Development of a New Care Model for Hospitalized Children With Medical Complexity

A Snapshot of Chronic Critical Illness in Pediatric Intensive Care Units

Children with chronic critical illness (CCI) represent the sickest subgroup of children with medical complexity. In this article, we applied a proposed definition of pediatric CCI to assess point prevalence in medical, cardiovascular, and combined pediatric intensive care units (PICUs), screening all patients admitted to six academic medical centers in the United States on May 17, 2017, for pediatric CCI (PCCI) eligibility. We gathered descriptive data to understand medical complexity and resource needs of children with PCCI in PICUs including data regarding hospitalization characteristics, previous admissions, medical technology, and chronic multiorgan dysfunction. Descriptive statistics were used to characterize the study population and hospital data. The study cohort was divided between PICU-prolonged (stay > 14 days) and PICU-exposed (any time in PICU); comparative analyses were conducted. On the study day, 185 children met inclusion criteria, 66 (36%) PICU-prolonged and 119 (64%) PICU-exposed. Nearly all had home medical technology and most ( n  = 152; 82%) required mechanical ventilation in the PICU. The PICU-exposed cohort mirrored the PICU-prolonged with a few exceptions as follows: they were older, had fewer procedures and surgeries, and had more recurrent hospitalizations. Most ( n  = 44; 66%) of the PICU-prolonged cohort had never been discharged home. Children with PCCI were a sizable proportion of the unit census on the study day. We found that children with PCCI are a prevalent population in PICUs. Dividing the cohorts between PICU-prolonged and PICU-exposed helps to better understand the care needs of the PCCI population. Identifying and studying PCCI, including variables relevant to PICU-prolonged and PICU-exposed, could inform changes to PICU care models and training programs to better enable PICUs to meet their unique needs.

Care Models and Discharge Services for Children With Medical Complexity

BACKGROUND AND OBJECTIVES

Children with medical complexity (CMC) are high health care utilizers prompting hospitals to implement care models focused on this population, yet practices have not been evaluated on a national level. Our objective with this study is to describe the presence and structure of care models and the use of discharge services for CMC admitted to freestanding children's hospitals across the nation.

METHODS

We distributed an electronic survey to 48 hospitals within the Pediatric Health Information System exploring the availability of care models and discharge services for CMC. Care models were grouped by type and number present at each institution. Discharge services were grouped by low (never, rarely), medium (sometimes), and high (most of the time, always) frequency use.

RESULTS

Of 48 eligible hospitals, 33 completed the survey (69%). There were no significant differences between responders and non-responders for both hospital and patient characteristics. Most participants identified an outpatient care model (67%), whereas 21% had no dedicated care model for CMC in the inpatient or outpatient setting. High-frequency discharge services included durable medical equipment delivery, medication delivery, and communication with outpatient provider before discharge. Low-frequency discharge services included the use of a structured handoff tool for outpatient communication, personalized access plans, inpatient team follow-up with family after discharge, and the use of discharge checklists.

CONCLUSIONS

Children's hospitals vary largely in care model structure and discharge services. Future work is needed to evaluate the associations between care models and discharge services for CMC with various health care outcomes.

Medication Rounds: A Tool to Promote Medication Safety for Children with Medical Complexity

Children with medical complexity (CMC) often have lengthy medication lists and are at risk of experiencing suboptimal medication management. This tool tutorial describes a novel and pragmatic strategy for the development and implementation of medication rounds, a model that promotes medication safety for hospitalized CMC. An interprofessional group designed and implemented a pharmacy-led medication rounding care model, in which clinicians and pharmacists partner weekly to conduct reviews of all patient medications on a general pediatrics CMC team using a comprehensive checklist. This approach fosters medication safety for hospitalized CMC and could be adapted to other complex inpatient populations.

Feasibility of Post-hospitalization Telemedicine Video Visits for Children With Medical Complexity

OBJECTIVES

To evaluate feasibility and acceptability of post-hospitalization telemedicine video visits (TMVV) during hospital-to-home transitions for children with medical complexity (CMC); and explore associations with hospital utilization, caregiver self-efficacy (CSE), and family self-management (FSM).

METHOD

This non-randomized pilot study assigned CMC (n=28) to weekly TMVV for four weeks post-hospitalization; control CMC (n=20) received usual care without telemedicine. Feasibility was measured by time to connection and proportion of TMVV completed; acceptability was measured by parent-reported surveys. Pre/post-discharge changes in CSE, FSM, and hospital utilization were assessed.

RESULTS

64 TMVV were completed; 82 % of patients completed 1 TMVV; 54 % completed four TMVV. Median time to TMVV connection was 1 minute (IQR=2.5). Parents reported high acceptability of TMVV (mean 6.42; 1 -7 scale). CSE and FSM pre/post-discharge were similar for both groups; utilization declined in both groups post-discharge.

DISCUSSION

Post-hospitalization TMVV for CMC were feasible and acceptable during hospital-to-home transitions.

A scoping review to inform care coordination strategies for youth with traumatic brain injuries: Care coordination personnel

Introduction & Importance:

Effective, patient-centered care coordination has been shown to improve outcomes for children with special healthcare needs (CSHCN), who often have complex, long-term involvement with multiple service providers. Traumatic brain injury (TBI) can result in long-term physical, intellectual, social, and emotional disabilities that persist long after acute treatment. Yet, even though it is a chronic condition, TBI remains an area with scarce standardization and research surrounding the complex, long-term care coordination need in this population. The purpose of this scoping review is to summarize current research on outcomes in CSHCN after implementation of care coordinators, whether individual or teams, to inform future research for youth with TBI.

Methods:

OVID/Medline, CINAHL, PsycINFO, EMBASE, and ERIC databases were searched for articles relevant to care coordination and CSHCN.

Results:

31 articles met inclusion criteria. Outcomes for children and families were grouped into 5 major categories: healthcare utilization, cost of care, disease status, parent and child quality of life, and healthcare satisfaction and perception of care.

Discussion:

Implementation of care coordinators, whether in the form of individuals, dyads, or teams, resulted in overall positive outcomes for CSHCN and their families across all 5 major outcome domains. Future research should be focused on the efficacy of care coordinators differing in profession, qualifications, and educational attainment specifically for the unique needs of children with TBI. Additionally, the application of care coordination within medical homes should be further investigated to increase proactive, preventative care of children with TBI and further reduce reactive, need-based treatment only.

Comparing subspecialty and intensive care providers perspectives on pediatric complex chronic patients: A survey study

Introduction

Pediatric complex chronic care patients present unique challenges regarding healthcare provision: complex medical regimes, complicated family/provider dynamics, and multiple healthcare teams that can result in inconsistent care. This study examined subspecialty providers’ perspectives regarding pediatric complex chronic care patients and compared them with acute care providers while exploring opportunities to better facilitate care provided to pediatric complex chronic care patients.

Methods

This survey study occurring within a Canadian tertiary care pediatric center, utilized REDCap to deploy surveys involving Likert Scale and short answer questions. The Kruskal–Wallis test compared subspecialty provider perspectives when providing care to pediatric complex chronic care patients versus non-pediatric complex chronic care patients; and perspectives between subspecialty and acute care providers.

Results

Survey response rate was 24/46 (52.2%). Eight overarching themes emerged from Likert scale questions. Short answer questions revealed factors that may facilitate care provided to pediatric complex chronic care patients: access to funding; discharge planning; communication methods between specialists; and healthcare provider continuity. Several differences were identified when working with pediatric complex chronic care patients, compared to non-pediatric complex chronic care patients: increased time/resource burden; managing expectations of patients/families; navigating discrepancies in goals of care; complexity of coordination between services; increased efforts in coordinating discharge from hospital and working with medicalized patients/families.

Discussion

Exploring pediatric subspecialty provider perspectives of pediatric complex chronic care patients revealed opportunities to enhance care provided: increased resources to ease the strain of care provision for parents, implementation of a discharge coordinator, complex care clinics with a pediatrician to “quarterback” care, and co-management between the complex care pediatrician and acute care physician when admitted to an acute care service. Implementation of these initiatives may improve the care provided to pediatric complex chronic care patients.

The Goldilocks problem: Healthcare delivery models for children with medical complexity

Health systems have increasingly adapted elements of the medical home model in designing complex care programs for children with medical complexity (CMC). In recent years, several key complex care program designs have emerged. These programs have been shown to be effective in improving the quality and cost of care for CMC. In designing and implementing a complex care model, there are many variables a health system must consider to ensure program viability. To address CMC across the continuum of care, tertiary care systems should implement a portfolio of complex care models to accommodate the population's diverse needs. Further study is needed to establish 'gold standards' for complex care delivery models, but a major factor affecting program innovation is reimbursement, as the fee for service model does not adequately support the enhanced services required to ensure high value, high quality care for CMC. It is thus critical that stakeholders from health systems and payers align to engage in innovation in complex care delivery design and implementation. Without this partnership, advances in care delivery for CMC will be limited.

The association between first-time accreditation and the delivery of recommended care: a before and after study in the Faroe Islands

Background

Significant resources are spent on hospital accreditation worldwide. However, documentation of the effects of accreditation on processes, quality of care and outcomes in healthcare remain scarce. This study aimed to examine changes in the delivery of patient care in accordance with clinical guidelines (recommended care) after first-time accreditation in a care setting not previously exposed to systematic quality improvement initiatives.

Methods

We conducted a before and after study based on medical record reviews in connection with introducing first-time accreditation. We included patients with stroke/transient ischemic attack, bleeding gastric ulcer, diabetes, chronic obstructive pulmonary disease (COPD), childbirth, heart failure and hip fracture treated at public, non-psychiatric Faroese hospitals during 2012–2013 (before accreditation) or 2017–2018 (after accreditation). The intervention was the implementation of a modified second version of The Danish Healthcare Quality Program (DDKM) from 2014 to 2016 including an on-site accreditation survey in the Faroese hospitals. Recommended care was assessed using 63 disease specific patient level process performance measures in seven clinical conditions. We calculated the fulfillment and changes in the opportunity-based composite score and the all-or-none score.

Results

We included 867 patient pathways (536 before and 331 after). After accreditation, the total opportunity-based composite score was marginally higher though the change did not reach statistical significance (adjusted percentage point difference (%): 4.4%; 95% CI: − 0.7 to 9.6). At disease level, patients with stroke/transient ischemic attack, bleeding gastric ulcer, COPD and childbirth received a higher proportion of recommended care after accreditation. No difference was found for heart failure and diabetes. Hip fracture received less recommended care after accreditation. The total all-or-none score, which is the probability of a patient receiving all recommended care, was significantly higher after accreditation (adjusted relative risk (RR): 2.32; 95% CI: 2.03 to 2.67). The improvement was particularly strong for patients with COPD (RR: 16.22; 95% CI: 14.54 to 18.10).

Conclusion

Hospitals were in general more likely to provide recommended care after first-time accreditation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06952-w.

Differential Impact of Home Nurse Contact After Discharge by Financial Strain, Primary Care Access, and Medical Complexity

BACKGROUND

The Hospital to Home Outcomes (H2O) trials examined the effectiveness of postdischarge nurse support on reuse after pediatric discharge. Unexpectedly, children randomly assigned to a nurse visit had higher rates of reuse than those in the control group. Participants in randomized control trials are heterogeneous. Thus, it is possible that the effect of the intervention differed across subgroups (ie, heterogeneity of treatment effect [HTE]). We sought to determine if different subgroups responded differently to the interventions.

METHODS

The H2O trial is a randomized controlled trial comparing standard hospital discharge processes with a nurse home visit within 96 hours of discharge. The second trial, H2O II, was similar, except the tested intervention was a postdischarge nurse phone call. For the purposes of the HTE analyses, we examined our primary trial outcome measure: a composite of unplanned 30-day acute health care reuse (unplanned readmission or emergency department or urgent care visit). We identified subgroups of interest before the trials related to (1) financial strain, (2) primary care access, (3) insurance, and (4) medical complexity. We used logistic regression modeling with an interaction term between subgroup and treatment group (intervention or control).

RESULTS

For the phone call trial (H2O II), financial strain significantly modified the effect of the intervention such that the subgroup of children with high financial strain who received the intervention experienced more reuse than their control counterparts.

CONCLUSIONS

In HTE analyses of 2 randomized controlled trials, only financial strain significantly modified the nurse phone call. A family's financial resources may affect the utility of postdischarge support.

Stakeholder perspectives: Communication, care coordination, and transitions in care for children with medical complexity

PURPOSE

The purpose of this study was to obtain feedback on communication, care coordination, and transitions in care for hospitalized children with medical complexity (CMC).

DESIGN AND METHODS

This descriptive, mixed-methods study used online surveys with forced-choice and open-ended questions to obtain stakeholder feedback. Stakeholders included parents, healthcare providers, and nurses. Participants over 18 years of age were recruited from a Midwest children's hospital inpatient unit dedicated to care of CMC. Quantitative data were analyzed using t-tests and one-way analysis of variance. Qualitative description was used to analyze responses to open-ended questions.

RESULTS

Parents' ratings of communication, care coordination, and transitions in care were generally high. Transitions from other facilities to the emergency department and unit received lower ratings. Providers and nurses gave high ratings to overall care, communication among providers and nurses on the patient unit, and experiences with discharge; however, between unit communication and unit-based coordination received lower ratings. Providers and nurses had higher ratings for discharge preparation than parents (p ≤ .001). Three themes were identified in responses to the open-ended questions: establishing balanced and collaborative relationships between the care team and families, taking a proactive approach to care coordination, and the importance of an inclusive, interdisciplinary, and centralized approach to care coordination and communication.

PRACTICE IMPLICATIONS

Collaboration among all stakeholders is needed to achieve coordinated care, inclusive communication, and transitions with positive outcomes during hospitalization. Parents identified a need for consistent communication from care teams, with the primary inpatient team taking a lead role. Including parents in care coordination and transitions in care is key, as they are the experts in their children's health and well-being.

The Parent Role in Advocating for a Deteriorating Child: A Qualitative Study

BACKGROUND AND OBJECTIVES

Families of children with medical complexity are experts on their child's baseline behavior and temperament and may recognize changes in their hospitalized child's health before clinicians. Our objective was to develop a comprehensive understanding of how families identify and communicate their child's deteriorating health with the hospital-based health care team.

METHODS

In this qualitative study, our multidisciplinary team recruited family members of hospitalized children with neurologic impairment. Interviews, conducted in the hospital, were audio recorded, deidentified, and transcribed. By using inductive thematic analysis, each transcript was independently coded by 3 or 4 team members. Members met regularly to reach consensus on coding decisions. Patterns observed were organized into themes and subthemes.

RESULTS

Participants included 28 family members of 26 hospitalized children 9 months to 17 years of age. Children had a mean of 9 hospitalizations in the previous 3 years. Analysis resulted in 6 themes. First, families often reported their child "writes his own book," meaning the child's illness narrative rarely conformed to textbooks. Second, families developed informal, learned pathways to navigate the inpatient system. Third, families stressed the importance of advocacy. Fourth, families self-identified as "not your typical parents" and discussed how they learned their roles as part of the care team. Fifth, medical culture often did not support partnership. Finally, families noted they are often "running on empty" from stress, fear, and lack of sleep.

CONCLUSIONS

Families of children with medical complexity employ mature, experience-based pathways to identify deteriorating health. Existing communication structures in the hospital are poorly equipped to incorporate families' expertise.

Children dependent on respiratory support: A 10-year review from one pediatric postacute care hospital

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.

Pediatric Hospitalists' Lessons Learned From an Innovation Award to Improve Care for Children With Medical Complexity

Children with medical complexity experience frequent hospitalizations and pose a unique challenge for the pediatric hospitalist and their healthcare team. Pediatric hospitalists are ideally positioned to champion improved care coordination for CMC and to address the areas of need in clinical practice, quality improvement and research. Lessons learned from programs who were Healthcare Innovation Award recipients from Center for Medicare and Medicaid Innovation that were aimed at improving care for this population are presented. We focused on care coordination activities implemented during hospitalization. Through a series of meetings with the participating programs, we identified common themes across awarded programs. Programs described key aspects of care coordination during the hospital stay, beginning on admission (multidisciplinary team goal setting, family partnership and action planning), through hospitalization (integrating outpatient and inpatient care), as well as during and after discharge (linking to community-based systems and supports, expanding the transition concept). Finally, we present actionable steps for inpatient providers seeking to improve care for this patient population at the time of hospitalization.

The Pediatric Hospital Medicine Core Competencies: 2020 Revision

BACKGROUND

The Pediatric Hospital Medicine (PHM) Core Competencies define the expertise required of practitioners and provide a framework for educational activities. Since initial publication in 2010, the scope of practice for pediatric hospitalists has evolved in clinical, research, administrative, and educational arenas.

OBJECTIVE

To describe the methodology utilized in the revision of The PHM Core Competencies to ensure a product reflective of current roles and expectations for pediatric hospitalists across all training pathways and practice settings.

METHODS

The Society of Hospital Medicine (SHM) Pediatrics Special Interest Group supported the initiation of the revision. A diverse group of editors and authors was engaged from among members of SHM, the American Academy of Pediatrics and the Academic Pediatrics Association. Editorial roles were expanded to represent all practice settings. More than 80 individuals contributed, representing both university and community sites, and all US geographic regions. Editors conducted a two-part needs assessment; a survey related to content was distributed to the PHM community and content from recent conferences and PHM related publications was reviewed. The final compendium consists of 4 sections and 66 chapters, including 12 new chapters and 36 chapters with substantial changes. Individual chapters and the entire compendium underwent rigorous internal and external review.

CONCLUSION

The PHM Core Competencies: 2020 Revision reflects the work of a broad spectrum of PHM practitioners responding to the practice and educational changes in PHM over the past decade. The compendium can inform education, training, and career development for pediatric hospitalists practicing now and in coming years.

Challenges Following Hospital Discharge for Children With Medical Complexity

OBJECTIVES

The transition from hospital to home is a period of risk, particularly for children with medical complexity. Our aim was to identify and address discharge challenges through execution of postdischarge phone calls.

METHODS

In this prospective study, we designed and executed a postdischarge phone call for patients discharged from an inpatient complex care team between May and November 2018. The call included dichotomous and open-ended questions to identify challenges regarding health status, follow-up appointments, medications, home nursing, medical supplies and/or equipment, and discharge instructions. These were recorded in the electronic health record. Details regarding identified challenges and corrective actions were categorized by 2 reviewers and adjudicated by a third reviewer if disagreement occurred.

RESULTS

Descriptive statistics were used to summarize these findings. Sixty-seven phone calls were completed within 1 week of discharge. Two-thirds of calls identified at least 1 challenge, and more than one-third of calls identified 2 or more challenges for a total of 90 challenges. The most common challenges involved health status (26.7%), follow-up appointments (21.1%), and medications (20%). The majority of challenges were addressed by either caregivers or the multidisciplinary team, with the exception of home nursing challenges.

CONCLUSIONS

Discharge challenges were commonly identified by caregivers of children with medical complexity. The majority of postdischarge challenges were addressed, with some addressed by families themselves. These results can inform health care providers about challenges to anticipate and suggest future interventions to mitigate anticipated challenges for a safe discharge and transition of care for these at-risk patients.

Care coordination for children with medical complexity

Children with medical complexity have complex health management and care coordination needs. Care models that address these needs rely on interprofessional teams that include NPs. Understanding these care models allows NPs from all disciplines to support the care of this growing patient population in pediatric and adult settings.

Parent Perspectives During Hospital Readmissions for Children With Medical Complexity: A Qualitative Study

OBJECTIVES

Children with medical complexity (CMC) have high readmission rates, but relatively little is known from the parent perspective regarding care experiences surrounding and factors contributing to readmissions. We aimed to elicit parent perspectives on circumstances surrounding 30-day readmissions for CMC.

METHODS

We conducted 20 semistructured interviews with parents of CMC experiencing an unplanned 30-day readmission at 1 academic medical center between December 2016 and January 2018, asking about topics such as previous discharge experiences, medical services and resources, and home environment and social support. Interviews were recorded, professionally transcribed, and analyzed thematically by using a modified grounded theory approach.

RESULTS

Children ranged in age from 0 to 15 years, with neurologic complex chronic conditions being predominant (35%). Although the majority of parents did not identify any factors that they perceived to have contributed to readmission, themes emerged regarding challenges associated with chronicity of care and transitions of care that might influence readmissions, including frequency of hospital use, symptom confusion, lack of inpatient continuity, resources needed but not received, and difficulty filling prescriptions.

CONCLUSIONS

Parents identified multiple challenges associated with chronicity of medical management and transitions of care for CMC. Future interventions aiming to improve continuity and communication between admissions, ensure that home services are provided when applicable and prescriptions are filled, and provide comprehensive support for families in both the short- and long-term may help improve patient and family experiences while potentially decreasing readmissions.

Identifying and Communicating Postdischarge Goals for Hospitalized Children With Medical Complexity: A Process Improvement Pilot in a Specialty Pediatric Setting

INTRODUCTION

Family-centered communication at transitions of care can decrease readmissions and costs for children with medical complexity (CMC). The purpose of this quality improvement project was to improve the communication of postdischarge goals for CMC in a pediatric specialty setting.

METHODS

We used process improvement strategies to implement a Post-Hospitalization Action Grid (PHAG) and a standardized discharge handoff process. Families of hospitalized CMC at high risk for readmission received the pilot intervention over 3 months. Indicators of successful implementation included rates of use of the PHAG, perceptions of integrated care, and usability of the tool.

RESULTS

The PHAG was implemented with 11 of 40 eligible CMC families. Most staff agreed that the new process could improve the communication of postdischarge goals; however, perceptions of integrated care in the organization changed only minimally.

DISCUSSION

The PHAG facilitates family engagement in discharge transitions but requires organizational investment of resources to implement.

Point Prevalence of Children Hospitalized With Chronic Critical Illness in the General Inpatient Units

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.

Improving Hospital-to-Home Transitions for Children Entering Foster Care

BACKGROUND AND OBJECTIVES

Hospital-to-home transitions present safety risks for patients. Children discharged with new foster caregivers may be especially vulnerable to poor discharge outcomes. With this study, our objective is to identify differences in discharge quality and outcomes for children discharged from the hospital with new foster caregivers compared with children discharged to their preadmission caregivers.

METHODS

Pediatric patients discharged from the Barbara Bush Children's Hospital at Maine Medical Center between January 2014 and May 2017 were eligible for inclusion in this retrospective cohort study. Chart review identified patients discharged with new foster caregivers. These patients were compared with a matched cohort of patients discharged with preadmission caregivers for 5 discharge quality process measures and 2 discharge outcomes.

RESULTS

Fifty-six index cases and 165 matched patients were identified. Index cases had worse performance on 4 of 5 discharge process measures, with significantly lower use of discharge readiness checklists (75% vs 92%; P = .004) and teach-back education of discharge instructions for caregivers (63% vs 79%; P = .02). Index cases had twice the odds of misunderstandings needing clarification at the postdischarge call; this difference was not statistically significant (26% vs 13%; P = .07).

CONCLUSIONS

Hospital-to-home transition quality measures were less often implemented for children discharged with new foster caregivers than for the cohort of patients discharged with preadmission caregivers. This may lead to increased morbidity, as suggested by more frequent caregiver misunderstandings. Better prospective identification of these patients and enhanced transition improvement efforts targeted at their new caregivers may be warranted.

Hospitalization due to bronchiolitis: factors influencing parents' experience

AIM

To describe the experience of the parents of children hospitalized due to bronchiolitis.

METHOD

Phenomenological qualitative study. Purposeful sampling was undertaken of parents with children diagnosed with bronchiolitis, from December 7, 2015 to January 8, 2016, and admitted to the paediatric department of a public hospital of the Madrid Health Service. Data collection strategies included focus groups and researchers' field notes. Afterwards, the data were analyzed using thematic analysis. We included 10 parents, aged between 30 and 39 years. Five themes were explored: perception of monitoring, need to know, perception of child fragility, coping strategies, and reorganization of the family environment.

RESULTS

Oxygen saturation monitoring through devices produced dependence and uncertainty in the parents. In addition, there was a need to know and understand the technical language, which encouraged searching for information on the Internet. The parents perceived the fragility of the hospitalized child through their appearance and physical state. In addition, they developed different coping strategies to seek and confirm information, to approach professionals and be present with their children. Finally, the family was reorganised to maintain the constant presence of the parents during hospitalization.

CONCLUSIONS

The results obtained can help paediatric professionals manage the information given to parents and thus empower them.

Postdischarge Nurse Home Visits and Reuse: The Hospital to Home Outcomes (H2O) Trial

BACKGROUND

Hospital discharge is stressful for children and families. Poor transitional care is linked to unplanned health care reuse. We evaluated the effects of a pediatric transition intervention, specifically a single nurse home visit, on postdischarge outcomes in a randomized controlled trial.

METHODS

We randomly assigned 1500 children hospitalized on hospital medicine, neurology services, or neurosurgery services to receive either a single postdischarge nurse-led home visit or no visit. We excluded children discharged with skilled home nursing services. Primary outcomes included 30-day unplanned, urgent health care reuse (composite measure of unplanned readmission, emergency department, or urgent care visit). Secondary outcomes, measured at 14 days, included postdischarge parental coping, number of days until parent-reported return to normal routine, and number of "red flags" or clinical warning signs a parent or caregiver could recall.

RESULTS

The 30-day reuse rate was 17.8% in the intervention group and 14.0% in the control group. In the intention-to-treat analysis, children randomly assigned to the intervention group had higher odds of 30-day health care use (odds ratio: 1.33; 95% confidence interval: 1.003-1.76). In the per protocol analysis, there were no differences in 30-day health care use (odds ratio: 1.14; confidence interval: 0.84-1.55). Postdischarge coping scores and number of days until returning to a normal routine were similar between groups. Parents in the intervention group recalled more red flags at 14 days (mean: 1.9 vs 1.6; P < .01).

CONCLUSIONS

Children randomly assigned to the intervention had higher rates of 30-day postdischarge unplanned health care reuse. Parents in the intervention group recalled more clinical warning signs 2 weeks after discharge.