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Glick AF, Yin HS, Silva B, Modi AC, Huynh V, Goodwin EJ, Farkas JS, Turock JS, Famiglietti HS, Dickson VV. Pediatrician perspectives on barriers and facilitators to discharge instruction comprehension and adherence for parents of children with medical complexity. J Hosp Med 2024; 19:278-286. [PMID: 38445808 PMCID: PMC10987266 DOI: 10.1002/jhm.13319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/06/2024] [Accepted: 02/12/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND High rates of posthospitalization errors are observed in children with medical complexity (CMC). Poor parent comprehension of and adherence to complex discharge instructions can contribute to errors. Pediatrician views on common barriers and facilitators to parent comprehension and adherence are understudied. OBJECTIVE To examine pediatrician perspectives on barriers and facilitators experienced by parents in comprehension of and adherence to inpatient discharge instructions for CMC. DESIGN, SETTINGS, AND PARTICIPANTS We conducted a qualitative, descriptive study of attending pediatricians (n = 20) caring for CMC in inpatient settings (United States and Canada) and belonging to listservs for pediatric hospitalists/complex care providers. We used purposive/maximum variation sampling to ensure heterogeneity (e.g., hospital, region). MAIN OUTCOME AND MEASURES A multidisciplinary team designed and piloted a semistructured interview guide with pediatricians who care for CMC. Team members conducted semistructured interviews via phone or video call. Interviews were audiorecorded and transcribed. We analyzed transcripts using content analysis; codes were derived a priori from a conceptual framework (based on the Pediatric Self-Management Model) and a preliminary transcript analysis. We applied codes and identified emerging themes. RESULTS Pediatricians identified three themes as barriers and facilitators to discharge instruction comprehension and adherence: (1) regimen complexity, (2) access to the healthcare team (e.g., inpatient team, outpatient pediatrician, home nursing) and resources (e.g., medications, medical equipment), and (3) need for a family centered and health literacy-informed approach to discharge planning and education. Next steps include the assessment of parent perspectives on barriers and facilitators to discharge instruction comprehension and adherence for prents of CMC and the development of intervention strategies.
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Affiliation(s)
- Alexander F. Glick
- Department of Pediatrics, NYU Langone Health and Bellevue Hospital Center, New York, New York, USA
| | - H. Shonna Yin
- Department of Pediatrics, NYU Langone Health and Bellevue Hospital Center, New York, New York, USA
- Department of Population Health, NYU Langone Health, New York, New York, USA
| | - Benjamin Silva
- NYU Grossman School of Medicine, New York, New York, USA
| | - Avani C. Modi
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Behavioral Medicine and Clinical Psychology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Vincent Huynh
- Department of Pediatrics, NYU Langone Health and Bellevue Hospital Center, New York, New York, USA
| | - Emily J. Goodwin
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri-Kansas City School of Medicine, University of Kansas School of Medicine, Kansas City, Missouri, USA
| | - Jonathan S. Farkas
- Department of Pediatrics, NYU Langone Health and Bellevue Hospital Center, New York, New York, USA
| | - Julia S. Turock
- Department of Pediatrics, NYU Langone Health and Bellevue Hospital Center, New York, New York, USA
| | - Hannah S. Famiglietti
- Department of Pediatrics, NYU Langone Health and Bellevue Hospital Center, New York, New York, USA
| | - Victoria V. Dickson
- University of Connecticut School of Nursing, Storrs, Connecticut, USA
- NYU Rory Meyers College of Nursing, New York, New York, USA
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Char D, Gal D, Hollander S. Sharing Decisions When Withdrawing a Technology Is Not the Same as Withholding It. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:69-72. [PMID: 36332051 DOI: 10.1080/15265161.2022.2123976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
| | - Dana Gal
- Children's Hospital of Los Angeles
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4
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Current state and practice variation in the use of Meningitis/Encephalitis (ME) FilmArray panel in children. BMC Infect Dis 2022; 22:811. [PMCID: PMC9620602 DOI: 10.1186/s12879-022-07789-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 10/18/2022] [Indexed: 11/10/2022] Open
Abstract
Background The Meningitis/Encephalitis FilmArray® Panel (ME panel) was approved by the U.S. Food and Drug Administration in 2015 and provides rapid results when assessing patients with suspected meningitis or encephalitis. These patients are evaluated by various subspecialties including pediatric hospital medicine (PHM), pediatric emergency medicine (PEM), pediatric infectious diseases, and pediatric intensive care unit (PICU) physicians. The objective of this study was to evaluate the current use of the ME panel and describe the provider and subspecialty practice variation. Methods We conducted an online cross-sectional survey via the American Academy of Pediatrics Section of Hospital Medicine (AAP-SOHM) ListServe, Brown University PEM ListServe, and PICU Virtual pediatric system (VPS) Listserve. Results A total of 335 participants out of an estimated 6998 ListServe subscribers responded to the survey. 68% reported currently using the ME panel at their institutions. Among test users, most reported not having institutional guidelines on test indications (75%) or interpretation (76%). 58% of providers self-reported lack of knowledge of the test’s performance characteristics. Providers from institutions that have established guidelines reported higher knowledge compared to those that did not (51% vs. 38%; p = 0.01). More PHM providers reported awareness of ME panel performance characteristics compared to PEM physicians (48% vs. 27%; p = 0.004); confidence in test interpretation was similar between both groups (72 vs. 69%; p = 0.80). Conclusion Despite the widespread use of the ME panel, few providers report having institutional guidelines on test indications or interpretation. There is an opportunity to provide knowledge and guidance about the ME panel among various pediatric subspecialties. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07789-2.
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Brady PW. The Second Decade of Hospital Pediatrics. Hosp Pediatr 2021; 11:659-661. [PMID: 34193587 DOI: 10.1542/hpeds.2021-006035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Patrick W Brady
- Division of Hospital Medicine and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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6
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Rogers J, Reed MP, Blaine K, Manning H. Children with medical complexity: A concept analysis. Nurs Forum 2021; 56:676-683. [PMID: 33625740 DOI: 10.1111/nuf.12559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 01/01/2021] [Accepted: 01/29/2021] [Indexed: 11/27/2022]
Abstract
AIM The aim of this paper is to conduct a concept analysis on the term, "children with medical complexity." BACKGROUND Children with medical complexity (CMC) describes pediatric patients with chronic, sustained acuity; however, there is a lack of consensus in the literature regarding its exact meaning, characteristics, and implications. DESIGN This analysis relied upon the framework described by Walker and Avant. DATA SOURCE The CINAHL, MEDLINE, and PubMed databases were queried from April 2020 to December 2020 with an initial search of the literature for the keyword, "children with medical complexity" and other associated terms, such as "pediatric medical complexity" and "nursing care of children with medical complexity." REVIEW METHODS This analysis will explore the concept of CMC and its significance, attributes, antecedents, and consequences. RESULTS This investigation revealed that CMC are a growing population of pediatric patients who have one or more complex chronic conditions that affect multiple body systems, experience functional limitations, require extensive care coordination from multiple providers, and are dependent upon life-sustaining medical technology. CONCLUSIONS The findings can serve as a foundation for future work advancing the understanding of the topic of CMC.
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Affiliation(s)
- Jayne Rogers
- Medical Nursing Service, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mary P Reed
- Medical Nursing Service, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kevin Blaine
- Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Haylee Manning
- Medical Nursing Service, Boston Children's Hospital, Boston, Massachusetts, USA
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Mosquera RA, Avritscher EBC, Pedroza C, Bell CS, Samuels CL, Harris TS, Eapen JC, Yadav A, Poe M, Parlar-Chun RL, Berry J, Tyson JE. Hospital Consultation From Outpatient Clinicians for Medically Complex Children: A Randomized Clinical Trial. JAMA Pediatr 2021; 175:e205026. [PMID: 33252671 PMCID: PMC7783544 DOI: 10.1001/jamapediatrics.2020.5026] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Children with medical complexity (CMC) frequently experience fragmented care. We have demonstrated that outpatient comprehensive care (CC) reduces serious illnesses, hospitalizations, and costs for high-risk CMC. Yet continuity of care for CMC is often disrupted with emergency department (ED) visits and hospitalizations. OBJECTIVE To evaluate a hospital consultation (HC) service for CMC from their outpatient CC clinicians. DESIGN, SETTING, AND PARTICIPANTS Randomized quality improvement trial at the University of Texas Health Science Center at Houston with an outpatient CC clinic and tertiary pediatric hospital (Children's Memorial Hermann Hospital). Participants included high-risk CMC (≥2 hospitalizations or ≥1 pediatric intensive care unit [PICU] admission in the year before enrolling in our clinic) receiving CC. Data were analyzed between January 11, 2018, and December 20, 2019. INTERVENTIONS The HC included serial discussions between CC clinicians, ED physicians, and hospitalists addressing need for admission, inpatient treatment, and transition back to outpatient care. Usual hospital care (UHC) involved routine pediatric hospitalist care. MAIN OUTCOMES AND MEASURES Total hospital days (primary outcome), PICU days, hospitalizations, and health system costs in skeptical bayesian analyses (using a prior probability assuming no benefit). RESULTS From October 3, 2016, through October 2, 2017, 342 CMC were randomized to either HC (n = 167) or UHC (n = 175) before meeting the predefined bayesian stopping guideline (>80% probability of reduced hospital days). In intention-to-treat analyses, the probability that HC reduced total hospital days was 91% (2.72 vs 6.01 per child-year; bayesian rate ratio [RR], 0.61; 95% credible interval [CrI], 0.30-1.26). The probability of a reduction with HC vs UHC was 98% for hospitalizations (0.60 vs 0.93 per child-year; RR, 0.68; 95% CrI, 0.48-0.97), 89% for PICU days (0.77 vs 1.89 per child-year; RR, 0.59; 95% CrI, 0.26-1.38), and 94% for mean total health system costs ($24 928 vs $42 276 per child-year; cost ratio, 0.67; 95% CrI, 0.41-1.10). In secondary analysis using a bayesian prior centered at RR of 0.78, reflecting the opinion of 7 experts knowledgeable about CMC, the probability that HC reduced hospital days was 96%. CONCLUSIONS AND RELEVANCE Among CMC receiving comprehensive outpatient care, an HC service from outpatient clinicians likely reduced total hospital days, hospitalizations, PICU days, other outcomes, and health system costs. Additional trials of an HC service from outpatient CC clinicians are needed for CMC in other centers. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02870387.
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Affiliation(s)
- Ricardo A. Mosquera
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston,Center for Clinical Research and Evidence Based Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Elenir B. C. Avritscher
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston,Center for Clinical Research and Evidence Based Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Claudia Pedroza
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston,Center for Clinical Research and Evidence Based Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Cynthia S. Bell
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston,Center for Clinical Research and Evidence Based Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Cheryl L. Samuels
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Tomika S. Harris
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Julie C. Eapen
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Aravind Yadav
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Michelle Poe
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston,Center for Clinical Research and Evidence Based Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Raymond L. Parlar-Chun
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Jay Berry
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Jon E. Tyson
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston,Center for Clinical Research and Evidence Based Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston
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Dumas HM, Hughes ML, O'Brien JE. Children dependent on respiratory support: A 10-year review from one pediatric postacute care hospital. Pediatr Pulmonol 2020; 55:2050-2054. [PMID: 32437015 DOI: 10.1002/ppul.24861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 05/17/2020] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Pediatric postacute care hospitals (PACH) provide long-term care for children with medical complexity including children dependent on respiratory support. Descriptions of PACH respiratory care populations and outcomes, however, remain under-reported. Our aim was to describe demographics, respiratory outcome, and longitudinal trend of children with respiratory support admitted to a single PACH in the United States. METHODS Using electronic records from 2009 to 2018, data were examined for all children dependent on respiratory support. Children were identified for inclusion using respiratory level of care classifications (type of support) as outlined in hospital policy. Outcome was defined as change in level from first admission to final discharge. Number of admissions by level and year during the study timeframe were analyzed. RESULTS There were 1423 admissions for 767 children requiring respiratory support during the study timeframe. Children with higher respiratory classification level (eg, mechanical ventilation) at initial admission had more admissions to PACH (P < .001) and longer length of stays (P < .001). From first admission to final discharge, there was a significant change (reduction) in respiratory level (z = -4.588, P < .001). An increase in the overall number of admissions for children with respiratory support during the study timeframe was noted, with the largest increase for children requiring the highest level of support. CONCLUSION There has been a consistent increase in the number of children requiring respiratory support at admission to PACH. Reduction in respiratory support with postacute care occurs but children admitted with a higher level of support stay longer and experience multiple admissions.
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Affiliation(s)
- Helene M Dumas
- Medical-Rehabilitation Research Center, Franciscan Children's Hospital, Boston, Massachusetts
| | - Mary Laurette Hughes
- Medical-Rehabilitation Research Center, Franciscan Children's Hospital, Boston, Massachusetts
| | - Jane E O'Brien
- Medical-Rehabilitation Research Center, Franciscan Children's Hospital, Boston, Massachusetts
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9
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Rogozinski L, Young A, Grybauskas C, Donohue P, Boss R, Biondi E. Point Prevalence of Children Hospitalized With Chronic Critical Illness in the General Inpatient Units. Hosp Pediatr 2019; 9:545-549. [PMID: 31201203 DOI: 10.1542/hpeds.2018-0208] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Children with medical complexity (CMC) have high rates of mortality and morbidity, prolonged lengths of stay, and use a disproportionately high amount of health care expenditures. A subset of children with CMC have chronic critical illness requiring even higher levels of clinical support and resource use. We aimed to describe the point prevalence of children hospitalized in general inpatient care units with pediatric chronic critical illness (PCCI). METHODS Point prevalence analysis across 6 pediatric tertiary medical centers in the United States on a "snapshot day" (May 17, 2017). On the day of sampling, a number of demographic, historical, and clinical descriptors were collected. A previously published definition of PCCI was used to establish inclusion criteria. RESULTS The point prevalence of patients with PCCI in general inpatient care units was 41% (232 out of 571). Of these, 91% (212 out of 232) had been admitted more than once in the previous 12 months, 50% (117 out of 232) had a readmission within 30 days of a previous admission, and 20% (46 out of 232) were oncology patients. Only 1 had a designated complex care team, and there were no attending physicians designated primarily for medically complex children. CONCLUSIONS Children with chronic critical illness, a subset of CMC, may make up a substantial proportion of pediatric patients hospitalized in general inpatient care units. There is a critical need to understand how to better care for this medically fragile population. In our data, it is suggested that resources should be allocated for PCCI in nonintensive care clinical areas.
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Affiliation(s)
- Lindsay Rogozinski
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York; and
| | - Ashley Young
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York; and
| | | | - Pamela Donohue
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, Maryland
| | - Renee Boss
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, Maryland
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Shah NH, Bhansali P, Barber A, Toner K, Kahn M, MacLean M, Kadden M, Sestokas J, Agrawal D. Children With Medical Complexity: A Web-Based Multimedia Curriculum Assessing Pediatric Residents Across North America. Acad Pediatr 2018; 18:79-85. [PMID: 28843486 DOI: 10.1016/j.acap.2017.08.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 08/08/2017] [Accepted: 08/15/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE No standardized curricula exist for training residents in the special needs of children with medical complexity. We assessed resident satisfaction, knowledge, and behavior after implementing a novel online curriculum composed of multimedia modules on care of children with medical complexity utilizing virtual simulation. METHODS We conducted a randomized controlled trial of residents across North America. A Web-based curriculum of 6 self-paced, interactive, multimedia modules was developed. Readings for each topic served as the control curriculum. Residents were randomized to 1 of 2 groups, each completing 3 modules and 3 sets of readings that were mutually exclusive. Outcomes included resident scores on satisfaction, knowledge-based assessments, and virtual simulation activities. RESULTS Four hundred forty-two residents from 56 training programs enrolled in the curriculum, 229 of whom completed it and were included in the analysis. Subjects were more likely to report comfort with all topics if they reviewed modules compared to readings (P ≤ .01 for all 6 topics). Posttest knowledge scores were significantly higher than pretest scores overall (mean increase in score 17.7%; 95% confidence interval 16.0, 19.4), and the mean pre-post score increase for modules was significantly higher than readings (20.9% vs 15.4%, P < .001). Mean scores on the verbal handoff virtual simulation increased by 1.1 points (95% confidence interval 0.2, 2.0, P = .02). There were no significant differences found in pre-post performance for the device-related emergency virtual simulation. CONCLUSIONS There was high satisfaction, significant knowledge acquisition, and specific behavior change after participating in this innovative online curriculum. This is the first multisite, randomized trial assessing satisfaction, knowledge impact, and behavior change in a virtually simulated environment with pediatric trainees.
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Affiliation(s)
- Neha H Shah
- Division of Hospitalist Medicine, Children's National Medical Center, Washington, DC.
| | - Priti Bhansali
- Division of Hospitalist Medicine, Children's National Medical Center, Washington, DC
| | - Aisha Barber
- Division of Hospitalist Medicine, Children's National Medical Center, Washington, DC
| | - Keri Toner
- Pediatric Residency Program, Children's National Medical Center, Washington, DC
| | - Michael Kahn
- School of Medicine and Health Sciences, The George Washington University, Washington, DC
| | - Meaghan MacLean
- Pediatric Residency Program, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Micah Kadden
- Pediatric Residency Program, Children's National Medical Center, Washington, DC
| | - Jeffrey Sestokas
- Office of Graduate Medical Education, Children's National Medical Center, Washington, DC
| | - Dewesh Agrawal
- Pediatric Residency Program, Children's National Medical Center, Washington, DC
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White CM, Thomson JE, Statile AM, Auger KA, Unaka N, Carroll M, Tucker K, Fletcher D, Hall DE, Simmons JM, Brady PW. Development of a New Care Model for Hospitalized Children With Medical Complexity. Hosp Pediatr 2017; 7:410-414. [PMID: 28596445 DOI: 10.1542/hpeds.2016-0149] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Children with medical complexity are a rapidly growing inpatient population with frequent, lengthy, and costly hospitalizations. During hospitalization, these patients require care coordination among multiple subspecialties and their outpatient medical homes. At a large freestanding children's hospital, a new inpatient model of care was developed in an effort to consistently provide coordinated, family-centered, and efficient care. In addition to expanding the multidisciplinary team to include a pharmacist, dietician, and social worker, the team redesign included: (1) medication reconciliation rounds, (2) care coordination rounds, and (3) multidisciplinary weekly handoff with outpatient providers. During weekly medication reconciliation rounds, the team pharmacist reviews each patient's current medications with the team. In care coordination rounds, the team collaborates with unit care managers to identify discharge needs and complete discharge tasks. Finally, at the end of the week, the outgoing hospital medicine attending physician hands off patient care to the incoming attending with input from the team's pharmacist, dietician, and social worker. Families and providers noted improvements in care coordination with the new care model. Remaining challenges include balancing resident autonomy and attending supervision, as well as supporting providers in delivering care that can be emotionally challenging. Aspects of this care model could be tested and adapted at other hospitals that care for children with medical complexity. Additionally, future work should study the impact of inpatient complex care models on patient health outcomes and experience.
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Affiliation(s)
- Christine M White
- Division of Hospital Medicine, .,James M. Anderson Center for Health Systems Excellence, and.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Joanna E Thomson
- Division of Hospital Medicine.,James M. Anderson Center for Health Systems Excellence, and.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Angela M Statile
- Division of Hospital Medicine.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Katherine A Auger
- Division of Hospital Medicine.,James M. Anderson Center for Health Systems Excellence, and.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ndidi Unaka
- Division of Hospital Medicine.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Matthew Carroll
- Hospitalist Group, Cook Children's, Fort Worth, Texas.,Department of Pediatrics, Texas A&M Health Science Center College of Medicine, Fort Worth, Texas
| | - Karen Tucker
- Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Derek Fletcher
- Complex Healthcare Program, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University, Columbus, Ohio; and
| | - David E Hall
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jeffrey M Simmons
- Division of Hospital Medicine.,James M. Anderson Center for Health Systems Excellence, and.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Patrick W Brady
- Division of Hospital Medicine.,James M. Anderson Center for Health Systems Excellence, and.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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12
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Foster CC, Mangione-Smith R, Simon TD. Caring for Children with Medical Complexity: Perspectives of Primary Care Providers. J Pediatr 2017; 182:275-282.e4. [PMID: 27916424 DOI: 10.1016/j.jpeds.2016.11.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 10/12/2016] [Accepted: 11/03/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To describe typical care experiences and key barriers and facilitators to caring for children with medical complexity (CMC) from the perspective of community primary care providers (PCPs). STUDY DESIGN PCPs participating in a randomized controlled trial of a care-coordination intervention for CMC were sent a 1-time cross-sectional survey that asked PCPs to (1) describe their experiences with caring for CMC; (2) identify key barriers affecting their ability to care for CMC; and (3) prioritize facilitators enhancing their ability to provide care coordination for CMC. PCP and practice demographics also were collected. RESULTS One hundred thirteen of 155 PCPs sent the survey responded fully (completion rate = 73%). PCPs endorsed that medical characteristics such as polypharmacy (88%), multiorgan system involvement (84%), and rare/unfamiliar diagnoses (83%) negatively affected care. Caregivers with high needs (88%), limited time with patients and caregivers (81%), and having a large number of specialists involved in care (79%) were also frequently cited. Most commonly endorsed strategies to improve care coordination included more time with patients/caregivers (84%), summative action plans (83%), and facilitated communication (eg, e-mail, phone meetings) with specialists (83%). CONCLUSIONS Community PCPs prioritized more time with patients and their families, better communication with specialists, and summative action plans to improve care coordination for this vulnerable population. Although this study evaluated perceptions rather than actual performance, it provides insights to improve understanding of which barriers and facilitators ideally might be targeted first for care delivery redesign.
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Affiliation(s)
- Carolyn C Foster
- Department of Pediatrics, University of Washington, Seattle, WA; Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, WA; Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA
| | - Tamara D Simon
- Department of Pediatrics, University of Washington, Seattle, WA; Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA
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13
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Navarra AM, Schlau R, Murray M, Mosiello L, Schneider L, Jackson O, Cohen B, Saiman L, Larson EL. Assessing Nursing Care Needs of Children With Complex Medical Conditions: The Nursing-Kids Intensity of Care Survey (N-KICS). J Pediatr Nurs 2016; 31:299-310. [PMID: 26777429 PMCID: PMC4862899 DOI: 10.1016/j.pedn.2015.11.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 11/14/2015] [Accepted: 11/15/2015] [Indexed: 01/06/2023]
Abstract
UNLABELLED Recent medical advances have resulted in increased survival of children with complex medical conditions (CMC), but there are no validated methods to measure their care needs. OBJECTIVES/METHODS To design and test the Nursing-Kids Intensity of Care Survey (N-KICS) tool and describe intensity of nursing care for children with CMC. RESULTS The psychometric evaluation confirmed an acceptable standard for reliability and validity and feasibility. Intensity scores were highest for nursing care related to infection control, medication administration, nutrition, diaper changes, hygiene, neurological and respiratory support, and standing program. CONCLUSIONS Development of a psychometrically sound measure of nursing intensity will help evaluate and plan nursing care for children with CMC.
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Affiliation(s)
| | - Rona Schlau
- ArchCare at Terence Cardinal Cooke Health Care Center, New York, NY.
| | - Meghan Murray
- Columbia University School of Nursing, New York, NY.
| | - Linda Mosiello
- Sunshine Children's Home and Rehabilitative Center, Ossining, NY.
| | - Laura Schneider
- Sunshine Children's Home and Rehabilitative Center, Ossining, NY.
| | | | - Bevin Cohen
- Center for Interdisciplinary Research to Prevent Infections (CIRI), Columbia University School of Nursing, New York, NY.
| | - Lisa Saiman
- Columbia University Medical Center, Division of Pediatric Infectious Diseases, New York, NY.
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Shah NH, Anspacher M, Davis A, Bhansali P. Development of a Curriculum on the Child With Medical Complexity: Filling a Gap When Few Practice Guidelines Exist. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2015; 35:278-283. [PMID: 26953859 DOI: 10.1097/ceh.0000000000000001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Pediatric hospitalists are increasingly involved in the clinical management of children with medical complexity (CMC), specifically those with neurologic impairment and technology dependence. Clinical care guidelines and educational resources on management of the diseases and devices prevalent in CMC are scarce. The objective of this study was to develop and evaluate a web-based curriculum on care of CMC for hospitalists at our institution using a novel approach to validate educational content. METHODS Junior faculty collaborated with senior hospitalist peer mentors to create multimedia learning modules on highly-desired topics as determined by needs assessment. Module authors were encouraged to work with subspecialty experts from within the institution and to submit their modules for external peer review. Pilot study participants were asked to complete all modules, associated knowledge tests, and evaluations over a 4-month period. RESULTS Sixteen of 33 eligible hospitalists completed the curriculum and associated assessments. High scores with respect to satisfaction were seen across all modules. There was a significant increase in posttest knowledge scores (P < 0.001) with sustained retention at 6 months posttest (P < 0.013). Participants were most likely to make changes to their teaching and clinical practice based on participation in this curriculum. CONCLUSIONS We used a novel approach for content development in this curriculum that incorporated consultation with experts and external peer review, resulting in improved knowledge, high satisfaction, and behavior change. Our approach may be a useful method to improve content validity for educational resources on topics that do not have established clinical care guidelines.
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Affiliation(s)
- Neha H Shah
- Drs. Shah, Anspacher, Davis, and Bhansali: Assistant Professors of Pediatrics, Division of Hospitalist Medicine, Children's National Medical Center and The George Washington University School of Medicine, Washington DC
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Jurgens V, Spaeder MC, Pavuluri P, Waldman Z. Hospital readmission in children with complex chronic conditions discharged from subacute care. Hosp Pediatr 2014; 4:153-8. [PMID: 24785559 DOI: 10.1542/hpeds.2013-0094] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Children with complex chronic conditions (CCC) are responsible for a disproportionate number of hospital readmissions. This study sought to determine 30-day hospital readmission rates in children with CCC discharged from a rehabilitation and transitional care hospital and to identify factors associated with increased risk of readmission. METHODS We conducted a retrospective cohort study identifying children with CCC discharged over an 18-month period from a subacute care facility staffed by hospitalists from a freestanding children's hospital. The primary outcome measure was readmission to the referring acute care hospital within 30 days of the subacute discharge. RESULTS Of the 272 discharged patients meeting inclusion criteria as children with at least 1 CCC, 19% had at least 1 readmission within 30 days of discharge. On univariate analysis, readmission was associated with the number of home medications (P = .001), underlying chronic respiratory illness (P < .001), home apnea or pulse oximetry monitor use (P = .02), tracheostomy and/or ventilator dependence (P = .003), length of stay (P = .04), and number of follow-up appointments (P = .02). On multivariate analysis, the number of discharge medications was associated with increased odds of readmission (odds ratio: 1.11 [95% confidence interval: 1.03-1.20]; P = .01). Receiver operating curve analysis identified a cutoff of 8 medications as most associated with readmission; in patients discharged with ≥8 medications, the hospital readmission rate was 29%. CONCLUSIONS This is the first known study that investigated hospital readmission rates in children with CCC discharged from a subacute facility and specifically identified the number of discharge medications as a significant risk factor for readmission.
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