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Pilarz MS, Bleed E, Rodriguez VA, Daniels LA, Jackson KL, Sanchez-Pinto LN, Foster CC. Medical Complexity, Language Use, and Outcomes in the Pediatric ICU. Pediatrics 2024; 153:e2023063359. [PMID: 38747049 PMCID: PMC11153320 DOI: 10.1542/peds.2023-063359] [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: 07/24/2023] [Revised: 02/27/2024] [Accepted: 03/05/2024] [Indexed: 06/02/2024] Open
Abstract
OBJECTIVES To determine whether use of a language other than English (LOE) would be associated with medical complexity, and whether medical complexity and LOE together would be associated with worse clinical outcomes. METHODS The primary outcome of this single-site retrospective cohort study of PICU encounters from September 1, 2017, through August 31, 2022 was an association between LOE and medical complexity. Univariable and multivariable analyses were performed between demographic factors and medical complexity, both for unique patients and for all encounters. We investigated outcomes of initial illness severity (using Pediatric Logistic Organ Dysfunction-2), length of stay (LOS), days without mechanical ventilation or organ dysfunction using a mixed effects regression model, controlling for age, sex, race and ethnicity, and insurance status. RESULTS There were 6802 patients and 10 011 encounters. In multivariable analysis for all encounters, Spanish use (adjusted odds ratio [aOR], 1.29; 95% confidence interval [CI], 1.11-1.49) and language other than English or Spanish (LOES) (aOR, 1.36; 95% CI, 1.02-1.80) were associated with medical complexity. Among unique patients, there remained an association between use of Spanish and medical complexity in multivariable analysis (aOR, 1.26; 95% CI, 1.05-1.52) but not between LOES and medical complexity (aOR, 1.30; 95% CI, 0.92-1.83). Children with medical complexity (CMC) who used an LOES had fewer organ dysfunction-free days (P = .003), PICU LOS was 1.53 times longer (P = .01), and hospital LOS was 1.45 times longer (P = .01) compared with CMC who used English. CONCLUSIONS Use of an LOE was independently associated with medical complexity. CMC who used an LOES had a longer LOS.
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Affiliation(s)
| | | | - Victoria A. Rodriguez
- Division of Hospital Based Medicine
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - L. Nelson Sanchez-Pinto
- Division of Critical Care
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Carolyn C. Foster
- Division of Advanced General Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
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2
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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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3
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van de Riet L, Alsem MW, van der Leest EC, van Etten-Jamaludin FS, Maaskant JM, van Woensel JBM, van Karnebeek CD. Delineating family needs in the transition from hospital to home for children with medical complexity: part 1, a meta-aggregation of qualitative studies. Orphanet J Rare Dis 2023; 18:386. [PMID: 38082309 PMCID: PMC10714518 DOI: 10.1186/s13023-023-02942-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 10/02/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Advances in diagnostic and therapeutic interventions for rare diseases result in greater survival rates, with on the flipside an expanding group of children with medical complexity (CMC). When CMC leave the protective hospital environment to be cared for at home, their parents face many challenges as they take on a new role, that of caregiver rather than care-recipient. However, an overview of needs and experiences of parents of CMC during transition from hospital-to-home (H2H) is lacking, which hampers the creation of a tailored H2H care pathway. Here we address this unmet medical need by performing a literature review to systematically identify, assess and synthesize all existing qualitative evidence on H2H transition needs of CMC parents. METHODS An extensive search in Medline, PsychINFO and CINAHL (up to September 2022); selection was performed to include all qualitative studies describing parental needs and experiences during H2H transition of CMC. All papers were assessed by two independent investigators for methodological quality before data (study findings) were extracted and pooled. A meta-aggregation method categorized the study findings into categories and formulated overarching synthesized findings, which were assigned a level of confidence, following the ConQual approach. RESULTS The search yielded 1880 papers of which 25 met eligible criteria. A total of 402 study findings were extracted from the included studies and subsequently aggregated into 50 categories and 9 synthesized findings: (1) parental empowerment: shifting from care recipient to caregiver (2) coordination of care (3) communication and information (4) training skills (5) preparation for discharge (6) access to resources and support system (7) emotional experiences: fatigue, fear, isolation and guilt (8) parent-professional relationship (9) changing perspective: finding new routines and practices. The overall ConQual Score was low for 7 synthesized findings and very low for 2 synthesized findings. CONCLUSIONS Despite the variability in CMC symptoms and underlying (rare disease) diagnoses, overarching themes in parental needs during H2H transition emerged. We will augment this new knowledge with an interview study in the Dutch setting to ultimately translate into an evidence-based tailored care pathway for implementation by our interdisciplinary team in the newly established 'Jeroen Pit Huis', an innovative care unit which aims for a safe and sustainable H2H transition for CMC and their families.
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Affiliation(s)
- L van de Riet
- Department of Pediatric Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- On Behalf of the Transitional Care Unit Consortium, Amsterdam, The Netherlands
| | - M W Alsem
- On Behalf of the Transitional Care Unit Consortium, Amsterdam, The Netherlands
- Department of Rehabilitation, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - E C van der Leest
- Department of Pediatric Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - F S van Etten-Jamaludin
- Medical Library AMC, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - J M Maaskant
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- On Behalf of the Transitional Care Unit Consortium, Amsterdam, The Netherlands
- Department of Pediatrics, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - J B M van Woensel
- Department of Pediatric Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- On Behalf of the Transitional Care Unit Consortium, Amsterdam, The Netherlands
| | - C D van Karnebeek
- On Behalf of the Transitional Care Unit Consortium, Amsterdam, The Netherlands.
- Emma Center for Personalized Medicine, Departments of Pediatrics and Human Genetics, Amsterdam Gastro-Enterology Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
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4
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Glick AF, Farkas JS, Magro J, Shah AV, Taye M, Zavodovsky V, Rodriguez RH, Modi AC, Dreyer BP, Famiglietti H, Yin HS. Management of Discharge Instructions for Children With Medical Complexity: A Systematic Review. Pediatrics 2023; 152:e2023061572. [PMID: 37846504 PMCID: PMC10598634 DOI: 10.1542/peds.2023-061572] [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] [Accepted: 07/25/2023] [Indexed: 10/18/2023] Open
Abstract
CONTEXT Children with medical complexity (CMC) are at risk for adverse outcomes after discharge. Difficulties with comprehension of and adherence to discharge instructions contribute to these errors. Comprehensive reviews of patient-, caregiver-, provider-, and system-level characteristics and interventions associated with discharge instruction comprehension and adherence for CMC are lacking. OBJECTIVE To systematically review the literature related to factors associated with comprehension of and adherence to discharge instructions for CMC. DATA SOURCES PubMed/Medline, Embase, Cochrane Central Register of Controlled Trials, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, Web of Science (database initiation until March 2023), and OAIster (gray literature) were searched. STUDY SELECTION Original studies examining caregiver comprehension of and adherence to discharge instructions for CMC (Patient Medical Complexity Algorithm) were evaluated. DATA EXTRACTION Two authors independently screened titles/abstracts and reviewed full-text articles. Two authors extracted data related to study characteristics, methodology, subjects, and results. RESULTS Fifty-one studies were included. More than half were qualitative or mixed methods studies. Few interventional studies examined objective outcomes. More than half of studies examined instructions for equipment (eg, tracheostomies). Common issues related to access, care coordination, and stress/anxiety. Facilitators included accounting for family context and using health literacy-informed strategies. LIMITATIONS No randomized trials met inclusion criteria. Several groups (eg, oncologic diagnoses, NICU patients) were not examined in this review. CONCLUSIONS Multiple factors affect comprehension of and adherence to discharge instructions for CMC. Several areas (eg, appointments, feeding tubes) were understudied. Future work should focus on design of interventions to optimize transitions.
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Affiliation(s)
| | | | - Juliana Magro
- Health Sciences Libraries, NYU Langone Health, New York, New York
| | | | | | | | | | - Avani C. Modi
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | | | - H. Shonna Yin
- Department of Pediatrics
- Department of Population Health, NYU Langone Health, New York, New York
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Williams EP, Madrigal VN, Leone TA, Aponte-Patel L, Baird JD, Edwards JD. Primary Intensivists and Nurses for Long-Stay Patients: A Survey of Practices and Perceptions at Academic PICUs. Pediatr Crit Care Med 2023; 24:436-446. [PMID: 36728255 DOI: 10.1097/pcc.0000000000003181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To determine the prevalence of the utilization of primary intensivists and primary nurses for long-stay patients in large, academic PICU and ascertain how these practices are operationalized and perceived. DESIGN A cross-sectional survey. SETTING U.S. PICUs with accredited Pediatric Critical Care Medicine fellowships. SUBJECTS One senior physician and one senior nurse at each institution. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Separate but largely analogous questionnaires for intensivists and nurses were created using an iterative process to enhance content/face validity and readability. Sixty-seven intensivists (representing 93% of the 72 institutions with fellowship programs and their PICUs) and 59 nurses (representing 82%) responded. Twenty-four institutions utilize primary intensivists; 30 utilize primary nurses; and 13 utilize both. Most institutions use length of stay and/or other criteria (e.g., medical complexity) for eligibility. Commonly, not all patients that meet eligibility criteria receive primaries. Primary providers are overwhelmingly volunteers, and often only a fraction of providers participate. Primary intensivists at a large majority (>75%) of institutions facilitate information sharing and decision-making, attend family/team meetings, visit patients/families regularly, and are otherwise available upon request. Primary nurses at a similar majority of institutions provide consistent bedside care, facilitate information sharing, and attend family/team meetings. A large majority of respondents thought that primary intensivists increase patient/family satisfaction, reduce their stress, improve provider communication, and reduce conflict, whereas primary nurses similarly increase patient/family satisfaction. More than half of respondents shared that these practices can sometimes require effort (e.g., time and emotion), complicate decision-making, and/or reduce staffing flexibility. CONCLUSIONS Primary practices are potential strategies to augment rotating PICU care models and better serve the needs of long-stay and other patients. These practices are being utilized to varying extents and with some operationalization uniformity at large, academic PICUs.
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Affiliation(s)
- Erin P Williams
- Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY
- Columbia University Vagelos College of Physician and Surgeons, New York, NY
| | - Vanessa N Madrigal
- Division of Critical Care Medicine, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC
- Pediatric Ethics Program, Children's National Medical Center, Washington, DC
| | - Tina A Leone
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Columbia University Vagelos College of Physician and Surgeons, New York, NY
| | - Linda Aponte-Patel
- Section of Critical Care, Department of Pediatrics, Columbia University Vagelos College of Physician and Surgeons, New York, NY
| | - Jennifer D Baird
- Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, Los Angeles, CA
| | - Jeffrey D Edwards
- Section of Critical Care, Department of Pediatrics, Columbia University Vagelos College of Physician and Surgeons, New York, NY
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6
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Rojas CR, Moore A, Coffin A, McClam C, Ehritz C, Hogan A, Hart J, Galligan MM. Medication Rounds: A Tool to Promote Medication Safety for Children with Medical Complexity. Jt Comm J Qual Patient Saf 2023; 49:226-234. [PMID: 36775713 DOI: 10.1016/j.jcjq.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 01/13/2023]
Abstract
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.
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7
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Parent and Provider Perspectives on Primary Continuity Intensivists and Nurses for Long-Stay Pediatric Intensive Care Unit Patients. Ann Am Thorac Soc 2023; 20:269-278. [PMID: 36322431 DOI: 10.1513/annalsats.202205-379oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Rationale: Primary continuity intensivists and nurses for long-stay patients (LSPs) in pediatric intensive care units (PICUs) are understudied strategies used to mitigate the fragmented care of typical rotating care models. Objectives: To investigate the advantages and disadvantages of primary continuity intensivists and nurses for LSPs as perceived by their parents and PICU providers. Methods: We conducted a prospective cross-sectional mixed-methods study of the perspectives of parents whose children were admitted to a PICU for >10 days and had one or more complex chronic conditions regarding the care provided by their PICU intensivists and nurses. As part of a trial, patients had been randomized to care provided by a rotating on-service intensivist who changed weekly and by PICU nurses who changed every 12 hours (usual care group) or to care provided by the same on-service intensivist plus a primary continuity intensivist and primary nurses (primary group). In addition, PICU providers (intensivists, fellows, and nurses) were queried for their perspectives on primary intensivists and nurses. Novel questionnaires, assessed for content and face validity and for readability, were used. The parental questionnaire involved indicating their degree of agreement with 16 statements about their children's care. The provider questionnaire involved rating potential advantages of primary continuity intensivists and nurses and estimating the frequency of disadvantages. Descriptive statistics and divergent stack bar charts were used; parents' and providers' responses were compared, stratified by their children's group (usual care or primary) and provider role, respectively. Results: The parental response rate was 71% (120 completed questionnaires). For 10 of 16 statements, parents whose children had primary continuity intensivists and nurses indicated significantly more positive perceptions of care (e.g., communication, listening, decision making, problems due to changing providers). The provider response rate was 61% (117 completed questionnaires); more than 80% believed that primary intensivists and nurses were highly or very highly beneficial for LSPs. Providers perceived more benefits for patients/families (e.g., informational continuity, facilitating and expediting decision making) than for staff/institutions (e.g., staff satisfaction). Providers reported associated stress, expenditure of time and effort, and decreased staffing flexibility with primary practices. Conclusions: Perceived benefits of primary continuity intensivists and nurses by both parents and providers support more widespread adoption and study of these continuity strategies.
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8
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Muñoz-Violant S, Violant-Holz V, Rodríguez MJ. Factors of well-being of youth with complex medical conditions from the experience of hospitalization and convalescence: A pilot study. PLoS One 2023; 18:e0285213. [PMID: 37141278 PMCID: PMC10159209 DOI: 10.1371/journal.pone.0285213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/18/2023] [Indexed: 05/05/2023] Open
Abstract
Well-being in children with a complex medical condition (CMC) impacts the way they view and communicate with their immediate environment as well as their development, and it is thus necessary to inquire about the contextual issues and different needs that a CMC carries. This pilot study aimed to identify factors of pediatric well-being from the experience of hospitalization and convalescence of youth with CMC and their caregivers, in a cross-sectional analysis using a selective methodology complemented by an indirect observational methodology. We analyzed the quality of life and well-being of youth with CMC using a validated KINDLR questionnaire. We collected 35 surveys: 11 from youth with CMC and 24 from caregivers from Spain. We focused the analysis on sociodemographics, well-being perceptions, and coping strategies variables. The results show that children aged between 3 and 6 years and their caregivers scored physical well-being the lowest out of all dimensions of well-being, and they scored family well-being the highest. Moreover, youth between the ages of 7 and 17 years and their caregivers scored school-related well-being the lowest. Coping strategies to deal with stressful situations differ between children and caregivers. While children mainly engage in social withdrawal, caregivers engage in cognitive restructuring and expressing emotions. However, we did not find a relationship between coping strategies and well-being perceptions. These results highlight the need to facilitate communication spaces with both families and health professionals where the voice of children is considered.
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Affiliation(s)
- Sarah Muñoz-Violant
- Hospital Pedagogy in Neonatology and Pediatrics-Research Group, Universitat de Barcelona, Barcelona, Spain
| | - Verónica Violant-Holz
- Hospital Pedagogy in Neonatology and Pediatrics-Research Group, Universitat de Barcelona, Barcelona, Spain
- Department of Didactics and Educational Organization, Faculty of Education, Universitat de Barcelona, Barcelona, Spain
- International Observatory in Hospital Pedagogy, Universitat de Barcelona, Barcelona, Spain
| | - Manuel J Rodríguez
- Department Biomedical Sciences, Institute of Neurosciences, School of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
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Abstract
OBJECTIVES Children with severe chronic illness are a prevalent, impactful, vulnerable group in PICUs, whose needs are insufficiently met by transitory care models and a narrow focus on acute care needs. Thus, we sought to provide a concise synthetic review of published literature relevant to them and a compilation of strategies to address their distinctive needs. DATA SOURCES English language articles were identified in MEDLINE using a variety of phrases related to children with chronic conditions, prolonged admissions, resource utilization, mortality, morbidity, continuity of care, palliative care, and other critical care topics. Bibliographies were also reviewed. STUDY SELECTION Original articles, review articles, and commentaries were considered. DATA EXTRACTION Data from relevant articles were reviewed, summarized, and integrated into a narrative synthetic review. DATA SYNTHESIS Children with serious chronic conditions are a heterogeneous group who are growing in numbers and complexity, partly due to successes of critical care. Because of their prevalence, prolonged stays, readmissions, and other resource use, they disproportionately impact PICUs. Often more than other patients, critical illness can substantially negatively affect these children and their families, physically and psychosocially. Critical care approaches narrowly focused on acute care and transitory/rotating care models exacerbate these problems and contribute to ineffective communication and information sharing, impaired relationships, subpar and untimely decision-making, patient/family dissatisfaction, and moral distress in providers. Strategies to mitigate these effects and address these patients' distinctive needs include improving continuity and communication, primary and secondary palliative care, and involvement of families. However, there are limited outcome data for most of these strategies and little consensus on which outcomes should be measured. CONCLUSIONS The future of pediatric critical care medicine is intertwined with that of children with serious chronic illness. More concerted efforts are needed to address their distinctive needs and study the effectiveness of strategies to do so.
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Kobussen TA, Hansen G, Holt TR. Comparing subspecialty and intensive care providers perspectives on pediatric complex chronic patients: A survey study. INTERNATIONAL JOURNAL OF CARE COORDINATION 2021. [DOI: 10.1177/20534345211068094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
| | - Gregory Hansen
- Division of Critical Care, Department of Pediatrics, University of Saskatchewan, Canada
| | - Tanya R Holt
- Division of Critical Care, Department of Pediatrics, University of Saskatchewan, Canada
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11
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Kemp KA, Fairie P, Steele B, McNeil D, Kromm S, Johnson D, Santana MJ. The Experience of Parents of Hospitalized Children Living With Medical Complexity. Hosp Pediatr 2021; 11:1065-1072. [PMID: 34580166 DOI: 10.1542/hpeds.2020-003038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Children living with medical complexity (CMC) experience frequent hospital admissions. Validated patient-reported experience measures may inform care improvements in this cohort. Our objectives were to examine the comprehensive inpatient experience of CMC by using a validated patient-reported experience measure and compare the results with all other respondents at 2 academic pediatric hospitals in a western Canadian province. METHODS Parents completed the Child Hospital Consumer Assessment of Healthcare Providers and Systems survey. Surveys were linked with inpatient records, and an accepted case definition was used to extract records pertaining to CMC. Results were reported as percent in "top box," represented by the most positive answer choice to each measure. Odds of reporting a top box response were calculated while controlling for demographic and clinical features. RESULTS From October 2015 to March 2019, 4197 surveys (1515 CMC; 2682 non-CMC) were collected. Among CMC, the highest-rated measures pertained to being kept informed while in the emergency department, a willingness to recommend the hospital, and parents having a clear understanding of their role in their child's care. The lowest-rated measures pertained to preventing mistakes and reporting concerns and the quietness of the hospital room at night. Compared with others, parents of CMC reported lower raw results on 20 of the 28 measures. They also reported lower a odds of reporting a top box score on 2 measures and higher odds on 1. CONCLUSIONS Parents of CMC revealed many perceived gaps. These findings can be used to inform strategies to improve care among CMC and policies to support the care of CMC and their families.
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Affiliation(s)
- Kyle A Kemp
- Departments of Community Health Sciences.,Patient Engagement Platform, Alberta Strategy for Patient-Oriented Research
| | - Paul Fairie
- Departments of Community Health Sciences.,Patient Engagement Platform, Alberta Strategy for Patient-Oriented Research
| | | | - Deborah McNeil
- Maternal, Neonatal, Child and Youth Strategic Clinical Network, Alberta Health Services
| | - Seija Kromm
- Maternal, Neonatal, Child and Youth Strategic Clinical Network, Alberta Health Services
| | - David Johnson
- Paediatrics.,Maternal, Neonatal, Child and Youth Strategic Clinical Network, Alberta Health Services.,Physiology and Pharmacology, Cumming School of Medicine, University of Calgary
| | - Maria J Santana
- Departments of Community Health Sciences .,Patient Engagement Platform, Alberta Strategy for Patient-Oriented Research.,Paediatrics
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12
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Gold JM, Chadwick W, Gustafson M, Valenzuela Riveros LF, Mello A, Nasr A. Parent Perceptions and Experiences Regarding Medication Education at Time of Hospital Discharge for Children With Medical Complexity. Hosp Pediatr 2021; 10:679-686. [PMID: 32737165 DOI: 10.1542/hpeds.2020-0078] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Children with medical complexity (CMC) often require complex medication regimens. Medication education on hospital discharge should provide a critical safety check before medication management transitions from hospital to family. Current discharge processes may not meet the needs of CMC and their families. The objective of this study is to describe parent perspectives and priorities regarding discharge medication education for CMC. METHODS We performed a qualitative, focus-group-based study, using ethnography. Parents of hospitalized CMC were recruited to participate in 1 of 4 focus groups; 2 were in Spanish. Focus groups were recorded, transcribed, and then coded and organized into themes by using thematic analysis. RESULTS Twenty-four parents participated in focus groups, including 12 native English speakers and 12 native Spanish speakers. Parents reported a range of 0 to 18 medications taken by their children (median 4). Multiple themes emerged regarding parental ideals for discharge medication education: (1) information quality, including desire for complete, consistent information, in preferred language; (2) information delivery, including education timing, and delivery by experts; (3) personalization of information, including accounting for literacy of parents and level of information desired; and (4) self-efficacy, or education resulting in parents' confidence to conduct medical plans at home. CONCLUSIONS Parents of CMC have a range of needs and preferences regarding discharge medication education. They share a desire for high-quality education provided by experts, enabling them to leave the hospital confident in their ability to care for their children once home. These perspectives could inform initiatives to improve discharge medication education for all patients, including CMC.
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Affiliation(s)
- Jessica M Gold
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California; and .,Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Whitney Chadwick
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California; and.,Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | | | - Luisa F Valenzuela Riveros
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California; and.,Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Ashley Mello
- Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Annette Nasr
- Lucile Packard Children's Hospital Stanford, Palo Alto, California
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13
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Connell SK, To T, Arora K, Ramos J, Haviland MJ, Desai AD. Perspectives of Parents and Providers on Reasons for Mental Health Readmissions: A Content Analysis Study. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2021; 48:830-838. [PMID: 33876319 DOI: 10.1007/s10488-021-01134-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 11/28/2022]
Abstract
Pediatric hospitalizations for mental health conditions are rapidly increasing, with readmission rates for mental health conditions surpassing those for non-mental health conditions. The objective of this study was to identify reasons for pediatric mental health readmissions from the perspectives of parents and providers. We performed a retrospective content analysis of surveys administered to parents and providers of patients with a 14-day readmission to an inpatient pediatric psychiatry unit between 5/2017 and 8/2018. Open-ended survey items assessed parent and provider perceptions of readmission reasons. We used deductive coding to categorize survey responses into an a priori coding scheme based on prior research. We used inductive coding to identify and categorize responses that did not fit into the a priori coding scheme. All data were recoded using the revised schema and reliability of the coding process was assessed using kappa statistics and consensus building. We had completed survey responses from 89 (64%) of 138 readmission encounters (56 parent surveys; 61 provider surveys). The top three readmission reasons that we identified from parent responses were: discordant inpatient stay expectations with providers (41%), discharge hesitancy (34%), and treatment plan failure (13%). Among providers, the top readmission reasons that we identified were: access to outpatient care (30%), treatment adherence (13%), and a challenging home (11%) and social environment (11%). We identified inpatient stay expectations, discharge hesitancy, and suboptimal access to outpatient care as the most prominent reasons for mental health readmissions, which provide targets for future quality improvement efforts.
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Affiliation(s)
- Sarah K Connell
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Research Institute, 2001 8th Ave., Seattle, WA, USA. .,Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, USA.
| | - Tony To
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, USA
| | - Kashika Arora
- Psychiatry and Behavioral Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Jessica Ramos
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, USA
| | - Miriam J Haviland
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, USA
| | - Arti D Desai
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Research Institute, 2001 8th Ave., Seattle, WA, USA.,Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, USA
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14
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Williams LJ, Waller K, Chenoweth RP, Ersig AL. Stakeholder perspectives: Communication, care coordination, and transitions in care for children with medical complexity. J SPEC PEDIATR NURS 2021; 26:e12314. [PMID: 33098752 PMCID: PMC8063923 DOI: 10.1111/jspn.12314] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/08/2020] [Accepted: 10/08/2020] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Lori J Williams
- American Family Children's Hospital, Madison, Wisconsin, USA
| | | | - Rachel P Chenoweth
- The University of Wisconsin-Madison School of Nursing, Madison, Wisconsin, USA
| | - Anne L Ersig
- The University of Wisconsin-Madison School of Nursing, Madison, Wisconsin, USA
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15
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Morse BL, Serna RW, LaLumiere M, Rogal M, Foley K, Lombardo M, Manganello C, Pugh V, Veloz A, Solodiuk JC, Mauskar S. Leveraging Parent Pain Perspectives to Improve Pain Practices for Children with Medical Complexity. Pain Manag Nurs 2020; 22:169-176. [PMID: 33384241 DOI: 10.1016/j.pmn.2020.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/02/2020] [Accepted: 11/21/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Children with medical complexity (MC) must rely on others to notice and address pain. Parents are aware of child pain behaviors and can serve as reliable proxy reporters. Thus, there is a critical need to understand parent perspectives to improve pain practices. DESIGN Individual interviews were used as a data collection method in this qualitative study. METHODS Participants were recruited via mail and social media postings. Interviews were audio-recorded and transcribed verbatim. Transcribed documents were imported to NVIVO for qualitative analysis. Conventional and directed approaches to qualitative content analysis were used. RESULTS From the data analysis, major themes included: pain experiences, confidence in caregivers, parents are partners, proactive communication, and a spontaneous theme, "they can hear us." Emotional pain and challenges identifying the source pain were identified as sub-themes of pain experiences. CONCLUSIONS Parents in this study shared methods helpful to identifying pain in their children, as well as suggestions for discussing pain with caregivers. Priorities for future research include identifying methods for sharing pain information that are thorough, but do not burden parents or providers. Researchers should also determine how parents and caregivers can partner to identify and address pain in children with MC. Going forward, conversations about pain should be a key part of any admission assessment or first encounter. As pain episodes among children with MC can be complex and may not always be re-created in front of a provider, nurses may advise parents to take photos or videos to share with caregivers.
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Affiliation(s)
- Brenna L Morse
- Solomont School of Nursing, University of Massachusetts Lowell, Lowell, Massachusetts.
| | - Richard W Serna
- College of Fine Arts, Humanities and Social Sciences, University of Massachusetts Lowell, Lowell, Massachusetts
| | - McKenzie LaLumiere
- Solomont School of Nursing, University of Massachusetts Lowell, Lowell, Massachusetts
| | - Micaela Rogal
- Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, Massachusetts
| | - Kerri Foley
- Solomont School of Nursing, University of Massachusetts Lowell, Lowell, Massachusetts
| | - Miranda Lombardo
- Solomont School of Nursing, University of Massachusetts Lowell, Lowell, Massachusetts
| | | | - Victoria Pugh
- Solomont School of Nursing, University of Massachusetts Lowell, Lowell, Massachusetts
| | - Amy Veloz
- Solomont School of Nursing, University of Massachusetts Lowell, Lowell, Massachusetts
| | - Jean C Solodiuk
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Sangeeta Mauskar
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
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16
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Conkol KJ, Martinez-Strengel A, Coller RJ, Bergman DA, Whelan EM. Pediatric Hospitalists' Lessons Learned From an Innovation Award to Improve Care for Children With Medical Complexity. Hosp Pediatr 2020; 10:694-701. [PMID: 32651217 DOI: 10.1542/hpeds.2020-0069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
| | - Angela Martinez-Strengel
- Department of Internal Medicine, National Clinician Scholars Program, School of Medicine, Yale University, New Haven, Connecticut
| | - Ryan J Coller
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - David A Bergman
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
| | - Ellen-Marie Whelan
- Center for Medicaid and Children's Health Insurance Program Services, Centers for Medicare and Medicaid Services, Baltimore, Maryland
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