Pediatric Patient-Centered Transitions From Hospital to Home: Improving the Discharge Medication Process

Pharmacist-Led Discharge Transitions of Care Interventions for Pediatric Patients: A Narrative Review

Transitions of care (TOC) before, during, and after hospital discharge are an opportune setting to optimize medication management. The quality standards for pediatric care transitions, however, are lacking, leading to reduced health outcomes in children. This narrative review characterizes the pediatric populations that would benefit from focused, TOC interventions. Different types of medication-focused TOC interventions during hospital discharge are described, including medication reconciliation, education, access, and adherence tools. Various TOC intervention delivery models following hospital discharge are also reviewed. The goal of this narrative review is to help pediatric pharmacists and pharmacy leaders better understand TOC interventions and integrate them into the hospital discharge process for children and their caregivers.

Incidence of Medication-Related Problems Following Pediatric Epilepsy Admissions

BACKGROUND

An estimated 26% to 33% of pediatric patients have at least one medication error at hospital discharge. Pediatric patients with epilepsy may be at greater risk due to complex medication regimens and frequent hospitalizations. This study aims to quantify the proportion of pediatric patients with epilepsy experiencing medication problems after discharge and determine if medication education decreases these problems.

METHODS

This was a retrospective cohort study including pediatric patients with epilepsy-related hospital admissions. Cohort 1 consisted of a control group, and cohort 2 consisted of patients who received discharge medication education, enrolled in a 2:1 ratio. The medical record was reviewed from hospital discharge to outpatient neurology follow-up to identify medication problems that occurred. The primary outcome was the difference in proportion of medication problems between the cohorts. Secondary outcomes were incidence of medication problems with harm potential, overall incidence of medication problems, and 30-day epilepsy-related readmissions.

RESULTS

A total of 221 patients were included (163 in the control cohort and 58 in the discharge education cohort) with balanced demographics. The incidence of medication problems was 29.4% in the control cohort and 24.1% in the discharge education cohort (P = 0.44). The most common problems were mismatched dose or direction. Medication problems with harm potential were 54.2% in the control group and 28.6% in the discharge education cohort (P = 0.131).

CONCLUSION

Medication problems and their harm potential were lower in the discharge education cohort, but the difference was not significant. This demonstrates education alone may not be enough to impact medication error rates.

Effect of a Pharmacist-Led Discharge Counseling Service at a Children's Hospital

OBJECTIVE

To evaluate the effect of a pharmacist-led discharge counseling service at a pediatric hospital.

METHODS

This was a prospective observational cohort study. Patients in the pre-implementation phase were identified by the pharmacist at the time of admission medication reconciliation, whereas patients in the pos-timplementation phase were identified at the time of pharmacist discharge medication counselling. Caregivers were contacted within 2 weeks of the patients' discharge date to complete a 7-question telephone survey. The primary objective was to measure the effect of the pharmacist-led service on caregiver satisfaction, using a pre- and post- implementation telephone survey. The secondary objectives were to evaluate the effect of the service on 90-day medication-related readmissions and determine the change in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey response (Question 25) regarding discharge medications following implementation of the new service.

RESULTS

A total of 32 caregivers were included in both the pre- and post-implementation groups. The most common reason for inclusion was high-risk medications (84%) in the pre-implementation group and device teaching (62.5%) in the post-implementation group. The primary outcome, the average composite score on the telephone survey, was 30.94 ± 3.50 (average ± SD) in the pre-implementation group and 32.5 ± 2.26 in the post-implementation group (p = 0.038). There were no medication-related readmissions within 90 days in either group. The score on HCAHPS Question 25 was not different between groups (p = 0.761).

CONCLUSIONS

Implementation of a pharmacist-led discharge counseling service in pediatric patients improved caregiver satisfaction and understanding as shown by a postdischarge telephone survey.

Interdisciplinary Quality Improvement Project Increases Vitamin D Supplementation in Infants

BACKGROUND

American Academy of Pediatrics guidelines recommend 400 IU of vitamin D supplementation daily for certain infants <1 year of age. We aimed to increase the proportion of reported appropriate vitamin D supplementation for infants born at our institution and those who followed up in our resident clinic through 6 months from 49% to 80% over 24 months.

METHODS

Our interdisciplinary quality improvement effort included vitamin D medication delivery before nursery discharge and family and staff education. The process measure was the percentage of families discharged from birth hospitalization with vitamin D and teaching. The outcome measure was the percentage of families reporting appropriate vitamin D supplementation at 2-, 4-, and 6-month well child visits. The balancing measure was the percentage of infants discharged from the nursery by 2 pm. Data were displayed on Statistical Process Control p charts and established rules for detecting special causes were applied.

RESULTS

Baseline and improvement data were collected for 587 hospital discharges and 220 outpatient encounters. The percentage of families discharged with vitamin D increased from 24.8% to 98% from 2016 to 2018. Percent of families reporting appropriate vitamin D supplementation at well child visits increased from 49% to 89% from 2016 to 2018. Overall, the percentage of discharges by 2 pm remained stable at 60%.

CONCLUSION

Bedside medication delivery and education in the newborn nursery improved reported vitamin D supplementation rates in the first 6 months of life. The intervention did not delay newborn hospital discharge.

Creation and implementation of a pharmacy-led meds-to-beds program at a large teaching hospital

BACKGROUND

"Meds-to-beds" programs are a quality improvement intervention that is gaining wider implementation throughout the United States. The University of Oklahoma hospital system did not have this program and sought to implement one. There are sufficient data on the benefits of meds-to-beds programs, but there is a lack of literature on describing the development and implementation process.

OBJECTIVES

The objective of this article is to describe the planning process, implementation, and barriers encountered during the organization of a pharmacy-led meds-to-beds program operating within 2 large teaching hospitals.

PRACTICE DESCRIPTION

The University of Oklahoma Health Sciences Center campus has 7 colleges, multiple primary care and specialty clinics, and 2 hospitals. In addition, there are 3 on-campus outpatient pharmacies operated by the University of Oklahoma College of Pharmacy (OUCOP).

PRACTICE INNOVATION

The college implemented a meds-to-beds program primarily serving 2 on-campus hospitals, The Oklahoma Children's Hospital and University of Oklahoma College of Pharmacy Medical Center. The program operated out of The Children's Pharmacy, an outpatient pharmacy located within the Children's Hospital.

EVALUATION METHODS

A Plan-Do-Study-Act model was used, which allowed for adaptation in response to barriers encountered throughout the process. Frequent meetings among stakeholders were held to continuously evaluate progress (e.g., awareness and utilization of the program and prescription counts) and make necessary changes.

RESULTS

Implementation of the program required changes in workflow both within the pharmacy and within the registration and discharge processes of medical teams. In addition, after the initiation of the meds-to-beds program, the daily prescription count more than doubled. The program averages 40 deliveries per day and 3 prescriptions per delivery and continues to grow, providing evidence of a successful meds-to-beds implementation.

CONCLUSION

The Plan-Do-Study-Act model allowed for many adjustments to be made throughout the process, including the conversion from an opt-in to an opt-out model to increase program utilization.

Meds to Beds: A Quality Improvement Approach to Optimizing the Discharge Medication Process for Pediatric Patients

BACKGROUND

Using an on-site pharmacy or medication to bedside (MTB) program allows patients to obtain prescriptions and education before discharge, potentially improving adherence and preventing harm. The aim of this project was to improve discharge processes for pediatric acute care patients by increasing the proportion of oral antibiotics (1) prescribed to the on-site pharmacy from 15% to 70% and (2) delivered to bedside from 0% to 50%.

METHODS

The Model for Improvement was used to iteratively implement interventions: increased on-site pharmacy capabilities, MTB program creation and streamlined enrollment, and secure electronic health record (EHR) messaging between clinicians and pharmacy staff regarding prescriptions. Process measures were proportion of antibiotics prescribed to the on-site pharmacy and delivered to bedside. Outcomes included surveys of family satisfaction with discharge medication education and discharge medication-related safety reports. Discharge before noon (DBN) was the balancing measure. Aims were analyzed using statistical process control charts and chi-square tests.

RESULTS

A total of 1,908 antibiotics were prescribed over 28-months. On-site pharmacy prescriptions increased from 15% to 46% after pharmacy capabilities increased, then to 86% after MTB program launch, optimized workflow, and initiation of EHR messaging. Bedside medication delivery increased from 0% to 58% with these interventions. Family satisfaction with discharge medication education and frequency of discharge medication-related safety reports was not significantly different pre- and postintervention. DBN varied throughout the study.

CONCLUSION

Through clinician and pharmacy staff partnership, this initiative increased on-site pharmacy use and discharge antibiotics delivered to bedside. Key interventions included increased pharmacy capabilities, MTB program with streamlined workflow, and EHR-based communication.

Implementation of a Standardized Approach to Improve the Pediatric Discharge Medication Process

BACKGROUND AND OBJECTIVES

The pediatric inpatient discharge medication process is complicated, and caregivers have difficulty managing instructions. Authors of few studies evaluate systematic processes for ensuring quality in these care transitions. We aimed to improve caregiver medication management and understanding of discharge medications by standardizing the discharge medication process.

METHODS

An interprofessional team at an urban, tertiary care children's hospital trialed interventions to improve caregiver medication management and understanding. These included mnemonics to aid in complete medication counseling, electronic medical record enhancements to standardize medication documentation and simplify dose rounding, and housestaff education. The primary outcome measure was the proportion of discharge medication-related failures in each 4-week period. Failure was defined as an incorrect response on ≥1 survey questions. Statistical process control was used to analyze improvement over time. Process measures related to medication documentation and dose rounding were compared by using the χ² test and process control.

RESULTS

Special cause variation occurred in the mean discharge medication-related failure rate, which decreased from 70.1% to 36.1% and was sustained. There were significantly more complete after-visit summaries (21.0% vs 85.1%; P < .001) and more patients with simplified dosing (75.2% vs 95.6%; P < .001) in the intervention period. Special cause variation also occurred for these measures.

CONCLUSIONS

A systematic approach to standardizing the discharge medication process led to improved caregiver medication management and understanding after pediatric inpatient discharge. These changes could be adapted by other hospitals to enhance the quality of this care transition.

A Quality Improvement Initiative To Improve Postdischarge Antimicrobial Adherence

OBJECTIVES

Bedside delivery of discharge medications improves caregiver understanding and experience. Less is known about its impact on medication adherence. We aimed to improve antimicrobial adherence by increasing on-time first home doses for patients discharged from the pediatric hospital medicine service from 33% to 80% over 1 year via creation of a discharge medication delivery and counseling "Meds to Beds" (M2B) program.

METHODS

Using sequential plan-do-study-act cycles, an interprofessional workgroup implemented M2B on select pediatric hospital medicine units at our quaternary children's hospital from October 2017 through December 2018. Scripted telephone surveys were conducted with caregivers of patients prescribed antimicrobial agents at discharge. The primary outcome measure was on-time administration of the first home antimicrobial dose, defined as a dose given within the time of the inpatient dose equivalent plus 25%. Process measures primarily assessed caregiver report of barriers to adherence. Run charts, statistical process control charts, and inferential statistics were used for data analysis.

RESULTS

Caregiver survey response rate was 35% (207 of 585). Median on-time first home antimicrobial doses increased from 33% to 67% (P < .001). Forty percent of M2B prescriptions were adjusted before discharge because of financial or insurance barriers. M2B participants reported significantly less difficulty in obtaining medications compared with nonparticipants (1% vs 17%, P < .001).

CONCLUSIONS

The M2B program successfully increased parental report of timely administration of first home antimicrobial doses, a component of overall adherence. The program enabled providers to identify and resolve prescription problems before discharge. Importantly, caregivers reported reduced barriers to medication adherence.

Outcomes from a pilot patient-centered hospital-to-home transition program for children hospitalized with asthma

OBJECTIVE

To evaluate a multi-component hospital-to-home (H2H) transition program for children hospitalized with an asthma exacerbation.

METHODS

A pilot prospective randomized clinical trial of guideline-based asthma care with and without a patient-centered multi-component H2H program among children enrolled in K-8^th grade on Medicaid hospitalized for an asthma exacerbation. H2H program includes 5 components: medications in-hand at discharge, school-based asthma therapy (SBAT) for controller medications, referral for home trigger assessments, communication with the primary care provider (PCP), and patient navigator support. Primary outcomes included feasibility and acceptability. Secondary outcomes included healthcare utilization, asthma morbidity, and caregiver quality of life.

RESULTS

A total of 32 children were enrolled and randomized. Feasibility outcomes in the intervention group included: medications in-hand at discharge (100%); SBAT for controller medication initiated (100%); home visit referrals made (100%) and home visits completed within 4 weeks of discharge (44%); PCP communication (100%); patient navigator communication at 3 days (81.3%) and 14 days (46.7%). Acceptability outcomes in the intervention group included: 87.5% of families continued SBAT, and 87.5% of families reported it was extremely helpful to have the home visit referral. Adjusting for baseline differences in age, asthma severity and control, there was no significant difference in healthcare utilization outcomes.

CONCLUSION

These pilot data suggest that comprehensive care coordination initiated during the inpatient stay is feasible and acceptable. A larger trial is justified to determine if the intervention may reduce healthcare utilization for urban, minority children with asthma.

Timely Delivery of Discharge Medications to Patients' Bedsides: A Patient-centered Quality Improvement Project

Introduction:

Patients who are unable to fill prescriptions after discharge are at risk of hospital readmission. Ensuring that patients have prescriptions in hand at the time of discharge is a critical component of a safe and effective discharge process. Using a “Meds to Beds” program, we aimed to increase the percentage of patients discharged from Holtz Children’s Hospital with medications in hand from 49% to 80%, reduce turnaround time (TAT) from electronic prescription signature to bedside delivery from 4.9 hours (±2.6 hours) to 2 hours, and increase caregiver satisfaction.

Methods:

We formed a multidisciplinary team and implemented 4 patient-centered interventions through iterative plan-do-study-act cycles. Statistical process control charts were used to understand the impact of the interventions over 10 months. Hospital length of stay and discharges before 2:00 pm were used as balancing measures. We measured caregiver satisfaction using a telephone survey administered by pediatric residents within 7 days after discharge.

Results:

The mean percentage of patients discharged with medications in hand increased to 76%. TAT decreased to 3.5 hours (±1.8 hours). Length of stay did not significantly increase, whereas the percentage of patients discharged before 2:00 pm did. Caregivers of patients who had prescriptions delivered to their bedside reported high levels of satisfaction.

Conclusions:

Using a “Meds to Beds” program, we increased the percentage of patients discharged with medications in hand, decreased TAT with reduced variability, and achieved high levels of caregiver satisfaction. Importantly, there was a shift in the culture of the institution toward improved medication access for patients.

Multidisciplinary Engagement Increases Medications in-Hand for Patients Hospitalized With Asthma

BACKGROUND

Asthma exacerbations in children are a leading cause of missed school days and health care use. Patients discharged from the hospital often do not fill discharge prescriptions and are at risk for future exacerbations.

METHODS

A multidisciplinary team aimed to increase the percentage of patients discharged from the hospital after an asthma exacerbation with their medications in-hand from 15% to 80%. Tools from the model of improvement were used to establish a process map, key driver diagram, and iterative plan-do-study-act cycles. Statistical process control charts were used to track the proportion of patients discharged with their medications in-hand as the primary outcome. Initiating multidisciplinary daily discharge huddles on the unit was the key intervention that facilitated change in the system.

RESULTS

During the study period, the percentage of patients with asthma who received their medications in-hand increased from 15% to >80% for all eligible children and >90% for children with public insurance. Children had a median age of 6.7 years, 47% were female, and 83.8% identified as non-Hispanic African American. Through iterative meetings and mapping with the multidisciplinary team, a process map for bedside delivery and a key driver diagram were created. Balancing measures, specifically length of stay and discharge medications forgotten at the hospital, remained constant.

CONCLUSIONS

Improvements in increasing medication possession at the time of discharge for children hospitalized with asthma were facilitated by multidisciplinary engagement. Standardizing discharge initiatives may play a key role in improving discharge transitions for children with asthma.

Impact of discharge medication bedside delivery service on hospital reutilization

PURPOSE

To evaluate the impact of a medication to bedside delivery (meds-to-beds) service on hospital reutilization in an adult population.

METHODS

A retrospective, single-center, observational cohort study was conducted within a regional academic medical center from January 2017 to July 2017. Adult patients discharged from an internal medicine unit with at least one maintenance medication were evaluated. The primary outcome was the incidence of 30-day hospital reutilization between two groups: discharged patients who received meds-to-beds versus those who did not. Additionally, the incidence of 30-day hospital reutilization between the two groups was compared within predefined subgroup patient populations: polypharmacy, high-risk medication use, and patients with a principal discharge diagnosis meeting the criteria set by the Centers for Medicare and Medicaid Services 30-day risk standardized readmission measures.

RESULTS

A total of 600 patients were included in the study (300 patients in the meds-to-beds group and 300 patients in the control group). The 30-day hospital reutilization (emergency department visits and/or hospital readmissions) related to the index visit was lower in the meds-to-beds group, but the difference was not statistically significant between the two groups (8.0% in the meds-to-beds group versus 10.0% in the control group; odds ratio, 0.78; 95% confidence interval, 0.45-1.37). There was no significant difference in the 30-day hospital reutilization related to the index visit between the control and meds-to-beds groups within the three subgroups analyzed.

CONCLUSION

There was no difference in 30-day hospital reutilization related to the index visit with the implementation of meds-to-beds service in the absence of other transitions-of-care interventions.

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.