics and Primary Care
| | - Soyang Kwon
- Departments of Pediatrics.,Mary Ann and J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, and
| | | | | | | | - Denise Goodman
- Departments of Pediatrics.,Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Matthew M Davis
- Departments of Pediatrics.,Mary Ann and J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, and.,Divisions of Academic General Pediatrics and Primary Care.,Medicine.,Medical Social Sciences, and.,Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; and
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43
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Parikh K, Hinds PS, Teach SJ. Using Stakeholder Engagement to Develop a Hospital-Initiated, Patient-Centered Intervention to Improve Hospital-to-Home Transitions for Children With Asthma. Hosp Pediatr 2019; 9:460-463. [PMID: 31068373 DOI: 10.1542/hpeds.2018-0261] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Stakeholder engagement is emerging as a tool for clinician investigators to learn from patients, families, and health professionals to better design and implement interventions that are responsive to patient and family needs and preferences. In this article, we demonstrate that multidisciplinary stakeholder engagement can meaningfully influence intervention design. We present a model of efficient yet substantive engagement of parents and health professionals in developing a hospital-to-home transition intervention for children hospitalized with asthma. We engaged parents during the acute hospitalization with one-on-one interviews, and we used one-on-one interviews and focus groups to engage key health professionals to facilitate meaningful engagement. We worked with a group of selected parent advisory council members (composed of parents of children with asthma) to refine the information gained from the parents and health professionals. We found that multidimensional stakeholder engagement can meaningfully shape intervention development, and we hope that these tools can be used or adapted to other hospital-based quality improvement, education, or research efforts.
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Bucholz EM, Toomey SL, Schuster MA. Trends in Pediatric Hospitalizations and Readmissions: 2010-2016. Pediatrics 2019; 143:e20181958. [PMID: 30696756 PMCID: PMC6764425 DOI: 10.1542/peds.2018-1958] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Health reform and policy initiatives over the last 2 decades have led to significant changes in pediatric clinical practice. However, little is known about recent trends in pediatric hospitalizations and readmissions at a national level. METHODS Data from the 2010-2016 Healthcare Cost and Utilization Project Nationwide Readmissions Database and National Inpatient Sample were analyzed to characterize patient-level and hospital-level trends in annual pediatric (ages 1-17 years) admissions and 30-day readmissions. Poisson regression was used to evaluate trends in pediatric readmissions over time. RESULTS From 2010 to 2016, the total number of index admissions decreased by 21.3%, but the percentage of admissions for children with complex chronic conditions increased by 5.7%. Unadjusted pediatric 30-day readmission rates increased over time from 6.26% in 2010 to 7.02% in 2016 with a corresponding increase in numbers of admissions for patients with complex chronic conditions. When stratified by complex or chronic conditions, readmission rates declined or remained stable across patient subgroups. Mean risk-adjusted hospital readmission rates increased over time overall (6.46% in 2010 to 7.14% in 2016) and in most hospital subgroups but decreased over time in metropolitan teaching hospitals. CONCLUSIONS Pediatric admissions declined from 2010 to 2016 as 30-day readmission rates increased. The increase in readmission rates was associated with greater numbers of admissions for children with chronic conditions. Hospitals serving pediatric patients need to account for the rising complexity of pediatric admissions and develop strategies for reducing readmissions in this high-risk population.
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Affiliation(s)
- Emily M Bucholz
- Department of Cardiology and
- Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Sara L Toomey
- Harvard Medical School, Harvard University, Boston, Massachusetts; and
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Mark A Schuster
- Harvard Medical School, Harvard University, Boston, Massachusetts; and
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
- Kaiser Permanente School of Medicine, Pasadena, California
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Perceived Access to Outpatient Care and Hospital Reutilization Following Acute Respiratory Illnesses. Acad Pediatr 2019; 19:370-377. [PMID: 30053631 PMCID: PMC6347552 DOI: 10.1016/j.acap.2018.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 06/29/2018] [Accepted: 07/04/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Efforts to decrease hospital revisits often focus on improving access to outpatient follow-up. Our objective was to assess the relationship between perceived access to timely office-based care and subsequent 30-day revisits following hospital discharge for 4 common respiratory illnesses. METHODS This was a prospective cohort study of children 2 weeks to 16years admitted to 5 US children's hospitals for asthma, bronchiolitis, croup, or pneumonia between July 2014 and June 2016. Hospital and emergency department (ED) (in the case of croup) admission surveys administered to caregivers included the Consumer Assessments of Healthcare Providers and Systems Timely Access to Care. Access composite scores (range 0-100, with greater scores indicating better access) were linked with 30-day ED revisits and inpatient readmissions from the Pediatric Health Information System. The relationship between access to timely care and repeat utilization was assessed using multivariable logistic regression adjusting for demographics, hospitalization, and home/outpatient factors. RESULTS Of the 2438 children enrolled, 2179 (89%) reported an office visit in the previous 6 months. Average access composite score was 52.0 (standard deviation, 36.3). In adjusted analyses, greater access scores were associated with greater odds of 30-day ED revisits (odds ratio [OR] = 1.07; 95% confidence interval [CI], 1.02-1.13)-particularly for croup (OR = 1.17; 95% CI, 1.02-1.36)-but not inpatient readmissions (OR = 1.02; 95% CI, 0.96-1.09). CONCLUSIONS Perceived access to timely office-based care was associated with significantly greater odds of subsequent ED revisit. Focusing solely on enhancing timely access to care following discharge for common respiratory illnesses may be insufficient to prevent repeat utilization.
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Åhsberg E. Discharge from hospital – a national survey of transition to out‐patient care. Scand J Caring Sci 2018; 33:329-335. [DOI: 10.1111/scs.12625] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 09/26/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Elizabeth Åhsberg
- Department of Knowledge Based Policy and Guidance The National Board of Health and Welfare Stockholm Sweden
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Heslin KC, Owens PL, Simpson LA, Guevara JP, McCormick MC. Annual Report on Health Care for Children and Youth in the United States: Focus on 30-Day Unplanned Inpatient Readmissions, 2009 to 2014. Acad Pediatr 2018; 18:857-872. [PMID: 30031903 DOI: 10.1016/j.acap.2018.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 06/10/2018] [Accepted: 06/12/2018] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To describe trends in unplanned 30-day all-condition hospital readmissions for children aged 1 to 17 years between 2009 and 2014. METHODS Analysis was conducted with the 2009-14 Nationwide Readmissions Database from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project. Annual hospital readmission rates, resource use, and the most common reasons for readmission were calculated for the 2009-14 period. RESULTS The rate of readmission for children aged 1 to 17 years was essentially stable between 2009 and 2014 (5.5% in 2009 and 5.9% in 2014). In 2009, the most common reason (principal diagnosis) for readmission was sickle cell anemia, whereas in 2014 the most common reason was epilepsy. Pneumonia fell from the second to the sixth most common reason for readmission over this period (from 3832 to 2418 stays). Other respiratory infections were among the top 10 principal readmission diagnoses in 2009, but not in 2014. Septicemia was among the 10 most common reasons for readmission in 2014, but not in 2009. Although the average cost of index (ie, initial) stays with a subsequent readmission were similar in 2009 and 2014, the average cost of index stays without a readmission and cost of readmission stays increased by approximately 23%. In both 2009 and 2014, the average cost of the index stays with a subsequent readmission was 73% to 89% higher than that of the index stays of children who were not readmitted within 30 days. The average cost of index stays preceding a readmission was 33% to 45% higher than average costs for readmitted stays. In 2014, the aggregate cost of index stays plus readmissions was $1.58 billion, with 42.9% of the costs attributable to readmissions. Regarding the average costs and lengths of stay for the 10 most common readmission diagnoses, in 2009 the average cost per stay for complications of devices, implants, or grafts was nearly 5 times greater than that of asthma ($21,200 vs $4500, respectively). In 2014, average cost per stay ranged from $5500 for asthma to $39,500 for septicemia. In 2009, the average length of stay (LOS) for complications of devices, implants, or grafts was more than 3 three times higher than that for asthma (7.8 days vs 2.5 days, respectively), and in 2014, the average LOS for septicemia was nearly 4 times higher than that for asthma (10.4 days vs. 2.6 days). CONCLUSIONS This study provides a baseline assessment for examining trends in 30-day unplanned pediatric readmissions, an important quality metric as the provisions of the Children's Health Insurance Program Reauthorization Act and the Affordable Care Act are changed and implemented in the future. More than 50,000 pediatric hospital stays in 2014 occurred within 30 days of a previous hospitalization, with an average cost of $13,800. This report is timely, as the health care system works to become more patient-centered and public and private payers grapple with how to pay for quality care for children. The report provides baseline information that can be used to further explore ways to reduce unplanned readmissions.
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Affiliation(s)
- Kevin C Heslin
- Center for Delivery, Organization, and Markets, Agency for Healthcare Research and Quality, US Department of Health and Human Services, Rockville, MD.
| | - Pamela L Owens
- Center for Delivery, Organization, and Markets, Agency for Healthcare Research and Quality, US Department of Health and Human Services, Rockville, MD
| | | | - James P Guevara
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Marie C McCormick
- Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Mass
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Hamline MY, Speier RL, Vu PD, Tancredi D, Broman AR, Rasmussen LN, Tullius BP, Shaikh U, Li STT. Hospital-to-Home Interventions, Use, and Satisfaction: A Meta-analysis. Pediatrics 2018; 142:e20180442. [PMID: 30352792 PMCID: PMC6317574 DOI: 10.1542/peds.2018-0442] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2018] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Hospital-to-home transitions are critical opportunities to promote patient safety and high-quality care. However, such transitions are often fraught with difficulties associated with increased health care use and poor patient satisfaction. OBJECTIVE In this review, we determine which pediatric hospital discharge interventions affect subsequent health care use or parental satisfaction compared with usual care. DATA SOURCES We searched 7 bibliographic databases and 5 pediatric journals. STUDY SELECTION Inclusion criteria were: (1) available in English, (2) focused on children <18 years of age, (3) pediatric data reported separately from adult data, (4) not focused on normal newborns or pregnancy, (5) discharge intervention implemented in the inpatient setting, and (6) outcomes of health care use or caregiver satisfaction. Reviews, case studies, and commentaries were excluded. DATA EXTRACTION Two reviewers independently abstracted data using modified Cochrane data collection forms and assessed quality using modified Downs and Black checklists. RESULTS Seventy one articles met inclusion criteria. Although most interventions improved satisfaction, interventions variably reduced use. Interventions focused on follow-up care, discharge planning, teach back-based parental education, and contingency planning were associated with reduced use across patient groups. Bundled care coordination and family engagement interventions were associated with lower use in patients with chronic illnesses and neonates. LIMITATIONS Variability limited findings and reduced generalizability. CONCLUSIONS In this review, we highlight the utility of a pediatric discharge bundle in reducing health care use. Coordinating follow-up, discharge planning, teach back-based parental education, and contingency planning are potential foci for future efforts to improve hospital-to-home transitions.
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Affiliation(s)
| | | | - Paul Dai Vu
- School of Aerospace Medicine, Wright-Patterson Air Force Base, United States Air Force, Dayton, Ohio
| | | | - Alia R Broman
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon; and
| | | | - Brian P Tullius
- Department of Pediatric Hematology, Oncology, and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio
| | - Ulfat Shaikh
- Department of Pediatrics
- School of Medicine, University of California, Davis, Sacramento, California
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Solan LG, Auger KA. The Continued Quest for Pediatric Readmission Risk Prediction. J Hosp Med 2018; 13:800-801. [PMID: 30156574 DOI: 10.12788/jhm.3071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Lauren G Solan
- Division of Pediatric Hospital Medicine, Golisano Children's Hospital at the University of Rochester Medical Center, Rochester, New York, USA
| | - Katherine A Auger
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Ehwerhemuepha L, Finn S, Rothman M, Rakovski C, Feaster W. A Novel Model for Enhanced Prediction and Understanding of Unplanned 30-Day Pediatric Readmission. Hosp Pediatr 2018; 8:578-587. [PMID: 30093373 DOI: 10.1542/hpeds.2017-0220] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To develop a model to assist clinicians in reducing 30-day unplanned pediatric readmissions and to enhance understanding of risk factors leading to such readmissions. METHODS Data consisting of 38 143 inpatient clinical encounters at a tertiary pediatric hospital were retrieved, and 50% were used for training on a multivariate logistic regression model. The pediatric Rothman Index (pRI) was 1 of the novel candidate predictors considered. Multivariate model selection was conducted by minimization of Akaike Information Criteria. The area under the receiver operator characteristic curve (AUC) and values for sensitivity, specificity, positive predictive value, relative risk, and accuracy were computed on the remaining 50% of the data. RESULTS The multivariate logistic regression model of readmission consists of 7 disease diagnosis groups, 4 measures of hospital resource use, 3 measures of disease severity and/or medical complexities, and 2 variables derived from the pRI. Four of the predictors are novel, including history of previous 30-day readmissions within last 6 months (P < .001), planned admissions (P < .001), the discharge pRI score (P < .001), and indicator of whether the maximum pRI occurred during the last 24 hours of hospitalization (P = .005). An AUC of 0.79 (0.77-0.80) was obtained on the independent test data set. CONCLUSIONS Our model provides significant performance improvements in the prediction of unplanned 30-day pediatric readmissions with AUC higher than the LACE readmission model and other general unplanned 30-day pediatric readmission models. The model is expected to provide an opportunity to capture 39% of readmissions (at a selected operating point) and may therefore assist clinicians in reducing avoidable readmissions.
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Affiliation(s)
| | - Stacey Finn
- Cedar Gate Technologies, Greenwich, Connecticut
| | | | - Cyril Rakovski
- School of Computational and Data Science, Chapman University, Orange, California
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