Foster Caregiver Experience of Pediatric Hospital-to-Home Transitions: A Qualitative Analysis

Promoting Health Equity for Children With Special Health Care Needs and Child Welfare Involvement

Noah, an 18-month-old infant with trisomy 21, was brought to the emergency department for adenovirus bronchiolitis. He was found to meet criteria for severe malnutrition, and his medical team called Child Protective Services (CPS) with concern for neglect. He remained hospitalized for 1 month while a safe discharge was coordinated by the medical and CPS teams. Through this case, we explore racism as a root cause of discharge delays among children with special health care needs who interact with the child welfare system. Our discussion delves into the origins and consequences of racial disproportionality within the child welfare system. We describe how Black children, including those with special health care needs, are disproportionately involved with the child welfare system and highlight the potential role of the health care system in these inequities. Ultimately, this racial disproportionality in CPS involvement may contribute to a cycle of oppression for Black families, undermining family and child health, well-being, and trust in the health care system. Understanding the role of racism in both the child welfare and health care systems can empower pediatric providers to be agents of change. Noah's case underscores the potential for pediatric providers to either perpetuate or mitigate racial disparities. We propose actions at the individual, institutional, and structural levels, emphasizing the importance of equitable family-centered care practices and trauma-informed care, establishing protocols for the management of potential abuse or neglect, and advocating for policies that reduce racial disparities in child welfare referral, support families, and prevent abuse and neglect.

Delays in Hospital Discharge for Children in Foster Care: Reasons and Recommendations From a Multisite Study

OBJECTIVE

To elucidate challenges to timely hospital discharge of children in foster care (CFC).

METHODS

Inpatient providers with prior experience caring for CFC were recruited from 6 mid-Atlantic hospitals. Semi-structured interviews were conducted to explore provider experience discharging CFC. Conventional content analysis was applied to interview transcripts with Dedoose software.

RESULTS

Interviews were completed with 15 MDs/NPs, 11 RNs, 10 social workers, and 2 case managers. Participants explained that delayed discharge is the norm for CFC, especially for those entering new foster care placements. Participants detailed challenges to efficiently discharging CFC, which were categorized into 3 themes: 1) Waiting for discharge disposition: Providers' ability to proceed with discharge planning is contingent on procedural steps (eg, court decisions) needed to determine disposition (eg, entering new foster care placement); 2) Medically cleared, but no place to go: Participants report placement searches are often not initiated by child welfare until the child is medically cleared. Lack of available, appropriate foster care placements delays discharge, particularly for children with complex medical or behavioral diagnoses; 3) Coordinating for a safe discharge: Establishing a safe discharge for CFC involves meticulous discharge planning, foster parent training, and multidisciplinary team communication/coordination.

CONCLUSION

Delayed discharge for CFC is multifactorial, yet often predictable. There are modifiable factors identified that can be addressed to promote timely hospital discharge and prevent medically unnecessary hospital days, benefitting patients in foster care and the hospital system.

Prevalence of medication discrepancies in pediatric patients transferred between hospital wards

Background Children are more susceptible to harm from medication errors and adverse drug reactions when compared to adults. Such events may occur from medication discrepancies while transitioning patients throughout the healthcare system. Contributing factors include medication discontinuity and lack of information by the healthcare team. Objective To analyze the prevalence of medication discrepancies in transition points of care in a pediatric department. Setting Pediatric department of a public hospital in Northeast Brazil. Method A cross-sectional study was carried out from August 2017 to March 2018. Data collection consisted of the following steps: collection of sociodemographic data, clinical interview with the patient's caregiver, registration of patient prescriptions, and evaluation of medical records. Medication discrepancies were classified as intentional and unintentional. The unintentional medication discrepancies were classified as omission of medication, therapeutic duplicity, and differences in dose, frequency, or route of administration. Main outcomes measure Discrepancy profile identified at admission, internal transfer and hospital discharge. Results Among the 114 patients included in the study, 85 (74.5%) patients had at least one unintentional medication discrepancy, of which 16 (14.0%) patients presented medication discrepancies at hospital admission, 42 (36.8%) patients at internal transfer, and 52 (45.6%) patients during discharge. Omission of medication represented 20 (74.1%) errors at admission, 26 (37.7%) errors at internal transfer, and 80 (100.0%) errors at hospital discharge. Conclusions The main transition points of care where unintentional discrepancies occurred in the studied pediatric department were at internal transfer and hospital discharge, with omission being the most common type of unintentional discrepancy.

Early Intervention Referral and Enrollment Among Infants with Neonatal Abstinence Syndrome

OBJECTIVE

To identify factors associated with referral and enrollment in early intervention (EI) for infants with neonatal abstinence syndrome (NAS).

METHODS

We conducted a retrospective cohort study of 256 infants born with NAS (2006-2013) at a tertiary care hospital in (Springfield), Massachusetts, linking maternal-infant birth hospitalization records with Department of Public Health EI records. We calculated the percent of infants retained at each step in the EI enrollment process over the first 3 years of life. We conducted separate multivariable logistic regression analyses to identify factors associated with EI referral and enrollment.

RESULTS

Among mothers, 82% received medication-assisted treatment at delivery, 36% endorsed illicit drug use during pregnancy, and 76% retained custody of their child at discharge. Among infants, 77% were referred to EI and 48% were enrolled in services. Of infants discharged to biological parents, 81% were referred to EI versus 66% of infants discharged to foster care (p ≤ 0.05); this difference persisted in multivariable analysis [adjusted odds ratio, 2.30; 95% confidence interval (CI), 1.09-4.86]. Infants in the highest tertile for length of stay had 2.70 times the odds of EI enrollment (95% CI, 1.37-5.31).

CONCLUSION

Fewer than half of the eligible infants with NAS were enrolled in EI services. Discharge to a biological parent and longer hospital stay had the strongest associations with EI referral and enrollment, respectively. Efforts to improve EI referral rates during the birth hospitalization, particularly among infants discharged into foster care, and close follow-up for infants with shorter hospital stays would enhance the developmental supports for this vulnerable population.