Structured discharge procedure for children admitted to hospital with acute asthma: a randomised controlled trial of nursing practice

Effectiveness of nursing interventions for management of children with bronchial asthma: A systematic review and meta-analysis

AIM

Nursing interventions include the preventive care that can support and guide the nurse's effort to provide asthma interventions for children. Hence, this review was done to assess the effectiveness of nursing interventions for management of childhood asthma.

METHODS

We conducted a search in Medline, the Cochrane library, EMBASE, ScienceDirect and Google Scholar from 1964 until April 2022. Meta-analysis was done using a random-effects model and pooled weighted mean difference (WMD) or standardized mean difference (SMD) and/or risk ratio (RR) with 95% confidence intervals (CIs).

RESULTS

Fourteen studies were analysed. The pooled RR was 0.49 for emergency visits (95% CI: 0.32 to 0.77) and 0.46 for hospitalizations (95% CI: 0.27 to 0.79). The pooled WMD was -1.20 for number of days with symptoms (95% CI: -3.50 to 1.11), -0.98 for number of nights with symptoms (95% CI: -2.94 to 0.98) and -0.69 for frequency of asthma attacks (95% CI: -1.19 to -0.20). The pooled SMD was 0.39 for quality of life (95% CI: 0.11 to 0.66) and 0.58 for asthma control (95% CI: -0.29 to 1.46).

CONCLUSION

Nursing interventions were relatively effective in improving the quality of life and reducing asthma related emergencies, acute attacks and hospitalization amongst childhood asthma patients.

Comprehensive In-Patient Education Consult for Asthma Exacerbations

BACKGROUND

Asthma is the most common chronic disease leading to hospital admissions and readmissions in childhood. Bedside nurses and respiratory therapists are the primary asthma educators, but they may lack time or knowledge to provide comprehensive asthma education and identify barriers to care. Patients and their parent(s) may benefit from comprehensive education and assessment of barriers from a certified asthma educator.

METHODS

A team of certified asthma educators used a quality improvement method to create an in-patient asthma education consulting service. The in-patient pulmonary consult and medical teams referred subjects ≥ 1 y in age with a new or existing diagnosis of asthma who had been admitted to the ICU or identified as having concerns for poor medication adherence to the asthma consult. The asthma consult provided face-to-face education with the subject and parent(s), addressed barriers to the plan of care, and helped facilitate appointments to an asthma specialist after discharge.

RESULTS

There were 126 subjects eligible for the asthma consult pilot implemented October 1, 2018-April 30, 2020. The asthma consult saw 52 subjects. Subjects who received consults had a higher rate of previous health care utilization and existing specialist for asthma. After the in-patient stay, the odds of returning to the emergency department/urgent care (UC) or hospital within the following 12 months did not differ between asthma consult and control group. However, after adjusting for covariates of age, race, ethnicity, previous health care utilization, and existing specialist, there was a significant difference in the odds of readmission and revisits (adjusted odds ratio 0.39 [95% CI 0.16-0.98], P = .04) for the asthma consult group compared to the control group.

CONCLUSIONS

Providing comprehensive, face-to-face asthma education and working with subjects and their parent(s) to address barriers to medication adherence and facilitate specialty follow-up post discharge decreased health care utilization.

Paediatric asthma education: Implementation of video-based education for families

AIM

To understand the impact of an asthma education video resource introduced to the short stay unit (SSU) of a tertiary paediatric hospital on: (i) parental understanding of and confidence in managing their child's asthma; (ii) the impact of this resource on nurse-led education practices; and (iii) readmission rates.

METHODS

A mixed methods study was conducted in the SSU over an 18-month period using quantitative survey data from parents and nursing staff and qualitative data from nursing staff focus groups.

RESULTS

Of 117 parents surveyed, 94% reported an increase in their understanding of asthma. Following the introduction of the resource, there were fewer nurse-led education sessions delivered (1.91 vs. 1.54, P = 0.04) and a trend towards reduction in time spent delivering this education (27.24 vs. 24.98 min, P = 0.47). Nursing staff confidence in the family's understanding of asthma education was similar pre- and post-implementation (4.22 vs. 4.30, P = 0.97). Readmission rates dropped by 25% (readmissions within 1 month) and by 33.3% (readmission within a week) in the post-intervention cohort.

CONCLUSIONS

Our asthma education video resource was demonstrated to be an acceptable and effective way of delivering asthma education to families. It created efficiency and consistency for nursing education and practice in our SSU. This resource was viewed by nursing staff as a useful adjunct to their education, enabling consistent messaging and helping structure education delivery. It has been incorporated into hospital systems and national resources which we hope will translate to a reduction in burden of asthma across the community.

Interactive Inpatient Asthma Education: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Inpatient asthma education interventions provide benefit compared with usual care, but evaluation of the most effective educational model is needed. We compared the impact of interactive versus didactic inpatient pediatric asthma education on subsequent emergency department (ED) visits and hospitalizations.

METHODS

Children (aged 2‒16) with asthma admitted to a tertiary care children's hospital with an asthma exacerbation between October 2016 and June 2017 were randomly assigned to interactive or didactic (control) asthma education. The primary outcome was asthma ED visits at 6 and 12 months; secondary outcomes included hospitalizations (6 and 12 months), inhaler technique, asthma knowledge, symptoms, quality of life, and parental management skills at baseline, discharge, and/or 12 months.

RESULTS

One hundred forty participants (69 interactive, 71 control) completed the study. There were no differences in ED visits at 6 or 12 months. Compared to controls, the interactive group had fewer hospitalizations (10.1% vs 22.5%; P = .04) at 6 months. Inhaler technique in the interactive group improved at discharge (mean change 4.07 [95% confidence interval (CI): 3.21-4.94]) and remained increased at 12 months (P = .03). Patient-reported asthma symptoms and quality of life were similar in both groups at baseline (19.9 vs 20.62, best possible score 8) and significantly improved in the interactive group at 12 months (least square mean change, 3.52 vs -1.75; P < .01).

CONCLUSIONS

There were no differences in ED visits; however, the interactive education reduced asthma hospitalizations over a 6-month period. These findings demonstrate that educational delivery methods can play a role in improving clinical outcomes for asthma.

An Asthma Population Health Improvement Initiative for Children With Frequent Hospitalizations

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.

Providing individualized written asthma action plans during the pediatric emergency department visit

Introduction: Among children presenting to the pediatric emergency department (PED) with an asthma exacerbation, the objective was to determine if creating an individualized written asthma action plan (WAAP) during the PED visit, when compared with standard discharge instructions, led to fewer asthma-related unplanned return visits up to three months after the PED visit. Secondary outcomes included rates of routine follow up with a healthcare provider, asthma control scores and caregiver confidence measures.Methods: Children ages 2-17 who presented to the PED with an asthma exacerbation and did not already have a WAAP were randomized to receive discharge instructions including a WAAP versus standard discharge instructions. The WAAP was ordered by the physician and reviewed with families by a respiratory therapist as part of a brief educational session during the PED visit. Parents completed follow-up surveys at one and three months after the PED visit.Results: 91 families were enrolled and 83/91 (91%) completed at least one follow-up survey. Fewer families in the WAAP group reported an unplanned visit to a healthcare provider during the follow-up period [WAAP 7/39 (18%), Control 17/44 (39%), p = 0.038]. Inhaled corticosteroids were prescribed more commonly in the WAAP group [WAAP 29/45 (64%), Control 15/46 (33%), p = 0.002]. There was no difference in rates of routine follow-up visits, asthma control scores or caregiver confidence measures during the follow-up period.Conclusions: Families who were provided a written asthma action plan during their pediatric emergency department visit for an asthma exacerbation reported fewer unplanned visits during the subsequent three months.

Predictors of severe asthma attack re-attendance in Ecuadorian children: a cohort study

Asthma is a common cause of emergency care attendance in low- and middle-income countries (LMICs). While few prospective studies of predictors for emergency care attendance have been undertaken in high-income countries, none have been performed in a LMIC.We followed a cohort of 5-15-year-old children treated for asthma attacks in emergency rooms of public health facilities in Esmeraldas City, Ecuador. We collected blood and nasal wash samples, and performed spirometry and exhaled nitric oxide fraction measurements. We explored potential predictors for recurrence of severe asthma attacks requiring emergency care over 6 months' follow-up.We recruited 283 children of whom 264 (93%) were followed-up for ≥6 months or until their next asthma attack. Almost half (46%) had a subsequent severe asthma attack requiring emergency care. Predictors of recurrence in adjusted analyses were (adjusted OR, 95% CI) younger age (0.87, 0.79-0.96 per year), previous asthma diagnosis (2.2, 1.2-3.9), number of parenteral corticosteroid courses in previous year (1.3, 1.1-1.5), food triggers (2.0, 1.1-3.6) and eczema diagnosis (4.2, 1.02-17.6). A parsimonious Cox regression model included the first three predictors plus urban residence as a protective factor (adjusted hazard ratio 0.69, 95% CI 0.50-0.95). Laboratory and lung function tests did not predict recurrence.Factors independently associated with recurrent emergency attendance for asthma attacks were identified in a low-resource LMIC setting. This study suggests that a simple risk-assessment tool could potentially be created for emergency rooms in similar settings to identify higher-risk children on whom limited resources might be better focused.

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?

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.

Completeness of Written Discharge Guidance for English- and Spanish-Speaking Patient Families

OBJECTIVES

Written discharge guidance for hospitalized pediatric patients should include language-appropriate key elements to ensure positive discharge outcomes. Our objective in this study was to determine the completeness of written pediatric discharge guidance and to test the hypothesis that Spanish-speaking families with limited English proficiency (LEP) receive less complete written discharge guidance than English-speaking families.

METHODS

We conducted a retrospective review of written discharge guidance provided to 100 English- and 100 Spanish-speaking families at an urban nonfreestanding children's hospital to assess the inclusion of key elements: follow-up plan, contingency plan, telephone contact, discharge medications, discharge diagnosis, and hospital course. We compared the completeness of discharge guidance (number of elements provided among number of applicable elements) between English- versus Spanish-speaking families.

RESULTS

When evaluating discharge guidance for the presence of key elements in any language, there was no significant difference between English- and Spanish-speaking families. However, the mean completeness of language-appropriate discharge guidance for English- and Spanish-speaking families was 87.8% (95% confidence interval [CI] 84.4%-91.1%) and 16.0% (95% CI 11.5%-20.4%), respectively. The ordinal logistic regression examining the association between the number of key element deficits and English- (reference group) versus Spanish-speaking families demonstrated an adjusted odds ratio of 339.8 (95% CI 112.4-1027.5).

CONCLUSIONS

Few Spanish-speaking families with LEP receive written discharge guidance in their preferred language. Complete, language-appropriate discharge guidance was identified as an area for improvement efforts to work toward improving care provided to families with LEP.

Medication self-management and the quality of discharge education among parents of children with epilepsy

INTRODUCTION

Medication self-management is critical among children with epilepsy. In the present study, we aimed to investigate the perceptions regarding the quality of discharge education among parents of children with epilepsy. In addition, we assessed the impact of their perceptions on medication self-management. The quality of discharge education was assessed in two parts: content and delivery. The quality of delivery was defined as the manner in which nurses teach the content regarding hospital discharge.

METHODS

Forty-seven parents of children with epilepsy completed the questionnaires regarding demographics, the quality of discharge education, and medication self-management (the Quality of Discharge Teaching Scale and the Pediatric Epilepsy Medication Self-Management Questionnaire).

RESULTS

Parent-reported quality of discharge education was positively correlated with medication self-management (r = 0.305; p = .037). Parent-reported quality of delivery, but not the amount of content, was positively correlated with medication self-management (r = 0.347; p = .017).

CONCLUSIONS

These data suggest that efforts to improve medication self-management among children with epilepsy should include strategies to develop teaching skills among nurses delivering the discharge education.

Caseworker-assigned discharge plans to prevent hospital readmission for acute exacerbations in children with chronic respiratory illness

BACKGROUND

Chronic respiratory conditions are major causes of mortality and morbidity. Children with chronic health conditions have increased morbidity associated with their physical, emotional, and general well-being. Acute respiratory exacerbations (AREs) are common in children with chronic respiratory disease, often requiring admission to hospital. Reducing the frequency of AREs and recurrent hospitalisations is therefore an important goal in the individual and public health management of chronic respiratory illnesses in children. Discharge planning is used to decide what a person needs for transition from one level of care to another and is usually considered in the context of discharge from hospital to the home. Discharge planning from hospital for ongoing management of an illness has historically been referral to a general practitioner or allied health professional or self management by the individual and their family with limited communication between the hospital and patient once discharged. Effective discharge planning can decrease the risk of recurrent AREs requiring medical care. An individual caseworker-assigned discharge plan may further decrease exacerbations.

OBJECTIVES

To evaluate the efficacy of individual caseworker-assigned discharge plans, as compared to non-caseworker-assigned plans, in preventing hospitalisation for AREs in children with chronic lung diseases such as asthma and bronchiectasis.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trials registries, and reference lists of articles. The latest searches were undertaken in November 2017.

SELECTION CRITERIA

All randomised controlled trials comparing individual caseworker-assigned discharge planning compared to traditional discharge-planning approaches (including self management), and their effectiveness in reducing the subsequent need for emergency care for AREs (hospital admissions, emergency department visits, and/or unscheduled general practitioner visits) in children hospitalised with an acute exacerbation of chronic respiratory disease. We excluded studies that included children with cystic fibrosis.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane Review methodological approaches. Relevant studies were independently selected in duplicate. Two review authors independently assessed trial quality and extracted data. We contacted the authors of one study for further information.

MAIN RESULTS

We included four studies involving a total of 773 randomised participants aged between 14 months and 16 years. All four studies involved children with asthma, with the case-planning undertaken by a trained nurse educator. However, the discharge planning/education differed among the studies. We could include data from only two studies (361 children) in the meta-analysis. Two further studies enrolled children in both inpatient and outpatient settings, and one of these studies also included children with acute wheezing illness (no previous asthma diagnosis); the data specific to this review could not be obtained. For the primary outcome of exacerbations requiring hospitalisation, those in the intervention group were significantly less likely to be rehospitalised (odds ratio (OR) 0.29, 95% confidence interval (CI) 0.16 to 0.50) compared to controls. This equates to 189 (95% CI 124 to 236) fewer admissions per 1000 children. No adverse events were reported in any study. In the context of substantial statistical heterogeneity between the two studies, there were no statistically significant effects on emergency department (OR 0.37, 95% CI 0.04 to 3.05) or general practitioner (OR 0.87, 95% CI 0.22 to 3.44) presentations. There were no data on cost-effectiveness, length of stay of subsequent hospitalisations, or adherence to medications. One study reported quality of life, with no significant differences observed between the intervention and control groups.We considered three of the studies to have an unclear risk of bias, primarily due to inadequate description of the blinding of participants and investigators. The fourth study was assessed as at high risk of bias as a single unblinded investigator was used. Using the GRADE system, we assessed the quality of the evidence as moderate for the outcome of hospitalisation and low for the outcomes of emergency department visits and general practitioner consultations.

AUTHORS' CONCLUSIONS

Current evidence suggests that individual caseworker-assigned discharge plans, as compared to non-caseworker-assigned plans, may be beneficial in preventing hospital readmissions for acute exacerbations in children with asthma. There was no clear indication that the intervention reduces emergency department and general practitioner attendances for asthma, and there is an absence of data for children with other chronic respiratory conditions. Given the potential benefit and cost savings to the healthcare sector and families if hospitalisations and outpatient attendances can be reduced, there is a need for further randomised controlled trials encompassing different chronic respiratory illnesses, ethnicity, socio-economic settings, and cost-effectiveness, as well as defining the essential components of a complex intervention.

Hospital-to-Home Interventions, Use, and Satisfaction: A Meta-analysis

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.

Barriers and Facilitators to Asthma Care After Hospitalization as Reported by Caregivers, Health Providers, and School Nurses

OBJECTIVES

To develop a comprehensive understanding of the barriers and/or facilitators for asthma management for the health professionals and caregivers of children with >1 hospitalization.

METHODS

Individual interviews were conducted with family caregivers and health professionals. Focus groups were conducted with school nurses. The interview and focus group guide were used to probe for barriers and facilitators of asthma management. Interviews were recorded, transcribed, and coded by using qualitative software. Themes were identified by using content analysis in the interviews and descriptive qualitative analysis in the focus groups.

RESULTS

Caregivers (n = 10), asthma educators (n = 4), physicians (n = 4), and a payer (n = 1) were individually interviewed. School nurses were interviewed via a focus group (n = 10). Children had a median age of 7 years, mean length of stay of 1.9 days, and 56% had a previous hospitalization in the previous 12 months. The "gaps in asthma knowledge" theme (which includes an inadequate understanding of asthma chronicity, activity restrictions, and management with controller medications) emerged as a theme for both caregivers and health professionals but with different health beliefs. School nurses reinforced the difficulty they have in managing children who have asthma in schools, and they identified using the asthma action plan as a facilitator.

CONCLUSIONS

Caregivers and health professionals have different health beliefs about asthma knowledge, which raises challenges in the care of a child who has asthma. In addition, school nurses highlight specific barriers that are focused on medication use in schools. A comprehensive understanding of the barriers and facilitators of asthma management that families experience after hospital discharge is crucial to design better efforts to support families.

Nurse-led Discharge in Pediatric Care: A Scoping Review

PROBLEM

Patients and caregivers frequently report feeling ill-prepared during the transition from hospital to home. Given the privileged position nurses occupy within the health care setting, they are often an appropriate health care professional to lead the discharge process. We aimed to map what is currently known about nurse-led/facilitated discharge programs, interventions, models, or frameworks for the pediatric population.

ELIGIBILITY CRITERIA

We conducted a scoping review following the Joanna Briggs Institute Methodology. Published literature targeting children 0-18 years old being discharged from acute care to home and describing a nurse leading the discharge planning/process was included.

SAMPLE

A search strategy was developed and implemented in four electronic databases; CINAHL, MEDLINE, Embase, and Web of Science. We also hand searched three high impact journals and reviewed reference lists of relevant articles. This search resulted in 1485 records. Based on our eligibility criteria, 9 articles were included in this review. Two independent reviewers screened each eligible article and extracted relevant information.

RESULTS

Terminology and program structure varied greatly across included studies. Critical appraisal revealed a lack of high quality research designs.

CONCLUSIONS

We identified a paucity of nurse-led/facilitated discharge programs evaluated within the pediatric population. The majority of studies were inadequately reported, leaving it difficult to identify development, implementation, and evaluation strategies.

IMPLICATIONS

Given the positive outcomes reported across all articles included in our review, future empirical research is warranted to explore this role within nursing practice.

Inpatient Quality Improvement Interventions for Asthma: A Meta-analysis

CONTEXT

Despite the availability of evidence-based guidelines for the management of pediatric asthma, health care utilization remains high.

OBJECTIVE

Systematically review the inpatient literature on asthma quality improvement (QI) and synthesize impact on subsequent health care utilization.

DATA SOURCES

Medline and Cumulative Index to Nursing and Allied Health Literature (January 1, 1991-November 16, 2016) and bibliographies of retrieved articles.

STUDY SELECTION

Interventional studies in English of inpatient-initiated asthma QI work.

DATA EXTRACTION

Studies were categorized by intervention type and outcome. Random-effects models were used to generate pooled risk ratios for health care utilization outcomes after inpatient QI interventions.

RESULTS

Thirty articles met inclusion criteria and 12 provided data on health care reutilization outcomes. Risk ratios for emergency department revisits were: 0.97 (95% confidence interval [CI]: 0.06-14.47) <30 days, 1.70 (95% CI: 0.67-4.29) for 30 days to 6 months, and 1.22 (95% CI: 0.52-2.85) for 6 months to 1 year. Risk ratios for readmissions were: 2.02 (95% CI: 0.73-5.61) for <30 days, 1.68 (95% CI: 0.88-3.19) for 30 days to 6 months, and 1.27 (95% CI 0.85-1.90) for 6 months to 1 year. Subanalysis of multimodal interventions suggested lower readmission rates (risk ratio: 1.49 [95% CI: 1.17-1.89] over a period of 30 days to 1 year after the index admission). Subanalysis of education and discharge planning interventions did not show effect.

LIMITATIONS

Linkages between intervention and outcome are complicated by the multimodal approach to QI in most studies.

CONCLUSIONS

We did not identify any inpatient strategies impacting health care reutilization within 30 days of index hospitalization. Multimodal interventions demonstrated impact over the longer interval.

Impact of Discharge Components on Readmission Rates for Children Hospitalized with Asthma

OBJECTIVES

To describe hospital-based asthma-specific discharge components at children's hospitals and determine the association of these discharge components with pediatric asthma readmission rates.

STUDY DESIGN

This is a multicenter retrospective cohort study of pediatric asthma hospitalizations in 2015 at children's hospitals participating in the Pediatric Health Information System. Children ages 5 to 17 years were included. An electronic survey assessing 13 asthma-specific discharge components was sent to quality leaders at all 49 hospitals. Correlations of combinations of asthma-specific discharge components and adjusted readmission rates were calculated.

RESULTS

The survey response rate was 92% (45 of 49 hospitals). Thirty-day and 3-month adjusted readmission rates varied across hospitals, ranging from 1.9% to 3.9% for 30-day readmissions and 5.7% to 9.1% for 3-month readmissions. No individual or combination discharge components were associated with lower 30-day adjusted readmission rates. The only single-component significantly associated with a lower rate of readmission at 3 months was having comprehensive content of education (P < .029). Increasing intensity of discharge components in bundles was associated with reduced adjusted 3-month readmission rates, but this did not reach statistical significance. This was seen in a 2-discharge component bundle including content of education and communication with the primary medical doctor, as well as a 3-discharge component bundle, which included content of education, medications in-hand, and home-based environmental mitigation.

CONCLUSIONS

Children's hospitals demonstrate a range of asthma-specific discharge components. Although we found no significant associations for specific hospital-level discharge components and asthma readmission rates at 30 days, certain combinations of discharge components may support hospitals to reduce healthcare utilization at 3 months.

Self-care support for children and adolescents with long-term conditions: the REfOCUS evidence synthesis

Background

Self-care support (e.g. education, training, peer/professional support) is intended to enhance the self-care capacities of children and young people, while simultaneously reducing the financial burden facing health-care systems.

Objectives

To determine which models of self-care support for long-term conditions (LTCs) are associated with significant reductions in health utilisation and costs without compromising outcomes for children and young people.

Design

Systematic review with meta-analysis.

Population

Children and young people aged 0–18 years with a long-term physical or mental health condition (e.g. asthma, depression).

Intervention

Self-care support in health, social care, educational or community settings.

Comparator

Usual care.

Outcomes

Generic/health-related quality of life (QoL)/subjective health symptoms and health service utilisation/costs.

Design

Randomised/non-randomised trials, controlled before-and-after studies, and interrupted time series designs.

Data sources

MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, ISI Web of Science, NHS Economic Evaluation Database, The Cochrane Library, Health Technology Assessment database, Paediatric Economic Database Evaluation, IDEAS, reference scanning, targeted author searches and forward citation searching. All databases were searched from inception to March 2015.

Methods

We conducted meta-analyses, simultaneously plotting QoL and health utilisation effects. We conducted subgroup analyses for evidence quality, age, LTC and intervention (setting, target, delivery format, intensity).

Results

Ninety-seven studies reporting 114 interventions were included. Thirty-seven studies reported adequate allocation concealment. Fourteen were UK studies. The vast majority of included studies recruited children and young people with asthma (n = 66, 68%). Four per cent of studies evaluated ‘pure’ self-care support (delivered through health technology without additional contact), 23% evaluated facilitated self-care support (≤ 2 hours’/four sessions’ contact), 65% were intensively facilitated (≥ 2 hours’/four sessions’ contact) and 8% were case management (≥ 2 hours’ support with multidisciplinary input). Self-care support was associated with statistically significant, minimal benefits for QoL [effect size (ES) –0.17, 95% confidence interval (CI) –0.23 to –0.11], but lacked clear benefit for hospital admissions (ES –0.05, 95% CI –0.12 to 0.03). This finding endured across intervention intensities and LTCs. Statistically significant, minimal reductions in emergency use were observed (ES –0.11, 95% CI –0.17 to –0.04). The total cost analysis was limited by the small number of data. Subgroup analyses revealed statistically significant, minimal reductions in emergency use for children aged ≤ 13 years (ES –0.10, 95% CI –0.17 to –0.04), children and young people with asthma (ES –0.12, 95% CI –0.18 to –0.06) and children and young people receiving ≥ 2 hours per four sessions of support (ES –0.10, 95% CI –0.17 to –0.03). Preliminary evidence suggested that interventions that include the child or young person, and deliver some content individually, may optimise QoL effects. Face-to-face delivery may help to maximise emergency department effects. Caution is required in interpreting these findings.

Limitations

Identification of optimal models of self-care support is challenged by the size and nature of evidence available. The emphasis on meta-analysis meant that a minority of studies with incomplete but potentially relevant data were excluded.

Conclusions

Self-care support is associated with positive but minimal effects on children and young people’s QoL, and minimal, but potentially important, reductions in emergency use. On current evidence, we cannot reliably conclude that self-care support significantly reduces health-care costs.

Future work

Research is needed to explore the short- and longer-term effects of self-care support across a wider range of LTCs.

Study registration

This study is registered as PROSPERO CRD42014015452.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

National estimates of 30-day readmissions among children hospitalized for asthma in the United States

OBJECTIVE

Previous single-center studies have reported that up to 40% of children hospitalized for asthma will be readmitted. The study objectives are to investigate the prevalence and timing of 30-day readmissions in children hospitalized with asthma, and to identify factors associated with 30-day readmissions.

METHODS

Data (n = 12,842) for children aged 6-18 years hospitalized for asthma were obtained from the 2013 Nationwide Readmission Database (NRD). The primary study outcome was time to readmission within 30 days after discharge attributable to any cause. Several predictors associated with the risk of admission were included: patient (age, sex, median household income, insurance type, county location, and pediatric chronic complex condition), admission (type, day, emergency services utilization, length of stay (LOS), and discharge disposition), and hospital (ownership, bed size, and teaching status). Cox's proportional hazards model was used to identify predictors.

RESULTS

Of 12,842 asthma-related index hospitalizations, 2.5% were readmitted within 30-days post-discharge. Time to event models identified significantly higher risk of readmission among asthmatic children aged 12-18 years, those who resided in micropolitan counties, those with >4-days LOS during index hospitalization, those who were hospitalized in an urban hospital, who had unfavorable discharge (hazard ratio 2.53, 95% confidence interval 1.33-4.79), and those who were diagnosed with a pediatric complex chronic condition, respectively, than children in respective referent categories.

CONCLUSION

A multi-dimensional approach including effective asthma discharge action plans and follow-up processes, home-based asthma education, and neighborhood/community-level efforts to address disparities should be integrated into the routine clinical care of asthma children.

Multifaceted quality improvement initiative to decrease pediatric asthma readmissions

BACKGROUND

Asthma is the most common chronic disease of childhood and a leading cause of hospitalization in children. A primary goal of asthma control is prevention of hospitalizations. A hospital admission is the single strongest predictor of future hospital admissions for asthma. The 30-day asthma readmission rate at our institution was significantly higher than that of other hospitals in the Children's Hospital Association. As a result, a multifaceted quality improvement project was undertaken with the goal of reducing the 30-day inpatient asthma readmission rate by 50% within two years.

METHODS

Analysis of our institution's readmission patterns, value stream mapping of asthma admission, discharge, and follow-up processes, literature review, and examination of comparable successful programs around the United States were all utilized to identify potential targets for intervention. Interventions were implemented in a stepwise manner, and included increasing inhaler availability after discharge, modifying asthma education strategies, and providing in-home post-discharge follow-up. The primary outcome was a running 12-month average 30-day inpatient readmission rate. Secondary outcomes included process measures for individual interventions.

RESULTS

From a peak of 7.98% in January 2013, a steady decline to 1.65% was observed by July 2014, which represented a 79.3% reduction in 30-day readmissions.

CONCLUSION

A significant decrease in hospital readmissions for pediatric asthma is possible, through comprehensive, multidisciplinary quality improvement that spans the continuum of care.

Who comes back with what: a retrospective database study on reasons for emergency readmission to hospital in children and young people in England

OBJECTIVE

To determine the proportion of children and young people (CYP) in England who are readmitted for the same condition.

DESIGN

Retrospective cohort study.

SETTING

National administrative hospital data (Hospital Episode Statistics).

PARTICIPANTS

CYP (0-year-olds to 24-year-olds) discharged after an emergency admission to the National Health Service in England in 2009/2010.

MAIN OUTCOME MEASURES

Coded primary diagnosis classified in six broad groups indicating reason for admission (infection, chronic condition, injury, perinatal related or pregnancy related, sign or symptom or other). We grouped readmissions as ≤30 days or between 31 days and 2 years after the index discharge. We used multivariable logistic regression to determine factors at the index admission that were predictive of readmission within 30 days.

RESULTS

9% of CYP were readmitted within 30 days. Half of the 30-day readmissions and 40% of the recurrent admissions between 30 days and 2 years had the same primary diagnosis group as the original admission. These proportions were consistent across age, sex and diagnostic groups, except for infants and young women with pregnancy-related problems (15-24 years) who were more likely to be readmitted for the same primary diagnostic group. CYP with underlying chronic conditions were readmitted within 30 days twice as often (OR: 1.93, 95% CI 1.89 to 1.99) compared with CYP without chronic conditions.

CONCLUSIONS

Financial penalties for readmission are expected to incentivise more effective care of the original problem, thereby avoiding readmission. Our findings, that half of children come back with different problems, do not support this presumption.

Pediatric asthma readmission: asthma knowledge is not enough?

OBJECTIVE

To characterize factors associated with readmission for acute asthma exacerbation, particularly around caregiver asthma knowledge, beliefs, and reported adherence to prescribed medication regimens.

STUDY DESIGN

We enrolled 601 children (aged 1-16 years) who had been hospitalized for asthma. Caregivers completed a face-to-face survey regarding their asthma knowledge, beliefs, and medication adherence. Caregivers also reported demographic data, child's asthma severity, exposure to triggers, access to primary care, and financial strains. We prospectively identified asthma readmission events via billing data over a 1-year minimum follow-up period. We examined time to readmission with Cox proportional hazards.

RESULTS

The study cohort's median age was 5 years, 53% were African American, and 57% were covered by Medicaid. At 1 year, 22% had been readmitted for asthma. In the multivariate analysis, a caregiver's demonstration of increased asthma knowledge was associated with increased readmission risk. In addition, children whose caregivers reported less-than-perfect adherence to daily medication regimens had increased readmission risk. Likewise, having previously been admitted for asthma, decreased medical home access, and black race were associated with increased readmission risk.

CONCLUSION

In a multifactorial assessment of risk factors for asthma readmission, greater asthma knowledge and decreased medication adherence were associated with readmission. Inpatient efforts to prevent readmission might best target medication adherence rather than continuing to primarily provide asthma education.

A framework of pediatric hospital discharge care informed by legislation, research, and practice

To our knowledge, no widely used pediatric standards for hospital discharge care exist, despite nearly 10 000 pediatric discharges per day in the United States. This lack of standards undermines the quality of pediatric hospital discharge, hinders quality-improvement efforts, and adversely affects the health and well-being of children and their families after they leave the hospital. In this article, we first review guidance regarding the discharge process for adult patients, including federal law within the Social Security Act that outlines standards for hospital discharge; a variety of toolkits that aim to improve discharge care; and the research evidence that supports the discharge process. We then outline a framework within which to organize the diverse activities that constitute discharge care to be executed throughout the hospitalization of a child from admission to the actual discharge. In the framework, we describe processes to (1) initiate pediatric discharge care, (2) develop discharge care plans, (3) monitor discharge progress, and (4) finalize discharge. We contextualize these processes with a clinical case of a child undergoing hospital discharge. Use of this narrative review will help pediatric health care professionals (eg, nurses, social workers, and physicians) move forward to better understand what works and what does not during hospital discharge for children, while steadily improving their quality of care and health outcomes.

Pediatric hospital discharge interventions to reduce subsequent utilization: a systematic review

BACKGROUND

Reducing avoidable readmission and posthospitalization emergency department (ED) utilization has become a focus of quality-of-care measures and initiatives. For pediatric patients, no systematic efforts have assessed the evidence for interventions to reduce these events.

PURPOSE

We sought to synthesize existing evidence on pediatric discharge practices and interventions to reduce hospital readmission and posthospitalization ED utilization.

DATA SOURCES

PubMed and the Cumulative Index to Nursing and Allied Health Literature.

STUDY SELECTION

Studies available in English involving pediatric inpatient discharge interventions with at least 1 outcome of interest were included.

DATA EXTRACTION

We utilized a modified Cochrane Good Practice data extraction tool and assessed study quality with the Downs and Black tool.

DATA SYNTHESIS

Our search identified a total of 1296 studies, 14 of which met full inclusion criteria. All included studies examined multifaceted discharge interventions initiated in the inpatient setting. Overall, 2 studies demonstrated statistically significant reductions in both readmissions and subsequent ED visits, 4 studies demonstrated statistically significant reductions in either readmissions or ED visits, and 2 studies found statistically significant increases in subsequent utilization. Several studies were not sufficiently powered to detect changes in either subsequent utilization outcome measure.

CONCLUSIONS

Interventions that demonstrated reductions in subsequent utilization targeted children with specific chronic conditions, providing enhanced inpatient feedback and education reinforced with postdischarge support. Interventions seeking to reduce subsequent utilization should identify an individual or team to assume responsibility for the inpatient-to-outpatient transition and offer ongoing support to the family via telephone or home visitation following discharge.

Rehospitalization for childhood asthma: timing, variation, and opportunities for intervention

OBJECTIVE

To assess the timing of pediatric asthma rehospitalization, variation in rate of rehospitalization across hospitals, and factors associated with rehospitalization at different intervals.

STUDY DESIGN

Retrospective cohort analysis of 44,204 hospitalizations for children with asthma within 42 children's hospitals between July 2008 and June 2011. The main outcome measures were rehospitalization for asthma within 7, 15, 30, 60, 180, and 365 days of an index asthma admission.

RESULTS

The rate of asthma rehospitalization ranged from 0.5% (n = 208) at 7 days to 17.2% (n = 7603) at 365 days. Black patients and patients with public insurance had higher odds of rehospitalization at 60 days and beyond (P ≤ .01 for both). Adolescents (12- to 18-year-old), patients with a diagnosis of a complex chronic condition, and patients with a prior year asthma admission had higher odds of rehospitalization at every time interval (P ≤ .001 for all). Significant hospital variation in case-mix adjusted rates of rehospitalization existed at each time interval (P ≤ .01 for all). Rates at 365 days were ≤ 10.9% for the top 10% of hospitals; if all hospitals achieved this rate, 36.6% of rehospitalizations might have been avoided.

CONCLUSIONS

Significant variation in asthma rehospitalization rates exists across children's hospitals from 7 to 365 days after an index admission. Racial/ethnic and economic disparities emerge at 60 days. By 1 year, rehospitalizations account for 1 in 6 hospitalizations. Assessing asthma rehospitalizations at longer intervals may augment our current understanding of and approach to post-hospitalization care improvement.

Parents' perceptions regarding readiness for their infant's discharge from the NICU

PURPOSE

To identify what parents need to feel ready for the discharge of their infant from the neonatal intensive care unit (NICU).

DESIGN

Qualitative.

SAMPLE

20 parents of infants admitted to a Canadian Level III NI CU were interviewed (2011-2012) and asked to identify what they require to feel ready for discharge. Interview transcripts underwent qualitative content analysis to produce a descriptive summary of parents' perceptions of their needs.

RESULTS

Parents indicated a need for information and hands-on experience to enhance their readiness for discharge. Observations of their infant and of the NI CU environment impacted parents' perceptions of their infant's readiness for discharge, which influenced perceptions of their own readiness for discharge. Finally, parents require tailoring of information and experiences to meet the unique needs of their family.

An observational study of nurse staffing ratios and hospital readmission among children admitted for common conditions

Background

Hospital patient-to-nurse staffing ratios are associated with quality outcomes in adult patient populations but little is known about how these factors affect paediatric care. We examined the relationship between staffing ratios and all-cause readmission (within 14 days, 15–30 days) among children admitted for common medical and surgical conditions.

Methods

We conducted an observational cross-sectional study of readmissions of children in 225 hospitals by linking nurse surveys, inpatient discharge data and information from the American Hospital Association Annual Survey. Registered Nurses (N=14 194) providing direct patient care in study hospitals (N=225) and children hospitalised for common conditions (N=90 459) were included.

Results

Each one patient increase in a hospital's average paediatric staffing ratio increased a medical child's odds of readmission within 15–30 days by a factor of 1.11, or by 11% (95% CI 1.02 to 1.20) and a surgical child's likelihood of readmission within 15–30 days by a factor of 1.48, or by 48% (95% CI 1.27 to 1.73). Children treated in hospitals with paediatric staffing ratios of 1 : 4 or less were significantly less likely to be readmitted within 15–30 days. There were no significant effects of nurse staffing ratios on readmissions within 14 days.

Discussion

Children with common conditions treated in hospitals in which nurses care for fewer patients each are significantly less likely to experience readmission between 15 and 30 days after discharge. Lower patient-to-nurse ratios hold promise for preventing unnecessary hospital readmissions for children through more effective predischarge monitoring of patient conditions, improved discharge preparation and enhanced quality improvement success.

The effectiveness of self-care support interventions for children and young people with long-term conditions: a systematic review

Children's health policy has highlighted the need to develop self-care programmes. However, there is a lack of evidence on which to base the development of such programmes. This paper reviews the published research on the effectiveness of self-care support interventions for children and young people with asthma, cystic fibrosis and diabetes. A systematic search was conducted of a range of electronic databases, supplemented by searching the reference lists of retrieved papers and published reviews. Retrieved studies were assessed against quality and eligibility criteria by two independent reviewers. The results were narratively synthesized to examine the effectiveness of self-care support interventions on health status, psycho-social well-being, condition-related knowledge, health service use and participant satisfaction. The search strategy identified 4261 papers which were screened against the review inclusion criteria. A total of 194 papers were assessed as being potentially eligible for inclusion with 15 papers being judged as adequate to include in the review. There is strong evidence of the effectiveness of interventions that target children/young people; use e-health or group-based methods; that are delivered in community settings. There is no evidence that interventions that focus on parents alone or are delivered only in hospital settings are effective. While there is some evidence to inform the development of self-care support programmes, there is a need for well-designed trials of interventions that are feasible to transfer into real-life settings and which involve parents and children in their development.

Perceptions of effective self-care support for children and young people with long-term conditions

AIMS AND OBJECTIVES

To: (1) Examine children's/young people's, parents' and professionals'/workers' perceptions of the effectiveness of different models of self-care support, (2) identify factors that support and inhibit self-care and (3) explore how different models integrate with self-care support provided by other organisations.

BACKGROUND

Childhood long-term illness has been largely overlooked in government policy and self-care support under-researched when compared with adults. There is a lack of evidence on which are the most appropriate models and methods to engage young people and their parents in self-care.

DESIGN

Case study.

METHODS

Case studies of six different models of self-care support were conducted using multiple methods of data collection in 2009. Semi-structured interviews were conducted with 26 young people, 31 parents and 36 self-care support providers. A sample of self-care support activities was observed and relevant documents reviewed. Data were analysed using the Framework approach.

RESULTS

The effectiveness of self-care support projects was defined in relation to four dimensions - providing a sense of community, promoting independence and confidence, developing knowledge and skills and engaging children/young people. Self-care support provided by schools appeared to be variable with some participants experiencing barriers to self-management and inclusion. Participants self-referred themselves to self-care support projects, and there was a lack of integration between some projects and other forms self-care support.

CONCLUSION

This study adds to knowledge by identifying four dimensions that are perceived to be central to effective self-care support and the contextual factors that appear to influence access and experiences of self-care support.

RELEVANCE TO CLINICAL PRACTICE

Study findings can inform the development of self-care support programmes to meet the needs of individuals, families and communities. In addition, the findings suggest that healthcare professionals need to support schools if young people with long-term conditions are to have the same educational and social opportunities as their peers.

The Joint Commission Children's Asthma Care quality measures and asthma readmissions

BACKGROUND AND OBJECTIVES

The Joint Commission introduced 3 Children's Asthma Care (CAC 1-3) measures to improve the quality of pediatric inpatient asthma care. Validity of the commission's measures has not yet been demonstrated. The objectives of this quality improvement study were to examine changes in provider compliance with CAC 1-3 and associated asthma hospitalization outcomes after full implementation of an asthma care process model (CPM).

METHODS

The study included children aged 2 to 17 years who were admitted to a tertiary care children's hospital for acute asthma between January 1, 2005, and December 31, 2010. The study was divided into 3 periods: preimplementation (January 1, 2005-December 31, 2007), implementation (January 1, 2008-March 31, 2009), and postimplementation (April 1, 2009-December 31, 2010) periods. Changes in provider compliance with CAC 1-3 and associated changes in hospitalization outcomes (length of stay, costs, PICU transfer, deaths, and asthma readmissions within 6 months) were measured. Logistic regression was used to control for age, gender, race, insurance type, and time.

RESULTS

A total of 1865 children were included. Compliance with quality measures before and after the CPM implementation was as follows: 99% versus 100%, CAC-1; 100% versus 100%, CAC-2; and 0% versus 87%, CAC-3 (P < .01). Increased compliance with CAC-3 was associated with a sustained decrease in readmissions from an average of 17% to 12% (P = .01) postimplementation. No change in other outcomes was observed.

CONCLUSIONS

Implementation of the asthma CPM was associated with improved compliance with CAC-3 and with a delayed, yet significant and sustained decrease in hospital asthma readmission rates, validating CAC-3 as a quality measure. Due to high baseline compliance, CAC-1 and CAC-2 are of questionable value as quality measures.

Effective discharge communication in the emergency department

Communication at discharge is an important part of high-quality emergency department (ED) care. This review describes the existing literature on patient understanding and implementation of discharge instructions, discusses previous interventions aimed at improving the discharge process, and recommends best practices and future research. MEDLINE and Cochrane databases were searched, using combinations of key terms. Literature from both the adult and pediatric ED populations was reviewed. Multiple reports have shown deficient comprehension at discharge, with patients or parents frequently unable to report their diagnosis, management plan, or reasons to return. Interventions to improve discharge communication have been, at best, moderately successful. Patients need structured content, presented verbally, with written and visual cues to enhance recall. Written instructions need to be provided in the patient's language and at an appropriate reading level. Understanding should be confirmed before the patient leaves the ED. Further research is needed to describe the optimal content, channel, and timing for the ED discharge process and the relationship between discharge process and outcomes.

Effects of a peer-led asthma self-management program for adolescents

OBJECTIVE

To evaluate the effectiveness of a peer-led asthma self-management program for adolescents.

DESIGN

Randomized controlled trial comparing a peer-led asthma program (intervention group) and a conventional adult-led asthma program (control group). Each program was implemented at a full-day camp.

SETTING

A city and adjacent suburbs in upstate New York.

PARTICIPANTS

A total of 112 adolescents aged 13 to 17 years with persistent asthma.

INTERVENTION

A peer-led asthma self-management program implemented at a day camp.

MAIN OUTCOME MEASURES

The Child Attitude Toward Illness Scale and the Paediatric Asthma Quality of Life Questionnaire were administered at baseline and immediately and 3, 6, and 9 months after the intervention. Spirometry was conducted twice: before and 9 months after the intervention.

RESULTS

The intervention group reported more positive attitudes at 6 months (mean difference, 4.11; 95% confidence interval [CI], 0.65-7.56) and higher quality of life at 6 months (difference, 11.38; 95% CI, 0.96-21.79) and 9 months (difference, 12.97; 95% CI, 3.46-22.48) than the control group. The intervention was found to be more beneficial to adolescents of male gender or low family income, as shown by greater improvement in positive attitudes toward asthma and quality of life than their counterparts.

CONCLUSION

An asthma self-management program led by peer leaders is a developmentally appropriate approach that can be effective in assisting adolescents with asthma in improving their attitudes and quality of life, particularly for males and those of low socioeconomic status.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01161225.

A matched-cohort evaluation of a bedside asthma intervention for patients hospitalized at a large urban children's hospital

Emergency care and hospitalizations account for 36% of asthma-related medical expenses for children. National asthma guidelines emphasize the need for asthma self-management education at multiple points of care, including the hospital, to help prevent acute exacerbations. The integration of a bedside asthma education program into discharge planning at a busy urban children's hospital aimed to reduce repeat emergency department (ED) visits and hospitalizations by educating the community's highest-risk children and their families about asthma. A trained respiratory professional provided 45 minutes of individualized bedside education to families at the hospital and one follow-up support phone call within 3 weeks after discharge. Children receiving the intervention were matched to a control group of children not receiving the intervention by age and 2 markers of past utilization using data obtained from hospital records. Repeat ED utilization was analyzed using a Cox proportional hazards model controlling for sex, residence, race or ethnicity, and year. Compared to 698 matched controls, no significant improvement was observed in the 698 intervention participants or any subgroups followed for 12 months after the intervention.

Educational and behavioral interventions for asthma: who achieves which outcomes? A systematic review

OBJECTIVES

Randomized clinical trial (RCT) data reviewed for outcomes and processes associated with asthma educational and behavioral interventions provided by different types of health professionals.

METHODS

Cochrane Collaboration, MEDLINE, PUBMED, Google Scholar search from 1998 to 2009 identified 1650 articles regarding asthma educational and behavioral interventions resulting in 249 potential studies and following assessment produced a final sample of 50 RCTs.

RESULTS

Approaches, intended outcomes, and program providers vary greatly. No rationale provided in study reports for the selection of specific outcomes, program providers, or program components. Health care utilization and symptom control have been the most common outcomes assessed. Specific providers favor particular teaching approaches. Multidisciplinary teams have been the most frequent providers of asthma interventions. Physician-led interventions were most successful for outcomes related to the use of health care. Multidisciplinary teams were best in achieving symptom reduction and quality of life. Lay persons were best in achieving self-management/self-efficacy outcomes. Components most frequently employed in successful programs are skills to improve patient-clinician communication and education to enhance patient self-management. Fifty percent of interventions achieved reduction in the use of health care and one-third in symptom control. A combination approach including self-management and patient-clinician communication involving multidisciplinary team members may have the greatest effect on most outcomes.

CONCLUSIONS

The extent to which and how different providers achieve asthma outcomes through educational and behavioral interventions is emerging from recent studies. Health care use and symptom control are evolving as the gold standard for intervention outcomes. Development of self-management and clinician-patient communication skills are program components associated with success across outcomes and providers.

A pediatric asthma management program in a low-income setting resulting in reduced use of health service for acute asthma

BACKGROUND

The effectiveness of pediatric asthma management programs in reducing health services utilization during exacerbations in developing countries is not widely studied. This study was carried out to assess the effectiveness of an asthma management program to reduce the overall health services utilization by acute asthma in children and adolescents.

METHODS

In this historical population-based real-life cohort study, we selected 582 patients with asthma aged 4-15 living in deprived areas in the town of Itabira, Brazil, of which 470 cases were assisted by the asthma management program and 112 were controls. The end point was the first physician-diagnosed asthma exacerbation occurring after study enrollment and within 12 months after admission. All 470 cases received a written plan about exacerbation self-management, including the use of inhaled albuterol at home. Three hundred and seventeen out of 470 cases (67.4%) were also treated with beclomethasone diproprionate (BDP).

RESULTS

Both groups were comparable regarding gender, age group, and place of residence. At the end of the study, only 5% of cases vs 34% of controls did seek health services because of acute asthma (P < 0.01). Statistical difference also remained when comparing the 112 controls with the 153 cases not treated with com BDP (Hazard Ratio = 0.04, 95% CI, 0.01-0.14, P < 0.01).

CONCLUSIONS

Results have demonstrated the effectiveness of the pediatric asthma management program in reducing dependence on the health services for acute asthma. Effectiveness was also observed in subjects with no use of BDP.

Discharge from outpatient orthopaedic physiotherapy: a qualitative descriptive study of physiotherapists' practices

PURPOSE

To describe the clinical and contextual factors that influence physiotherapists' discharge decision-making processes in outpatient orthopaedic settings.

METHODS

The study used a descriptive qualitative design that included three key-informant interviews and two focus groups (n=7) of orthopaedic physiotherapists (total n=10) working in the Greater Toronto Area. Interviews and focus groups followed a semi-structured interview guide that included questions pertaining to participants' discharge decision-making processes, salient contextual factors, and challenges. Data were coded and analyzed for emerging categories and themes using constant comparison techniques and group analyses.

RESULTS

Participants indicated that a combination of factors and strategies were brought to bear on discharge decision making but that the process changed with clinical experience. Over time, further emphasis was attributed to the patient's role in his or her rehabilitation, and self-management goals were increasingly promoted. Experience affected how therapists conceptualized their roles in discharge decisions and how they negotiated goals with patients.

CONCLUSIONS

Discharge decision making is a complex process that requires integrating numerous factors and negotiating with patients. Physiotherapists' decision-making practices evolve with experience and reveal the complexity of implementing models of "client-centred care" in practice. Further research is needed to explore these findings in other settings.

Group asthma education in a pediatric inpatient setting

Asthma education is an important component of asthma care and management. Children and parents often do not receive asthma education, and frequently, education programs are time consuming. The purpose of this medical record review was to retrospectively determine the impact of a short, group-based, inpatient asthma self-management program on the number of children/parents who received complete asthma education before discharge. The self-management program was instituted in 2006. Participants consisted of all children admitted to a New England children's hospital from January 1, 2005, through December 31, 2006, with a primary diagnosis of asthma. Findings revealed that significantly more (p < .001) children/parents received complete asthma education before discharge in 2006 versus 2005.

Clinical pharmacy-led disease and medicine management programme for patients with COPD

AIM

The aim was to investigate the impact of a disease and medicine management programme, focusing on self-management in patients with chronic obstructive pulmonary disease (COPD).

METHODS

One hundred and seventy-three patients (mean age 67 years; 54% female) were recruited; 86 patients were randomly assigned to an intervention group and 87 to a usual care (control) group. Intervention patients received education on disease state, medications and breathing techniques. Patients were given booklets and a customized action plan (antibiotic and oral steroid to be initiated promptly by patients for exacerbations). Patients were followed up at 6 and 12 months during a scheduled visit. The St George's Respiratory Questionnaire (SGRQ), COPD Knowledge and Morisky adherence questionnaires were administered to all patients at baseline, 6 and 12 months. Outcome measures included hospital admissions, emergency department (ED) visits, health-related quality of life (HRQoL) and medication adherence.

RESULTS

Over the 12-month period in the intervention group, ED visits decreased by 50% (P= 0.02) and hospitalization by approximately 60% (P= 0.01). On the SGRQ, differences reached statistical significance on the symptom (-7.5; P= 0.04) and impact (-7.4; P= 0.03) subscales but not on the physical activity subscale. There was a significant difference between the intervention and usual care groups regarding knowledge scores (75.0 vs. 59.3; P= 0.001) and good adherence to medication (77.8% vs. 60.0%, P= 0.019). There was no significant difference regarding smoking between study groups.

CONCLUSIONS

The clinical pharmacy-led management programme can improve adherence, reduce the need for hospital care in patients with COPD and improve aspects of their HRQoL.

Discharge readiness: an integrative review focusing on discharge following pediatric hospitalization

PURPOSE

This review aims to identify factors associated with parental discharge readiness following pediatric hospitalization, with focus applicability to solid organ transplant patients.

DESIGN AND METHODS

Thirty-eight publications, including research and clinical practice papers, were identified using Cooper's methodology for conducting integrative research reviews (1982).

RESULTS

Four concepts emerged influencing discharge readiness: support, identification of unique and individual needs, education, and communication and coordination. Synthesis of themes resulted in two overarching concepts: meaningful interactions and confidence building.

PRACTICE IMPLICATIONS

Nurses have a singular opportunity to enhance meaningful interactions and confidence building, ultimately promoting a successful transition home.

Clinical pharmacy-led disease and medicine management programme for patients with COPD

AIM

The aim was to investigate the impact of a disease and medicine management programme, focusing on self-management in patients with chronic obstructive pulmonary disease (COPD).

METHODS

One hundred and seventy-three patients (mean age 67 years; 54% female) were recruited; 86 patients were randomly assigned to an intervention group and 87 to a usual care (control) group. Intervention patients received education on disease state, medications and breathing techniques. Patients were given booklets and a customized action plan (antibiotic and oral steroid to be initiated promptly by patients for exacerbations). Patients were followed up at 6 and 12 months during a scheduled visit. The St George's Respiratory Questionnaire (SGRQ), COPD Knowledge and Morisky adherence questionnaires were administered to all patients at baseline, 6 and 12 months. Outcome measures included hospital admissions, emergency department (ED) visits, health-related quality of life (HRQoL) and medication adherence.

RESULTS

Over the 12-month period in the intervention group, ED visits decreased by 50% (P= 0.02) and hospitalization by approximately 60% (P= 0.01). On the SGRQ, differences reached statistical significance on the symptom (-7.5; P= 0.04) and impact (-7.4; P= 0.03) subscales but not on the physical activity subscale. There was a significant difference between the intervention and usual care groups regarding knowledge scores (75.0 vs. 59.3; P= 0.001) and good adherence to medication (77.8% vs. 60.0%, P= 0.019). There was no significant difference regarding smoking between study groups.

CONCLUSIONS

The clinical pharmacy-led management programme can improve adherence, reduce the need for hospital care in patients with COPD and improve aspects of their HRQoL.

Small-group, interactive education and the effect on asthma control by children and their families

BACKGROUND

Effective approaches to education about asthma need to be identified. We evaluated the impact on asthma control by children and their caregivers of an intervention involving small-group, interactive education about asthma.

METHODS

We randomly assigned children who visited an emergency department for an exacerbation of asthma (n = 398) to either of 2 groups. Children assigned to the control group followed the usual care recommended by their primary care physician. Those assigned to the intervention group participated in a small-group, interactive program of education about asthma. We examined changes in the number of visits to the emergency department during the year after the intervention.

RESULTS

During the year after enrolment, children in the intervention group made significantly fewer visits to the emergency department (0.45 visits per child) compared with those in the control group (0.75 visits per child) (p = 0.004). The likelihood of a child in the intervention group requiring emergency care was reduced by 38% (relative risk [RR] 0.62, 95% confidence interval CI 0.48-0.81, p = 0.004). Fewer courses of oral corticosteroids (0.63 per child) were required by children in the intervention group than by those in the control group (0.85 per child) (p = 0.006). We observed significant improvements in the symptom domain of the questionnaire on pediatric asthma quality-of-life (p = 0.03) and the activity domain of the questionnaire on caregivers' quality of life (p = 0.05). Parents of children in the intervention group missed less work because of their child's asthma after participating in the educational program (p = 0.04). No impact on hospital admissions was observed.

INTERPRETATION

Education about asthma, especially in a small-group, interactive format, improved clinically important outcomes and overall care of children with asthma.

[Non-physician health care providers for the treatment and care of the chronically ill (focusing on DMP diagnoses)]

BACKGROUND

This systematic review will investigate the question of how non-physician health care providers may be involved in the care and treatment of patients with chronic disease and which role they could play within the scope of the German Disease Management Programmes (DMP).

METHODS

This article is limited to the German DMP diagnoses asthma, COPD, coronary heart disease, and type-1 and -2 diabetes mellitus. Several databases were systematically searched to find national and international studies with interventions carried out by non-physician health care providers such as nurses, dieticians, physiotherapists or occupational therapists.

RESULTS

More than 300 studies and reviews were included in this systematic review. Nurses and dieticians were by far the prevailing professional groups performing the largest number of the interventions identified. Transferring. the results of the literature review to the German setting, non-physician health care providers could both undertake certain tasks on their own responsibility and provide other services in support of the medical treatment of the chronically ill. Some interventions are given as examples.

Interventions for educating children who are at risk of asthma-related emergency department attendance

BACKGROUND

Asthma is the most common chronic childhood illness and is a leading cause for paediatric admission to hospital. Asthma management for children results in substantial costs. There is evidence to suggest that hospital admissions could be reduced with effective education for parents and children about asthma and its management.

OBJECTIVES

To conduct a systematic review of the literature and update the previous review as to whether asthma education leads to improved health outcomes in children who have attended the emergency room for asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group Trials Register, including the MEDLINE, EMBASE and CINAHL databases, and reference lists of trials and review articles (last search May 2008).

SELECTION CRITERIA

We included randomised controlled trials of asthma education for children who had attended the emergency department for asthma, with or without hospitalisation, within the previous 12 months.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We pooled dichotomous data with a fixed-effect risk ratio. We used a random-effects risk ratio for sensitivity analysis of heterogenous data.

MAIN RESULTS

A total of 38 studies involving 7843 children were included. Following educational intervention delivered to children, their parents or both, there was a significantly reduced risk of subsequent emergency department visits (RR 0.73, 95% CI 0.65 to 0.81, N = 3008) and hospital admissions (RR 0.79, 95% CI 0.69 to 0.92, N = 4019) compared with control. There were also fewer unscheduled doctor visits (RR 0.68, 95% CI 0.57 to 0.81, N = 1009). Very few data were available for other outcomes (FEV1, PEF, rescue medication use, quality of life or symptoms) and there was no statistically significant difference between education and control.

AUTHORS' CONCLUSIONS

Asthma education aimed at children and their carers who present to the emergency department for acute exacerbations can result in lower risk of future emergency department presentation and hospital admission. There remains uncertainty as to the long-term effect of education on other markers of asthma morbidity such as quality of life, symptoms and lung function. It remains unclear as to what type, duration and intensity of educational packages are the most effective in reducing acute care utilisation.

The role of written action plans in childhood asthma

PURPOSE OF REVIEW

The aim of this article is to examine the evidence for the effectiveness of a written action plan as an important element of guided self-management and to identify key features associated with its effectiveness in children and adolescents.

RECENT FINDINGS

Various written action plans are available for use; however, few have been specifically designed or validated for children. Strong, but limited pediatric evidence confirms that the addition of a written action plan to guided self-management education significantly improves outcome. Use of daily controller medication, with no step-up therapy other than as needed inhaled beta2-agonist, best prevents asthma exacerbations. Symptom-based appear superior to peak-flow based written action plans. The paucity of pediatric trials does not permit the identification of other keys features that enhance the dispensing of written action plans by healthcare professionals or uptake of recommendations by children, adolescents and their parents.

SUMMARY

Written action plans are effective tools to facilitate self-management. While step-up therapy is not superior to daily controller medication, symptom-based are superior to peak-flow based action plans for preventing exacerbations, other keys features associated with effectiveness have yet to be identified.

Asthma education and monitoring: what has been shown to work

Cochrane systematic reviews and meta-analyses on education and monitoring of asthmatic children have come to divergent conclusions, mainly because of the heterogeneity of education programmes and patients. There is little doubt that education is useful. However, the useful components of the education programmes remain to be elucidated, not only by randomized controlled trials but also by observational studies performed within distinct asthma phenotypes. Any education and monitoring package needs to contain basic explanation about the disease and its influencing factors, as well as inhalation instructions. There is no good evidence to justify home monitoring of lung function; symptom monitoring suffices. Probably, the crucial part of asthma education programmes is a high level of agreement between patient and doctor regarding the goals of the treatment (patient-doctor partnership). Therefore, further exploration of the patient's needs should be worthwhile.

Readiness for discharge in parents of hospitalized children

Parental preparation for a child's discharge from the hospital sets the stage for successful transitioning to care and recovery at home. In this study of 135 parents of hospitalized children, the quality of discharge teaching, particularly the nurses' skills in "delivery" of parent teaching, was associated with increased parental readiness for discharge, which was associated with less coping difficulty during the first 3 weeks postdischarge. Parental coping difficulty was predictive of greater utilization of posthospitalization health services. These results validate the role of the skilled nurse as a teacher in promoting positive outcomes at discharge and beyond the hospitalization.

Effect of an integrated care pathway on acute asthma/wheeze in children attending hospital: cluster randomized trial

OBJECTIVE

To determine whether an integrated care pathway (ICP) could improve care delivered to patients coming to an emergency department only or to patients who were subsequently admitted.

STUDY DESIGN

Children (age, 2-16 years; n = 298) coming to the ED with acute asthma/wheeze, were randomized by using a cluster design to either standard care or care delivered by an ICP.

RESULTS

Children discharged from the ED who received care with an ICP (n = 118) received more prednisolone (81%; standard, 63%; P = .03) and increased advice to obtain primary care review (72%; standard, 33%; P < .0001). A total of 180 children were admitted (94 ICP, 86 standard). The rate of recovery was unchanged by ICP. The mean ICP length of stay (37.6 hours; range, 33.5-42.4 hours), was 93% of the mean standard length of care (40.7 hours; range, 35.9-46; P = .36). When a discharge checklist was completed (60 of 94 cases), the mean ICP length of stay was 34.2 hours (range, 30.5-38.4 hours; P = .07 versus standard). An ICP resulted in a 30% reduction in prescribing errors (mean, 10.4; standard, 14.8; P = .002). Eighty-four of 94 children with an ICP received a 48-hour discharge plan (89%) versus 35 of 86 children with standard care (41%). More clinical contacts were observed in children receiving care by an ICP (mean, 22, versus standard, 19.2: P = .0004).

CONCLUSION

An acute asthma/wheeze ICP improved education and prescribing errors, modestly reduced the length of stay when discharge criteria were adhered to, but did not influence recovery time. Further consideration of the effect on staff workload is required.

[Therapeutic education in asthma management]

All guidelines, protocols and recommendations underline the importance of therapeutic education as a key element in asthma management and control. Considerable evidence supports the efficacy and effectiveness of this measure. Health personnel, as well as patients and their parents, can and should be educated with two main objectives: to achieve the best possible quality of life and to allow self control of the disease. These goals can be attained through an educational process that should be individually tailored, continuous, progressive, dynamic, and sequential. The process poses more than a few difficulties involving patients, health professionals, and the health systems. Knowledge of the various psychological factors that can be present in asthmatic patients, as well as the factors related to the highly prevalent phenomenon of non-adherence, is essential. Awareness of the factors influencing physician-patient-family communication is also highly important to achieve the objectives set in therapeutic education. The educational process helps knowledge and abilities to be acquired and allows attitudes and beliefs to be modified. Patients and caregivers should be provided with an individual written action plan based on symptoms and/or forced expiratory volume in 1 second. Periodic follow-up visits are also required.

A library-site asthma education program for inner-city communities

Asthma education programs are reportedly effective for children and adolescents. Urban and minority children continue to have poor asthma outcomes and limited access to asthma education programs. The purpose of this study was to determine whether a library-based asthma education program, the Columbus Ohio Partnership for Inner-City Asthma Education (COPICAE), offered to urban and minority children (with their parents) could improve asthma-related outcomes and reduce billing claims for asthma-related hospital visits. A prospective/observational study was conducted to evaluate asthma-related outcomes of 87 children who completed 6 hours of asthma education using telephone follow-up at 12 and 24 months with a scored Living With Asthma Survey (LWAS). Hospital billing claims for asthma as the primary diagnosis were compared over a 24-month period for 64 children who completed 6 hours of asthma education with an age and zip code match control. Two separate focus groups with Spanish-speaking and English-speaking parents who completed 6 hours of asthma education with their children obtained parental perspectives about the asthma education classes. LWAS follow-up data were obtained on 67% of the participants at year 1 and 43% at year 2. Compared to pre-intervention mean scores, there were decreases in scores to all LWAS items. Parents reported improvements in compliance with asthma medication use and overall control of their child's asthma. Parents also found the information from the asthma education classes to be "beneficial." Total asthma-related billing claims for children who completed 6 hours of asthma education decreased 63.2%, while those for age and zip code matched controls increased 0.7%. Inner-city and minority children (with their parents) who attended 6 hours of asthma education offered in a public library showed improvements in asthma-related outcomes over a 24-month period and decreased billing claims for asthma-related hospital visits. Parents found 6 hours of asthma education to be beneficial in gaining basic knowledge about asthma and improving their child's illness control and self-esteem in living with asthma.

Evaluation of a paediatric asthma education package for health professionals

AIM

To evaluate an evidence-based paediatric asthma management education package designed for health professionals with particular emphasis on formulation of written asthma action plans (AAPs) and inhalation device technique.

METHODS

A prospective cohort study was conducted involving graduate medical programme medical students and tertiary paediatric hospital junior house staff. Three case-based Microsoft Powerpoint presentations were used to highlight important aspects of asthma management including the formulation of an AAP and inhalation device technique. This was delivered in small-group sessions to medical students and as a self-directed learning exercise to junior house staff. Outcome measures were ability to write an accurate AAP, confidence and competence in using and teaching asthma devices, and knowledge of asthma.

RESULTS

Forty medical students and 14 junior house staff were recruited. Mean scores for the written AAP improved from 4.2 (out of 19) to 16.2 for medical students (mean change 12.0; 95% confidence interval (CI) 11.0-13.0; P < 0.001) and from 11.5 to 16.8 for junior doctors (mean change 5.3; 95% CI 3.5-7.2; P < 0.001). Confidence in using and teaching asthma inhalation devices also improved (P < 0.001 for students and P < 0.05 for house staff), as did asthma knowledge and skills in using the devices in the students (P < 0.001).

CONCLUSION

The education package was effective in teaching participants how to write an accurate AAP and improved their confidence and ability in demonstrating proper inhalation device technique. We believe that the package has the potential to be used more widely for either small-group or self-directed learning.