Development of a Multidisciplinary Medical Home Program for NICU Graduates

Clinical Outcomes of Neonatal Intensive Care Unit Graduates with Bridled Nasogastric Feeding Tubes

OBJECTIVE

The aim of this study was to describe clinical outcomes of bridled nasogastric tube (NGT) program implementation for infants requiring assisted home feeding (AHF) to discharge from the neonatal intensive care unit (NICU).

STUDY DESIGN

This was a descriptive prospective analysis of a pilot cohort of infants after implementation of a bridled NGT AHF program to facilitate discharge from level III and IV NICUs from March 2019 to October 2020.

RESULTS

Of 29 attempts in infants, 22 infants were discharged with bridled NGTs over 18 months. Bridle placement was unsuccessful in three patients, and four bridles were removed before discharge. Bridle use ranged from 7 to 125 days, with a median duration of 37 days. Dislodgement rate was 0.69 per 100 days. Seventeen infants (77%) achieved full oral feeds, while five (23%) discharged with bridled NGTs later converted to gastrostomy tubes.

CONCLUSION

Implementation of a bridled NGT program is feasible for level III and IV NICUs to facilitate discharging infants who require feeding support to transition home.

KEY POINTS

· Bridled NGT use after NICU is typically 1 month.. · Infants have low bridle NGT dislodgement.. · Most bridled NGT NICU grads attain full oral feeds..

Families as partners in neonatal neuro-critical care programs

Parents of neonates with neurologic conditions face a specific breadth of emotional, logistical, and social challenges, including difficulties coping with prognostic uncertainty, the need to make complex medical decisions, and navigating new hopes and fears. These challenges place parents in a vulnerable position and at risk of developing mental health issues, which can interfere with bonding and caring for their neonate, as well as compromise their neonate's long-term neurodevelopment. To optimize neurologic and developmental outcomes, emerging neonatal neuro-critical care (NNCC) programs must concurrently attend to the unique needs of the developing newborn brain and of his/her parents. This can only be accomplished by embracing a family-centered care environment-one which prioritizes effective parent-clinician communication, longitudinal parent support, and parents as equitable partners in clinical care. NNCC programs offer a multifaceted approach to critical care for neonates at-risk for neurodevelopmental impairments, integrating expertise in neonatology and neurology. This review highlights evidence-based strategies to guide NNCC programs in developing a family-partnered approach to care, including primary staffing models; staff communication, implicit bias, and cultural competency trainings; comprehensive and tailored caregiver training; single-family rooms; flexible visitation policies; colocalized neonatal and maternal care; uniform mental health screenings; follow-up care referrals; and connections to peer support. IMPACT: Parents of neonates with neurologic conditions are at high-risk for experiencing mental health issues, which can adversely impact the parent-neonate relationship and long-term neurodevelopmental outcomes of their neonates. While guidelines to promote families as partners in the neonatal intensive care unit (NICU) have been developed, no protocols integrate the unique needs of parents in neonatal neurologic populations. A holistic approach that makes families true partners in the care of their neonate with a neurologic condition in the NICU has the potential to improve mental and physical well-being for both parents and neonates.

Three-Year Post-Neonatal Intensive Care Unit Health Care Utilization Among Infants with Congenital Anomalies

OBJECTIVE

To describe 3-year post-neonatal intensive care unit (NICU) health care use among children with congenital anomalies discharged home from a level IV NICU.

STUDY DESIGN

Retrospective chart review of children with congenital anomalies enrolled in a previous prospective cohort study from 201 to 2020. We assessed hospital readmission rate, number of surgeries, and durable medical equipment (DME) use by type of anomaly.

RESULTS

Among 166 infants enrolled in the original study, 158 survived to NICU discharge. One-third of the cohort had a genetic anomaly. Six of 158 patients (4%) died before 3 years of age. More than one-half the children were readmitted within the first 2 years of life, and one-third were readmitted in the third year of life. Readmissions were greatest for those with multiple, musculoskeletal, and central nervous system anomalies and lowest for abdominal-wall defects. Approximately one-half the children underwent surgeries, and this proportion remained constant over the 3-year time. Sixty-two percent of patients received DME at discharge, with gastrostomy tubes being the most common. Gastrostomy tubes were still present in 75% of the patients at 3 years of age.

CONCLUSION

Children with congenital anomalies are at risk for increased health care use during early childhood. Those with multiple anomalies, a genetic syndrome, musculoskeletal, and central nervous system anomalies and those discharged with DME are at greatest risk whereas those with abdominal-wall defects are at lowest risk. Provider awareness, high-quality discharge training, parent psychological support, greater assimilation of families in the NICU, and telehealth may be some strategies to better support these families.

Family-centred care interventions for children with chronic conditions: A scoping review

INTRODUCTION

Children with chronic conditions have greater health care needs than the general paediatric population but may not receive care that centres their needs and preferences as identified by their families. Clinicians and researchers are interested in developing interventions to improve family-centred care need information about the characteristics of existing interventions, their development and the domains of family-centred care that they address. We conducted a scoping review that aimed to identify and characterize recent family-centred interventions designed to improve experiences with care for children with chronic conditions.

METHODS

We searched Medline, Embase, PsycInfo and Cochrane databases, and grey literature sources for relevant articles or documents published between 1 January 2019 and 11 August 2020 (databases) or 7-20 October 2020 (grey literature). Primary studies with ≥10 participants, clinical practice guidelines and theoretical articles describing family-centred interventions that aimed to improve experiences with care for children with chronic conditions were eligible. Following citation and full-text screening by two reviewers working independently, we charted data covering study characteristics and interventions from eligible reports and synthesized interventions by domains of family-centred care.

RESULTS

Our search identified 2882 citations, from which 63 articles describing 61 unique interventions met the eligibility criteria and were included in this review. The most common study designs were quasiexperimental studies (n = 18), randomized controlled trials (n = 11) and qualitative and mixed-methods studies (n = 9 each). The most frequently addressed domains of family-centred care were communication and information provision (n = 45), family involvement in care (n = 37) and access to care (n = 30).

CONCLUSION

This review, which identified 61 unique interventions aimed at improving family-centred care for children with chronic conditions across a range of settings, is a concrete resource for researchers, health care providers and administrators interested in improving care for this high-needs population.

PATIENT OR PUBLIC CONTRIBUTION

This study was co-developed with three patient partner co-investigators, all of whom are individuals with lived experiences of rare chronic diseases as parents and/or patients and have prior experience in patient engagement in research (I. J., N. P., M. S.). These patient partner co-investigators contributed to this study at all stages, from conceptualization to dissemination.

Ensuring Optimal Outcomes for Preterm Infants after NICU Discharge: A Life Course Health Development Approach to High-Risk Infant Follow-Up

Children born prematurely (<37 weeks' gestation) have an increased risk for chronic health problems and developmental challenges compared to their term-born peers. The threats to health and development posed by prematurity, the unintended effects of life-sustaining neonatal intensive care, the associated neonatal morbidities, and the profound stressors to families affect well-being during infancy, childhood, adolescence, and beyond. Specialized clinical programs provide medical and developmental follow-up care for preterm infants after hospital discharge. High-risk infant follow-up, like most post-discharge health services, has many shortcomings, including unclear goals, inadequate support for infants, parents, and families, fragmented service provisions, poor coordination among providers, and an artificially foreshortened time horizon. There are well-documented inequities in care access and delivery. We propose applying a life course health development framework to clinical follow-up for children born prematurely that is contextually appropriate, developmentally responsive, and equitably deployed. The concepts of health development, unfolding, complexity, timing, plasticity, thriving, and harmony can be mapped to key components of follow-up care delivery to address pressing health challenges. This new approach envisions a more effective version of clinical follow-up to support the best possible functional outcomes and the opportunity for every premature infant to thrive within their family and community environments over their life course.

Parent Perspectives: Part 2-Considerations for the Transition Home Post-NICU Discharge

This paper is part two of a series of papers written by the mothers of Neonatal Intensive Care Unit (NICU) graduates. The companion paper, "Parent Perspectives: Part 1-Considerations for Changing the NICU Culture", considers all aspects of the NICU experience and provides recommendations for interventions and improvements from a life-course perspective while families are in the NICU. In part two, the focus is the transition home post-NICU stay. The time after NICU discharge is a critical and sensitive developmental period for NICU babies and their families, and an important life course transition. This paper provides a parent's perspective of how to improve the transition home post-NICU stay. Our perspectives draw on the Life Course Health Development approach, which regards health as an active process that is developed over time based on a person's internal biologic and physiologic systems, their external environment and circumstances, and the interactions or relationships between them. This paper describes a collaborative care model where parents and their healthcare teams work together to develop shared care plans. It also describes how we can build trust and family capacity to support long-term care, ensure family well-being, and link families to needed resources and support that can ease the transition from the NICU back to the home and optimize family health trajectories.

Characterization of combined endoscopies and aerodigestive care: An analysis of utilization and financial feasibility

BACKGROUND

Aerodigestive care is one model of multi-disciplinary care, which is a valuable tool for both providers and patients. Aerodigestive care models are associated with improved outcomes, reduced anesthesia exposure, reduction in hospital admissions, and fewer days of missed work or school. This is the first study to explore national usage and cost trends in combined endoscopy utilization to identify gaps in care and the potential for financial resource optimization.

METHODS

Data from the Healthcare Cost and Utilization Project (HCUP) Kid's Inpatient Sample (KID) was used from 2016 and 2019. Diagnoses and procedures were identified using ICD-10 codes, for patients with hospital length of stay less than 1 day. Demographic data were identified, and survey-weighted means and proportions were computed. Bivariate comparisons were made using Rao Scott Chi-Square tests. National estimates of charges were computed with discharge weights, developed using the American Hospital Association (AHA) universe.

KEY RESULTS

White, high-income patients, and those at urban teaching hospitals received the greatest proportion of combined endoscopic procedures. The cost/charges associated with combined endoscopies are less than for separate gastrointestinal (GI) or airway only endoscopies combined. However, combined procedures comprise a smaller share of national aggregate cost.

CONCLUSIONS

National utilization trends highlight racial and socioeconomic disparities and suggest differences in access based on hospital characteristics, despite the reduced cost/charges of the combined procedure. For patients with a need for combined aerodigestive procedures, there appears to be a cost-savings opportunity to increase efforts for combined procedures at the level of the clinician or hospital.

Parent Experiences in the NICU and Transition to Home

Families (n = 12) with infants born at <29 weeks gestation shared their experiences while in the NICU and transitioning home. Parents were interviewed 6-8 weeks after NICU discharge, including some during the acute phase of the COVID-19 pandemic. Findings regarding the parent experience in the NICU were focused around challenges navigating parent-infant separation, social isolation, communication difficulties, limited knowledge of preterm infants, mental health challenges. Parents also discussed supports that were present and supports they wished were present, as well as the impact of COVID-19 on their experiences. In the transition to home, primary experiences included the sudden nature of the transition, anxiety around discharge preparation, and the loss of the support from nursing staff. During the first few weeks at home, parents expressed joy and anxiety, particularly around feeding. The COVID-19 pandemic limited emotional, informational, and physical support to parents and resulted in limited mutual support from other parents of infants in the NICU. Parents of preterm infants in the NICU present with multiple stressors, rendering attending to parental mental health crucial. NICU staff need to address logistical barriers and familial priorities impacting communication and parent-infant bonding. Providing multiple opportunities for communication, participating in caretaking activities, and meeting other families can be important sources of support and knowledge for parents of very preterm infants.

Video Conference Discharge Process for NICU Infants with Medical Complexity

Purpose: Discharging infants from the NICU is complex, requiring the coordination of multiple aspects of care. Patient follow-up includes transferring medical care to primary care providers (PCP) who initially may have to rely on parents/caregivers for details about the child's history and current needs. Improving communication between the NICU and primary care offices within this pediatric health system was a goal of the organization, especially as value-based care was launched. Design: A pilot program was introduced in which families, PCP, and NICU providers for medically complex infants were offered the opportunity to participate in video conference calls. Sample: Infants selected for this pilot were those discharging from a Level IV NICU for the first time with medical complexity, such as those who would require care from multiple specialists, those with nasogastric feeding tubes, gastrostomy feeding tubes, and/or requiring oxygen post-discharge. The agenda during calls consisted of a review of the infant's birth, NICU course, and post-discharge needs. Participants were encouraged to provide detail and ask clarifying questions. Main Outcome Variable: Outcomes of this project included the evaluation of satisfaction with newer phone call methods for all participants and tracking readmission rates for those infants whose families experienced the video conference call. Results: High satisfaction levels were recorded among stakeholders as evidenced by 77 percent of parents and NICU providers being "very satisfied" or "completely satisfied" and 96 percent of primary care physicians being "very satisfied" or "completely satisfied." The rate of 30-day readmission for those who participated in the pilot was 23 percent and those readmissions were not unexpected. Conclusion: Involving families and accepting primary care physicians into the discharge communication are satisfying to stakeholders and allow participants the opportunity to have bidirectional conversations regarding the unique care needs of infants discharged from the NICU with special needs.

High-Risk Infant Follow-Up After NICU Discharge: Current Care Models and Future Considerations

Preterm infants are at heightened risk for chronic health problems and developmental delays compared with term-born peers. High-risk infant follow-up programs provide surveillance and support for problems that may emerge during infancy and early childhood. Although considered standard of care, program structure, content, and timing are highly variable. Families face challenges accessing recommended follow-up services. Here, the authors review common models of high-risk infant follow-up, describe novel approaches, and outline considerations for improving the quality, value, and equity of follow-up care.

Family and Provider Experiences With Longitudinal Care Coordination for Infants With Medical Complexity

BACKGROUND

Parents in the neonatal intensive care unit (NICU) report low self-confidence managing their children's ongoing medical and social needs. While bedside nurses provide critical support for families throughout their NICU admission, there may be a role for nursing coordination throughout hospitalization, discharge, and in the transition to outpatient care.

PURPOSE

This program evaluation explores parent and provider experiences of a novel longitudinal care coordination program for infants with medical complexity from the NICU through their first year of life post-discharge.

METHODS

First, a sequential exploratory mixed-methods approach was used to evaluate parental experiences (n = 5 interviewed followed by n = 23 surveyed). Provider perspectives were elicited through semi-structured interviews (n = 8) and focus groups (n = 26 in 3 groups).

RESULTS

Parent-reported benefits included frequent communication and personalized support that met families' and patients' evolving needs. Care coordinators, who were trained as nurses and social workers, developed longitudinal relationships with parents. This seemed to facilitate individualized support throughout the first year of life. Providers reported that smaller caseloads were central to the success of the program.

IMPLICATIONS FOR PRACTICE AND RESEARCH

This longitudinal care coordination program can be used as a translatable model in NICUs elsewhere to address the unique needs of families of infants with medical complexity throughout the first year of life. Future implementations should consider how to expand program size while maintaining individualized supports. As the care coordinators are former NICU nurses and social workers, there may be a growing role for nursing coordination of care in the neonatal population.

Racial and ethnic disparities in outcomes after NICU discharge: An equity-focused model

Significant racial and ethnic disparities exist in birth outcomes and complications related to prematurity. However, little is known about racial and ethnic variations in health outcomes after premature infants are discharged from the neonatal intensive care unit (NICU). We propose a novel, equity-focused conceptual model to guide future evaluations of post-discharge outcomes that centers on a multi-dimensional, comprehensive view of health, which we call thriving. We then apply this model to existing literature on post-discharge inequities, revealing a need for rigorous analysis of drivers and strength-based, longitudinal outcomes.

Discharge of Medically Complex Infants and Developmental Follow-up

At the time of discharge from the NICU, many infants have ongoing complex medical issues that will require coordinated, multispecialty follow-up. Discharge planning and transfer of care for infants with medical complexity require a multidisciplinary team effort that begins early during the NICU hospitalization. It is critical that the primary care physician is involved in this process because he or she will serve as the chief communicator and coordinator of care after discharge. Although some infants with medical complexity may be followed in specialized multidisciplinary NICU follow-up clinics, these are not universally available. The responsibility then falls to the primary care physician to coordinate with different subspecialties based on the infant's needs. Many infants with medical complexity are technology-dependent at the time of discharge and may require home oxygen, ventilators, monitors, or tube feeding. Prematurity, critical illness, and prolonged NICU hospitalization that lead to medical complexity also increase the risk of neurodevelopmental delay or impairment. As such, these infants will not only require routine developmental surveillance and screening by the primary care physician but also should be followed longitudinally by a neurodevelopmental specialist, either a developmental-behavioral pediatrician or a neonatologist with experience in neurodevelopmental assessment.

Research Trends of Follow-Up Care after Neonatal Intensive Care Unit Graduation for Children Born Preterm: A Scoping Review

The purpose of this study was to describe the trends of research on follow-up care after neonatal intensive care unit (NICU) graduation for children born preterm. This scoping review was conducted according to Arksey and O'Malley's guidelines. Reviewed studies were searched in PubMed, CHINAHL, and Web of Science. Fifteen studies were analyzed according to general characteristics, elements of follow-up care after NICU graduation, and characteristics of follow-up care intervention after NICU graduation. Most research was conducted in the medical field (60%), with experimental studies (40%) being the majority, and a few studies focused on families (3%) and parents (3%). The major follow-up care after NICU graduation elements were growth/developmental monitoring and support, continuity of care, parent- and family-centered elements, and a multidisciplinary approach. The intervention methods included home visits, phone calls, video calls, and applications. In addition, the intervention period ranged from two weeks to three years. It is suggested that multidisciplinary research with interactive media for a various age of children over longer periods for further study.