Issues Identified by Postdischarge Contact after Pediatric Hospitalization: A Multisite Study

Essential elements nurses have to address to promote a safe discharge in paediatrics: A systematic review and narrative synthesis

AIM

The aim of the study was to synthesize the evidence on the essential elements, nurses must address when they perform therapeutic education to patients and their caregivers to promote a safe paediatric hospital-to-home discharge.

DESIGN

A systematic review and narrative synthesis.

METHODS

The search strategy identifies studies published between 2016 and 2023. The quality of the included studies was assessed using the Critical Appraisal Skills Programme checklists. The protocol of this review was not registered. A search of three electronic databases (PubMed, CINAHL and Web of Science) and a search in the reference lists of the included studies was conducted in February 2021 and June 2023.

RESULTS

Fifteen studies met the inclusion criteria. The essential elements identified are grouped into the following topics: emergency management, physiological needs, medical device and medications management, long-term management and short-term management. Nurses have a critical role in ensuring patient safety and quality of care, and the nurses' competence makes the difference in the discharge's related outcomes. Our results can help the nursing profession implement comprehensive discharge projects. Our results support the improvement of nurse-led paediatric discharge programmes. Nurse managers can identify the grey areas of therapeutic education provided in their units and work for their improvement. Following the implementation of therapeutic education on these topics, measuring the discharge's related outcomes could be interesting. This study addresses the problem of managing a safe and efficient nurse-led discharge in a paediatric setting. It presents evidence on the essential elements to promote a safe paediatric discharge at home. These could impact nursing practice by using them to implement project and discharge pathways. We have adhered to relevant EQUATOR guidelines-PRISMA guidelines for reporting systematic review. No patients, service users, caregivers or public members were involved in this study due to its nature (systematic review).

Reduced Postdischarge Incidents After Implementation of a Hospital-to-Home Transition Intervention for Children With Medical Complexity

OBJECTIVES

Prior research suggests that errors occur frequently for patients with medical complexity during the hospital-to-home transition. Less is known about effective postdischarge communication strategies for this population. We aimed to assess rates of 30-day (1) postdischarge incidents and (2) readmissions and emergency department (ED) visits before and after implementing a hospital-to-home intervention.

METHODS

We conducted a prospective intervention study of children with medical complexity discharged at a children's hospital from April 2018 to March 2020. A multistakeholder team developed a bundled intervention incorporating the I-PASS handoff framework including a postdischarge telephone call, restructured discharge summary, and handoff communication to outpatient providers. The primary outcome measure was rate of postdischarge incidents collected via electronic medical record review and family surveys. Secondary outcomes were 30-day readmissions and ED visits.

RESULTS

There were 199 total incidents and the most common were medication related (60%), equipment issues (15%), and delays in scheduling/provision of services (11%). The I-PASS intervention was associated with a 36.4% decrease in the rate of incidents per discharge (1.51 versus 0.95, P = 0.003). There were fewer nonharmful errors and quality issues after intervention (1.27 versus 0.85 per discharge, P = 0.02). The 30-day ED visit rate was significantly lower after intervention (12.6% versus 3.4%, per 100 discharges, P = 0.05). Thirty-day readmissions were 15.8% versus 10.2% postintervention (P = 0.32).

CONCLUSIONS

A postdischarge communication intervention for patients with medical complexity was associated with fewer postdischarge incidents and reduced 30-day ED visits. Standardized postdischarge communication may play an important role in improving quality and safety in the transition from hospital-to-home for vulnerable populations.

Parents' Adherence to Follow-up Testing Instructions Following Hospital Discharge

The adherence to follow-up testing instructions post-hospitalization is influenced by a variety of factors. Our aim was to assess the parental adherence to follow-up instructions and identify the factors that influence it. Parents of 200 children were asked about their adherence with these instructions; responses were obtained from 184 of 200. Parents did not adhere in 20 of 194 (10.9%) of cases. Families of infants under 12 months and children older than 10 years had lower adherence rates. Test completion was more frequent for children discharged with a test appointment compared with those discharged without an appointment (96% vs 86.6%; P = .07). The main reasons for non-adherence were disagreement as to the value of the testing (45%) or parental misunderstanding (30%). In conclusion, in order to increase adherence with post-hospitalization follow-up testing, physicians should focus on explaining the need and importance of the test and schedule an appointment prior to discharge.

Implementing a Post-Discharge Telemedicine Service Pilot to Enhance the Hospital to Home Transition

OBJECTIVES

The objectives of this study are to (1) describe our postdischarge telemedicine program and (2) evaluate program implementation.

METHODS

At our single-center tertiary care children's hospital, we launched our postdischarge telemedicine program in April 2020. We used the Template for Intervention Description and Replication framework to describe our pilot program and Proctor's conceptual framework to evaluate implementation over a 9-month period. Retrospective chart review was conducted. Descriptive analyses were used to compare demographics and health care reutilization rates across patients. Implementation outcomes included adoption (rate of scheduled visits) and feasibility (rate of completed visits). Effectiveness outcomes included the rate of postdischarge issues and unscheduled healthcare utilization.

RESULTS

We established a postdischarge telemedicine program for a general pediatric population that ensured follow-up at a time when in-person evaluation was limited because of the coronavirus disease 2019 pandemic. For implementation evaluation, we included all 107 patients in the pilot program. Adoption was 100% and feasibility was 58%. Eighty-two percent of patients completing a visit reported one or more postdischarge issues. There was no difference in health system reutilization between those who completed a visit and those who did not.

CONCLUSIONS

Implementation of a postdischarge telemedicine service is achievable and promotes early detection of failures in the hospital to home transition. Directions for future study will include rigorous program evaluation via telemedicine program assessment tools and sustainability efforts that build upon known implementation and health service outcomes.

Drug-related risk of hospital readmission in children with chronic diseases, a systematic review

BACKGROUND

Drug-related problems (DRPs) are one of the leading causes of hospital readmissions. Children with chronic diseases are more likely to experience DRPs than adults. The burden and characteristics of drug-related readmissions at and after hospital discharge in children remain unclear.

OBJECTIVE

We aimed to summarize the impact of DRPs at and after hospital discharge on the risk of readmissions in children with chronic diseases.

METHODS

We conducted a systematic review searching PubMed from inception until January 2022. Study selection criteria were studies assessing the impact of different factors at discharge and after discharge on the risk of hospital readmissions in children with chronic diseases, reporting an assessment of DRPs. DRP could be the only risk factor assessed or one among others. Included studies were assessed with the Risk of Bias in Non-Randomized Studies - of Exposure (ROBINS-E) tool. We summarized the qualitative impact of the reported DRPs on hospital readmission as conclusive (significant association) or inconclusive.

RESULTS

Of the 4734 studies initially identified, 13 met inclusion criteria. Eleven studies were retrospective, using electronic health records. The studies assessed the impact of DRPs at or after discharge according to the type of medication (in 6 studies), number of medication (in 5 studies) and medication nonadherence (in 2 studies). From the 44 reported associations between DRPs and the risk of readmission 26 (59% [95% CI, 43%-73%]) were conclusive, of which 81% increased the risk and 19% decreased the risk, and 17 (39% [95% CI, 24%-55%]) were inconclusive.

CONCLUSION

The impact of DRPs on hospital readmissions in children with chronic diseases displayed conflicting results, estimated associations having potentially a serious risk of bias. We need more evidence with a lower risk of bias.

One Call Away: Addressing a Safety Gap for Urgent Issues Post Discharge

OBJECTIVES

The transition period from hospitalization to outpatient care can be high risk for pediatric patients. Our aim was to profile the use of a "safety net" for families through provision of specific inpatient provider contact information for urgent issues post discharge.

METHODS

In this prospective study, we implemented an updated after-visit summary that directed families to call the hospital operator and specifically ask for the pediatric hospital medicine attending on call if they were unable to reach their primary care provider (PCP) with an urgent postdischarge concern. Education for nursing staff, operators, and pediatric hospital medicine providers was completed, and contact information was automatically populated into the after-visit summary. Information collected included the number of calls, the topic, time spent, whether the family contacted the PCP first, and the time of day. Descriptive statistics and Fisher's exact test were used to summarize findings.

RESULTS

Over a 13-month period, of 5145 discharges, there were 47 postdischarge phone calls, which averaged to 3.6 calls per month. The average length of time spent on a call was 21 minutes. For 30% of calls, families had tried contacting their PCPs first, and 55% of calls occurred at night. Topics of calls included requesting advice about symptoms, time line for reevaluation, and assistance with medications.

CONCLUSIONS

This safety net provided families with real-time problem-solving for an urgent need post discharge, which included triaging patient symptoms at home, counseling on medication questions, information about the time line of illness recovery, and provision of additional resources.

Patient Safety in Ambulatory Pediatrics

Purpose of Review

The majority of patient care occurs in the ambulatory setting, and pediatric patients are at high risk of medical error and harm. Prior studies have described various safety threats in ambulatory pediatrics, and little is known about effective strategies to minimize error. The purpose of this review is to identify best practices for optimizing safety in ambulatory pediatrics.

Recent Findings

The majority of the patient safety literature in ambulatory pediatrics describes frequencies and types of medical errors. Study of effective interventions to reduce error, and particularly to reduce harm, have been limited. There is evidence that medical complexity and social context are important modifiers of risk. Telemedicine has emerged as a care delivery model with potential to ameliorate and exacerbate safety threats. Though there is variation across studies, developing a safety culture, partnerships with patients and families, and use of structured communication are strategies that support patient safety.

Summary

There is no standardized taxonomy for errors in ambulatory pediatrics, but errors related to medications, vaccines, diagnosis, and care coordination and care transitions are commonly described. Evidence-based approaches to optimize safety include standardized prescribing and medication reconciliation practices, appropriate use of decision support tools in the electronic health record, and communication strategies like teach-back. Further high-quality intervention studies in pediatric ambulatory care that assess impact on patient harm and clinical outcomes should be prioritized.

A Quality Improvement Intervention Bundle to Reduce 30-Day Pediatric Readmissions

Supplemental Digital Content is available in the text.

Introduction:

Pediatric hospital readmissions can represent gaps in care quality between discharge and follow-up, including social factors not typically addressed by hospitals. This study aimed to reduce the 30-day pediatric readmission rate on 2 general pediatric services through an intervention to enhance care spanning the hospital stay, discharge, and follow-up process.

Methods:

A multidisciplinary team developed an intervention bundle based on a needs assessment and evidence-based models of transitional care. The intervention included pre-discharge planning with a transition coordinator, screening and intervention for adverse social determinants of health (SDH), medication reconciliation after discharge, communication with the primary care provider, access to a hospital-based transition clinic, and access to a 24-hour direct telephone line staffed by hospital attending pediatricians. These were implemented sequentially from October 2013 to February 2017. The primary outcome was the readmission rate within 30 days of index discharge. The length of stay was a balancing measure.

Results:

During the intervention, the included services discharged 4,853 children. The pre-implementation readmission rate of 10.3% declined to 7.4% and remained stable during a 4-month post-intervention observation period. Among 1,394 families screened for adverse SDH, 48% reported and received assistance with ≥ 1 concern. The length of stay increased from 4.10 days in 2013 to 4.30 days in 2017.

Conclusions:

An intervention bundle, including SDH, was associated with a sustained reduction in readmission rates to 2 general pediatric services. Transitional care that addresses multiple domains of family need during a child’s health crisis can help reduce pediatric readmissions.

Validation of a Parent-Reported Hospital-to-Home Transition Experience Measure

OBJECTIVES

The Pediatric Transition Experience Measure (P-TEM) is an 8-item, parent-reported measure that globally assesses hospital-to-home transition quality from discharge through follow-up. Our goal was to examine the convergent validity of the P-TEM with existing, validated process and outcome measures of pediatric hospital-to-home transitions.

METHODS

This was a prospective, cohort study of English-speaking parents and legal guardians who completed the P-TEM after their children's discharge from a tertiary children's hospital between January 2016 and October 2016. By using data from 3 surveys, we assessed convergent validity by examining associations between total and domain-specific P-TEM scores (0-100 scale) and 4 pediatric hospital-to-home transition validation measures: (1) Child Hospital Consumer Assessment of Healthcare Providers and Systems Discharge Composite, (2) Center of Excellence on Quality of Care Measures for Children With Complex Needs parent-reported transition measures, (3) change in health-related quality of life from admission to postdischarge, and (4) 30-day emergency department revisits or readmissions.

RESULTS

P-TEM total scores were 7.5 points (95% confidence interval: 4.6 to 10.4) higher for participants with top-box responses on the Child Hospital Consumer Assessment of Healthcare Providers and Systems Discharge Composite compared with those of participants with lower Discharge Composite scores. Participants with highet P-TEM scores (ie, top-box responses) had 6.3-points-greater improvement (95% confidence interval: 2.8 to 9.8) in health-related quality of life compared with participants who reported lower P-TEM scores. P-TEM scores were not significantly associated with 7- or 30-day reuse.

CONCLUSIONS

The P-TEM demonstrated convergent validity with existing hospital-to-home process and outcome validation measures in a population of hospitalized children.

Visiting Jack: Mixed Methods Evaluation of a Virtual Home Visit Curriculum With a Child With Medical Complexity

BACKGROUND

There are limited training opportunities for pediatricians in caring for children with medical complexity (CMC) in the home and community. Prior studies have described a lack of comfort caring for CMC among pediatric residents.

OBJECTIVE

1) To evaluate the impact of participation in a virtual home visit curriculum on pediatric residents' confidence, knowledge, and application of knowledge in complex care; 2) to explore changes in perspectives relating to the care of CMC after participation in the curriculum.

METHODS

This was a prospective pre-post intervention study in 2019 with first-year pediatric residents, using quantitative and qualitative methods. The intervention, co-created with a family partner, was an online video-based curriculum followed by an in-person seminar. Pre- and postassessments were compared using paired t tests. Follow-up interviews and focus groups were performed 5 to 8 weeks after training. Transcripts were analyzed using inductive thematic analysis.

RESULTS

Twenty-four residents (100%) participated. Residents reported increased confidence in all aspects of complex care presented in the curriculum, with significant increase in knowledge and application of knowledge (all P < .001). Twelve residents (50%) participated in a follow-up interview or focus group. Four themes were identified: 1) recognizing prior attitudes toward complexity, 2) new mental framework for complex care at home, 3) drivers of behavior change, and 4) commitment to change practice.

CONCLUSIONS

Participation in this curriculum was associated with increased confidence, knowledge, and application of knowledge in complex care outside of the hospital. Qualitative findings align with transformative learning theory, lending insight into effective approaches to complex care training.

Parents Support Teach-back, Demonstration, and a Postdischarge Phone Call to Augment Discharge Education

OBJECTIVES

To identify caregiver preferences for discharge education components, content, and techniques.

METHODS

Before discharge education, a 9-question structured interview was performed with caregivers of children from 2 populations admitted to the hospital medicine service: patients with asthma (age 2-17 years) or children who were not dependent on technology (age <2 years). McNemar's tests were used to evaluate for significant differences between response options. Open coding was used for theme development to interpret qualitative responses about information caregivers wished to receive before leaving the hospital.

RESULTS

The interview was administered to 100 caregivers. More than 90% of caregivers believed that instruction regarding follow-up appointments, medications, and reasons to call the pediatrician or return to the emergency department were important aspects of discharge education. Caregivers also identified a desire for education on their child's condition, care at home, and illness prevention. Most caregivers reported that teach-back, early discharge education, and a postdischarge phone call would be beneficial. Caregivers varied in their preferences for written, verbal, and video instruction, whereas live demonstration was rated almost universally as an effective method by 97% of caregivers (P < .0001).

CONCLUSIONS

In our study, we provide insight into caregivers' perspectives on the content, timing, and style of education needed to promote a safe transition of care from the hospital to the home. These findings add caregiver support to the expert consensus in Project Improving Pediatric Patient-Centered Care Transitions and elucidate additional themes to aid in further study and optimization of discharge education.