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Warniment A, Sauers-Ford H, Brady PW, Beck AF, Callahan SR, Giambra BK, Herzog D, Huang B, Loechtenfeldt A, Loechtenfeldt L, Miller CL, Perez E, Riddle SW, Shah SS, Shepard M, Sucharew HJ, Tegtmeyer K, Thomson JE, Auger KA. Garnering effective telehealth to help optimize multidisciplinary team engagement (GET2HOME) for children with medical complexity: Protocol for a pragmatic randomized control trial. J Hosp Med 2023; 18:877-887. [PMID: 37602537 DOI: 10.1002/jhm.13192] [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: 05/24/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Children and young adults with medical complexity (CMC) experience high rates of healthcare reutilization following hospital discharge. Prior studies have identified common hospital-to-home transition failures that may increase the risk for reutilization, including medication, technology and equipment issues, financial concerns, and confusion about which providers can help with posthospitalization needs. Few interventions have been developed and evaluated for CMC during this transition period. OBJECTIVE We will compare the effectiveness of the garnering effective telehealth 2 help optimize multidisciplinary team engagement (GET2HOME) transition bundle intervention to the standard hospital-based care coordination discharge process by assessing healthcare reutilization and patient- and family-centered outcomes. DESIGNS, SETTINGS, AND PARTICIPANTS We will conduct a pragmatic 2-arm randomized controlled trial (RCT) comparing the GET2HOME bundle intervention to the standard hospital-based care discharge process on CMC hospitalized and discharged from hospital medicine at two sites of our pediatric medical center between November 2022 and February 2025. CMC of any age will be identified as having complex chronic disease using the Pediatric Medical Complexity Algorithm tool. We will exclude CMC who live independently, live in skilled nursing facilities, are in custody of the county, or are hospitalized for suicidal ideation or end-of-life care. INTERVENTION We will randomize participants to the bundle intervention or standard hospital-based care coordination discharge process. The bundle intervention includes (1) predischarge telehealth huddle with inpatient providers, outpatient providers, patients, and their families; (2) care management discharge task tracker; and (3) postdischarge telehealth huddle with similar participants within 7 days of discharge. As part of the pragmatic design, families will choose if they want to complete the postdischarge huddle. The standard hospital-based discharge process includes a pharmacist, social worker, and care management support when consulted by the inpatient team but does not include huddles between providers and families. MAIN OUTCOME AND MEASURES Primary outcome will be 30-day urgent healthcare reutilization (unplanned readmission, emergency department, and urgent care visits). Secondary outcomes include 7-day urgent healthcare reutilization, patient- and family-reported transition quality, quality of life, and time to return to baseline using electronic health record and surveys at 7, 30, 60, and 90 days following discharge. We will also evaluate heterogeneity of treatment effect for the intervention across levels of financial strain and for CMC with high-intensity neurologic impairment. The primary analysis will follow the intention-to-treat principle with logistic regression used to study reutilization outcomes and generalized linear mixed modeling to study repeated measures of patient- and family-reported outcomes over time. RESULTS This pragmatic RCT is designed to evaluate the effectiveness of enhanced discharge transition support, including telehealth huddles and a care management discharge tool, for CMC and their families. Enrollment began in November 2022 and is projected to complete in February 2025. Primary analysis completion is anticipated in July 2025 with reporting of results following.
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Affiliation(s)
- Amanda Warniment
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Hadley Sauers-Ford
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Patrick W Brady
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Andrew F Beck
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Cincinnati Children's HealthVine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Michael Fisher Child Health Equity Center Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Scott R Callahan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Barbara K Giambra
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- College of Nursing, University of Cincinnati, Cincinnati, Ohio, USA
| | - Diane Herzog
- Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Bin Huang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Allison Loechtenfeldt
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Chelsey L Miller
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Combined Pediatrics/Medicine House Staff, Cincinnati Children's Hospital Medical Center and University of Cincinnati Hospital, Cincinnati, Ohio, USA
| | | | - Sarah W Riddle
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Heidi J Sucharew
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ken Tegtmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Center for Telehealth, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Joanna E Thomson
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Katherine A Auger
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Huth K, Hotz A, Emara N, Robertson B, Leaversuch M, Mercer AN, Khan A, Campos ML, Liss I, Hahn PD, Graham DA, Rossi L, Thomas MV, Elias N, Morris M, Glader L, Pinkham A, Bardsley KM, Wells S, Rogers J, Berry JG, Mauskar S, Starmer AJ. Reduced Postdischarge Incidents After Implementation of a Hospital-to-Home Transition Intervention for Children With Medical Complexity. J Patient Saf 2023; 19:493-500. [PMID: 37729645 DOI: 10.1097/pts.0000000000001155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
OBJECTIVES Prior research suggests that errors occur frequently for patients with medical complexity during the hospital-to-home transition. Less is known about effective postdischarge communication strategies for this population. We aimed to assess rates of 30-day (1) postdischarge incidents and (2) readmissions and emergency department (ED) visits before and after implementing a hospital-to-home intervention. METHODS We conducted a prospective intervention study of children with medical complexity discharged at a children's hospital from April 2018 to March 2020. A multistakeholder team developed a bundled intervention incorporating the I-PASS handoff framework including a postdischarge telephone call, restructured discharge summary, and handoff communication to outpatient providers. The primary outcome measure was rate of postdischarge incidents collected via electronic medical record review and family surveys. Secondary outcomes were 30-day readmissions and ED visits. RESULTS There were 199 total incidents and the most common were medication related (60%), equipment issues (15%), and delays in scheduling/provision of services (11%). The I-PASS intervention was associated with a 36.4% decrease in the rate of incidents per discharge (1.51 versus 0.95, P = 0.003). There were fewer nonharmful errors and quality issues after intervention (1.27 versus 0.85 per discharge, P = 0.02). The 30-day ED visit rate was significantly lower after intervention (12.6% versus 3.4%, per 100 discharges, P = 0.05). Thirty-day readmissions were 15.8% versus 10.2% postintervention (P = 0.32). CONCLUSIONS A postdischarge communication intervention for patients with medical complexity was associated with fewer postdischarge incidents and reduced 30-day ED visits. Standardized postdischarge communication may play an important role in improving quality and safety in the transition from hospital-to-home for vulnerable populations.
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Affiliation(s)
| | | | - Norah Emara
- From the Department of Pediatrics, Boston Children's Hospital
| | | | | | | | | | | | - Isabella Liss
- From the Department of Pediatrics, Boston Children's Hospital
| | - Phillip D Hahn
- Program for Patient Safety and Quality, Boston Children's Hospital
| | | | | | - Margaret V Thomas
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Nahel Elias
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Marie Morris
- From the Department of Pediatrics, Boston Children's Hospital
| | - Laurie Glader
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Amy Pinkham
- From the Department of Pediatrics, Boston Children's Hospital
| | | | - Sarah Wells
- From the Department of Pediatrics, Boston Children's Hospital
| | - Jayne Rogers
- From the Department of Pediatrics, Boston Children's Hospital
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Daoust D, Dodin P, Sy E, Lau V, Roumeliotis N. Prevalence and Readmission Rates of Discharge Directly Home From the PICU: A Systematic Review. Pediatr Crit Care Med 2023; 24:62-71. [PMID: 36594800 DOI: 10.1097/pcc.0000000000003114] [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: 01/04/2023]
Abstract
OBJECTIVES Critically ill patients are increasingly being discharged directly home from PICU as opposed to discharged home, via the ward. The objective was to assess the prevalence, safety, and satisfaction of discharge directly home from PICUs. DATA SOURCES We searched PubMed, Medline, EMBASE, PsycINFO, and CINAHL for studies published between January 1991 and June 2021. STUDY SELECTION We included observational or randomized studies, of children up to 18 years old, that reported on the prevalence, safety, or satisfaction of discharge directly home from the PICU, compared with the ward. Safety outcomes included readmission, unplanned visits to hospital, and any adverse events. We excluded case series, reviews, and studies discharging patients to other facilities. DATA EXTRACTION Two independent reviewers evaluated 88 full-text articles; five studies met eligibility (362,868 patients). Only one study had discharge directly home as a primary outcome. DATA SYNTHESIS Prevalence of discharge directly to home from the PICU ranged from less than 1% to 23% (random effects proportion 7.7 [95% CI, 1.3-18.6]). Readmissions to the PICU (only safety outcome) were significantly lower in the discharge directly home group compared with the ward group, in two of three studies (p < 0.0001). No studies reported on patient or family satisfaction. CONCLUSIONS The prevalence of discharge directly home from the PICU ranges from 1% to 23%. PICU readmission rates do not appear to increase after discharge directly home. Caution is needed in the interpretation of the results, given the significant heterogeneity of the included studies. Further high-quality studies are needed to evaluate the safety of discharge directly home from the PICU and support families in this transition.
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Affiliation(s)
- Daphne Daoust
- Faculty of Medicine, University of Montreal, Montreal, QC, Canada
| | - Philippe Dodin
- Medical Librarian, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montreal, QC, Canada
| | - Eric Sy
- Department of Medicine, College of Medicine, University of Saskatchewan, Regina, SK, Canada
| | - Vincent Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Nadia Roumeliotis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
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Hester G, Nickel AJ, Watson D, Maalouli W, Bergmann KR. Use of a Clinical Guideline and Orderset to Reduce Hospital Admissions for Croup. Pediatrics 2022; 150:188776. [PMID: 35970819 DOI: 10.1542/peds.2021-053507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Studies have found infrequent interventions after croup admission. Our objectives were to achieve 25% reduction in (1) admission rate and (2) neck radiograph utilization among patients presenting to the emergency department. METHODS At our tertiary children's hospital, we implemented clustered interventions including education, guideline, and orderset integration. We included patients 3 months to 8 years old with an emergency department, observation, or inpatient encounter for croup. We excluded patients with direct or ICU admissions, complex chronic conditions, or concurrent asthma, pneumonia, or bronchiolitis. We reviewed a random sample of 60% of encounters from baseline (October 1, 2017 to September 30, 2019) and implementation (October 1, 2019 to September 30, 2020) periods. We conducted a posthoc analysis from October 1, 2017 to December 1, 2021 to assess sustainment during coronavirus disease 2019. Interrupted time series analysis was used to evaluate changes in outcome, process, and balancing measures. RESULTS There were 2906 (2123 baseline and 783 implementation) encounters included. Extrapolating preintervention trend estimates, the baseline admission rate of 8.7% decreased to 5.5% postintervention (relative decrease 37% [95% confidence interval: 8 to 66]) and sustained over 26 months after implementation. Admission rate in patients receiving 2 or fewer racemic epinephrine was significantly lower in implementation (1.7%) compared with baseline (6.3%), relative decrease of 72% (95% confidence interval: 68 to 88). There were no significant changes in neck radiographs, length of stay, or revisits. CONCLUSIONS Croup quality improvement interventions were associated with a significant decrease in hospital admissions with no increase in revisits.
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Affiliation(s)
| | | | | | - Walid Maalouli
- University of Minnesota Masonic Children's Hospital, Minneapolis, Mennesota
| | - Kelly R Bergmann
- Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota
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Leyenaar JK, Esporas M, Mangione-Smith R. How Does Pediatric Quality Measure Development Reflect the Real World Needs of Hospitalized Children? Acad Pediatr 2022; 22:S70-S72. [PMID: 35339245 PMCID: PMC9614710 DOI: 10.1016/j.acap.2021.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/14/2021] [Accepted: 01/31/2021] [Indexed: 12/25/2022]
Affiliation(s)
- JoAnna K. Leyenaar
- The Department of Pediatrics and The Dartmouth Institute of Health Policy & Clinical Practice, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03755
| | - Megan Esporas
- Children’s Hospital Association, 600 13th Street, NW, Suite 500, Washington, DC 20005
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Gal DB, Kwiatkowski DM, Cribb Fabersunne C, Kipps AK. Direct Discharge to Home From the Pediatric Cardiovascular ICU. Pediatr Crit Care Med 2022; 23:e199-e207. [PMID: 35044343 DOI: 10.1097/pcc.0000000000002883] [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: 11/26/2022]
Abstract
OBJECTIVES To describe direct discharge to home from the cardiovascular ICU. DESIGN Mixed-methods including retrospective Pediatric Cardiac Critical Care Consortium and Pediatric Acute Care Cardiology Collaborative data and survey. SETTING Tertiary pediatric heart center. PATIENTS Patients less than 25 years old, with a cardiovascular ICU stay of greater than 24 hours and direct discharge to home from January 1, 2016, to December 8, 2020, were included. Select data describing patients discharged from acute care internally and nationally from Pediatric Acute Care Cardiology Collaborative sites were compared with the direct discharge to home cohort. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Encounter- and patient-specific characteristics. Seven-day and 30-day readmission and 30-day mortality served as surrogate safety markers. A survey of cardiovascular ICU frontline providers assessed comfort and skills related to direct discharge to home.There were 364 direct discharge to home encounters that met inclusion criteria. The majority of direct discharge to home encounters were associated with a surgery or procedure (305; 84%). There were 27 encounters (7.4%) for medical technology-dependent patients requiring direct discharge to home. Unplanned 7-day readmissions among direct discharge to home patients was 1.9% compared with 4.6% (p = 0.04) of patients discharged from acute care internally. Readmission among those discharged from acute care internally did not differ from those at Pediatric Acute Care Cardiology Collaborative sites nationally. Frontline cardiovascular ICU providers had mixed levels of confidence in technical aspects and low levels of confidence in logistics of direct discharge to home. CONCLUSIONS Cardiovascular ICU direct discharge to home was not associated with increased unplanned readmissions compared with patients discharged from acute care and may be safe in select patients. Frontline cardiovascular ICU providers feel time constraints challenge direct discharge to home. Further research is needed to identify patient characteristics associated with safe direct discharge to home and systems needed to support this practice.Summary statistics are described using proportions or medians with interquartile ranges (IQRs) and were performed using Microsoft Excel (Microsoft, Redmond, WA). Two-sample tests of proportions were used to compare readmission frequency of the DDH cohort compared with internal and national PAC3 data using STATA Version 15 (StataCorp, College Station, TX).
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Affiliation(s)
- Dana B Gal
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
| | - David M Kwiatkowski
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
| | - Camila Cribb Fabersunne
- San Francisco Department of Public Health, Division of Maternal and Child Health, San Francisco, CA
| | - Alaina K Kipps
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
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Banker SL, Lakhaney D, Hooe BS, McCann TA, Kostacos C, Lane M. A Quality Improvement Approach to Improving Discharge Documentation. Pediatr Qual Saf 2022; 7:e428. [PMID: 38586219 PMCID: PMC10997293 DOI: 10.1097/pq9.0000000000000428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/31/2020] [Indexed: 11/27/2022] Open
Abstract
Introduction Accurate discharge documentation is critical to ensuring a safe and effective transition of care following hospitalization, yet many discharge summaries do not meet consensus standards for content. A local needs assessment demonstrated gaps in documentation of 3 essential elements: discharge diagnosis, discharge medications, and follow-up appointments. This study aimed to increase the completion of three discharge elements from a baseline of 45% by 20 percentage points over 16 months for patients discharged from the general pediatrics service. Methods Ten discharge summaries were randomly selected and analyzed during each successive 2-week time period. Plan-Do-Study-Act cycles aimed to improve provider knowledge of essential discharge summary content, clarify communication during rounds, and create electronic health record shortcuts and quick-reference tools. Results The percentage of discharge summaries containing all 3 required elements increased from 45% to 73%. Specifically, documentation increased for discharge diagnosis (65%-87%), discharge medications (71%-90%), and follow-up appointments (88%-93%). There was no significant delay in discharge summary completion. Conclusions Discharge summaries are meaningfully and sustainably improved through provider education, workflows for clear communication, and electronic health record optimization.
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Affiliation(s)
- Sumeet L. Banker
- From the Division of Critical Care and Hospital Medicine, Department of Pediatrics, Columbia University Irving Medical Center, New York, N.Y
| | - Divya Lakhaney
- From the Division of Critical Care and Hospital Medicine, Department of Pediatrics, Columbia University Irving Medical Center, New York, N.Y
| | - Benjamin S. Hooe
- From the Division of Critical Care and Hospital Medicine, Department of Pediatrics, Columbia University Irving Medical Center, New York, N.Y
| | - Teresa A. McCann
- From the Division of Critical Care and Hospital Medicine, Department of Pediatrics, Columbia University Irving Medical Center, New York, N.Y
| | - Connie Kostacos
- Division of Child and Adolescent Health, Department of Pediatrics, Columbia University Irving Medical Center, New York, N.Y
| | - Mariellen Lane
- Division of Child and Adolescent Health, Department of Pediatrics, Columbia University Irving Medical Center, New York, N.Y
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Hlyva O, Rae C, Deibert S, Kamran R, Shaikh H, Thabane L, Rosenbaum P, Klassen A, Lim A. A Mixed-Methods Feasibility Study of Integrated Pediatric Complex Care: Experiences of Parents With Care and the Value of Parent Engagement in Research. FRONTIERS IN REHABILITATION SCIENCES 2021; 2:710335. [PMID: 36188846 PMCID: PMC9397898 DOI: 10.3389/fresc.2021.710335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/15/2021] [Indexed: 11/13/2022]
Abstract
Introduction: Children with medical complexity (CMC) are among the most vulnerable children in society. These children and their families face challenges of fragmented care and are at risk for poorer health outcomes. Families with CMC play a vital role in providing care and navigating the complexities of healthcare systems. It is essential to understand the best ways to engage these families in research to improve the care and optimize the health of CMC.Objectives: This study explored parent engagement within the context of a feasibility study evaluating an Integrated Tertiary Complex Care (ITCC) clinic created to support CMC closer to home. This paper aimed: (1) to understand the family experiences of care and (2) to explore parent engagement in the study.Method: This mixed-methods feasibility study included three components. First, feedback from focus groups was used to identify the common themes that informed interviews with parents. Second, one-on-one interviews were conducted with parents to explore their experience with care, such as the ITCC clinic, using an interpretative description approach. Third, the questionnaires were completed by parents at baseline and 6-months post-baseline. These questionnaires included demographic and cost information and three validated scales designed to measure the caregiver strain, family-centered care, and parental health. The recruitment rate, percentage completion of the questionnaires, and open-ended comments were used to assess parent engagement in the study.Results: The focus groups involved 24 parents, of which 19 (14 women, five men) provided comments. The findings identified the importance of Complex Care Team (CC Team) accessibility, local access, and family-centered approach to care. The challenges noted were access to homecare nursing, fatigue, and lack of respite affecting caregiver well-being. In this study, 17 parents participated in one-on-one interviews. The identified themes relevant to care experience were proximity, continuity, and coordination of care. The parents who received care through the ITCC clinic appreciated receiving care closer to home. The baseline questionnaires were completed by 44 of 77 (57%) eligible parents. Only 24 (31%) completed the 6-month questionnaire. The challenges with study recruitment and follow-up were identified.Conclusion: Family engagement was a challenging yet necessary endeavor to understand how to tailor the healthcare to meet the complex needs of families caring for CMC.
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Affiliation(s)
- Oksana Hlyva
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Charlene Rae
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Shelby Deibert
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Rakhshan Kamran
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Haniah Shaikh
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Health, Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Peter Rosenbaum
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Anne Klassen
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Audrey Lim
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- *Correspondence: Audrey Lim
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Clark NA, Simmons J, Etzenhouser A, Pallotto EK. Improving Outpatient Provider Communication for High-Risk Discharges From the Hospitalist Service. Hosp Pediatr 2021; 11:1033-1048. [PMID: 34526327 DOI: 10.1542/hpeds.2020-005421] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Patients are at risk for adverse events during inpatient-to-outpatient transitions of care. Previous improvement work has been targeted at this care transition, but gaps in discharge communication still exist. We aimed to increase documentation of 2-way communication between hospitalists and primary care providers (PCPs) for high-risk discharges from pediatric hospital medicine (PHM) services from 7% to 60% within 30 months. METHODS A3 improvement methodology was used. A list of high-risk discharge communication criteria was developed through engagement of PCPs and hospitalists. A driver diagram guided interventions. The outcome measure was documentation of successful 2-way communication with the PCP. Any documented 2-way discharge communication attempt was the process measure. Via a survey, hospitalist satisfaction with the discharge communication expectation served as the balancing measure. All patients discharged from PHM services meeting ≥1 high-risk criterion were included. Statistical process control charts were used to assess changes over time. RESULTS There were 3241 high-risk discharges (442 baseline: November 2017 to January 2018; 2799 intervention and sustain: February 2018 to June 2020). The outcome measure displayed iterative special cause variation from a mean baseline of 7% to peak of 39% but regressed and was sustained at 27%. The process measure displayed iterative special cause variation from a 13% baseline mean to a 64% peak, with regression to 41%. The balancing measure worsened from baseline of 5% dissatisfaction to 13%. Interventions temporally related to special cause improvements were education, division-level performance feedback, standardization of documentation, and offloading the task of communication coordination from hospitalists to support staff. CONCLUSIONS Improvement methodology resulted in modestly sustained improvements in PCP communication for high-risk discharges from the PHM services.
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Affiliation(s)
- Nicholas A Clark
- Division of Hospital Medicine
- School of Medicine, University of Missouri-Kansas City
| | - Julia Simmons
- Mercy Children's Hospital St Louis, St Louis, Missouri
| | - Angela Etzenhouser
- Division of Hospital Medicine
- School of Medicine, University of Missouri-Kansas City
- Graduate Medical Education, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
| | - Eugenia K Pallotto
- Division of Neonatology, Department of Pediatrics, Atrium Health Levine Children's Hospital, Charlotte, North Carolina
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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 PMCID: PMC8638015 DOI: 10.1007/s10488-021-01134-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [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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11
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Connell SK, Burkhart Q, Tolpadi A, Parast L, Gidengil CA, Yung S, Basco WT, Williams D, Britto MT, Brittan M, Wood KE, Bardach N, McGalliard J, Mangione-Smith R. Quality of Care for Youth Hospitalized for Suicidal Ideation and Self-Harm. Acad Pediatr 2021; 21:1179-1186. [PMID: 34058402 PMCID: PMC8448557 DOI: 10.1016/j.acap.2021.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine performance on quality measures for pediatric inpatient suicidal ideation/self-harm care, and whether performance is associated with reutilization. METHODS Retrospective observational 8 hospital study of patients [N = 1090] aged 5 to 17 years hospitalized for suicidal ideation/self-harm between 9/1/14 and 8/31/16. Two medical records-based quality measures assessing suicidal ideation/self-harm care were evaluated, one on counseling caregivers regarding restricting access to lethal means and the other on communication between inpatient and outpatient providers regarding the follow-up plan. Multivariable logistic regression assessed associations between quality measure scores and 1) hospital site, 2) patient demographics, and 3) 30-day emergency department return visits and inpatient readmissions. RESULTS Medical record documentation revealed that, depending on hospital site, 17% to 98% of caregivers received lethal means restriction counseling (mean 70%); inpatient-to-outpatient provider communication was documented in 0% to 51% of cases (mean 16%). The odds of documenting receipt of lethal means restriction counseling was higher for caregivers of female patients compared to caregivers of male patients (adjusted odds ratio [aOR] 1.51, 95% confidence interval [CI], 1.07-2.14). The odds of documenting inpatient-to-outpatient provider follow-up plan communication was lower for Black patients compared to White patients (aOR 0.45, 95% CI, 0.24-0.84). All-cause 30-day readmission was lower for patients with documented caregiver receipt of lethal means restriction counseling (aOR 0.48, 95% CI, 0.28-0.83). CONCLUSIONS This study revealed disparities and deficits in the quality of care received by youth with suicidal ideation/self-harm. Providing caregivers lethal means restriction counseling prior to discharge may help to prevent readmission.
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Affiliation(s)
- Sarah K Connell
- Department of Pediatrics, University of Washington (SK Connell), Seattle, Wash; Center for Child Health, Behavior, and Development, Seattle Children's Research Institute (SK Connell and J McGalliard), Seattle, Wash.
| | - Q Burkhart
- RAND Corporation (Q Burkhart, A Tolpadi, L Parast), Santa Monica, Calif
| | - Anagha Tolpadi
- RAND Corporation (Q Burkhart, A Tolpadi, L Parast), Santa Monica, Calif
| | - Layla Parast
- RAND Corporation (Q Burkhart, A Tolpadi, L Parast), Santa Monica, Calif
| | | | - Steven Yung
- Mount Sinai Hospital (S Yung), New York, NY; Maimonides Medical Center (S Yung), Brooklyn, NY
| | - William T Basco
- Medical University of South Carolina (WT Basco), Charleston, SC
| | - Derek Williams
- Vanderbilt University Medical Center (D Williams), Nashville, Tenn
| | - Maria T Britto
- Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine (MT Britto), Cincinnati, Ohio
| | - Mark Brittan
- Children's Hospital Colorado (M Brittan), Aurora, Colo
| | - Kelly E Wood
- University of Iowa Stead Family Children's Hospital (KE Wood), Iowa City, Iowa
| | - Naomi Bardach
- UCSF Department of Pediatrics (N Bardach), San Francisco, Calif
| | - Julie McGalliard
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute (SK Connell and J McGalliard), Seattle, Wash
| | - Rita Mangione-Smith
- Kaiser Permanente Washington Health Research Institute (R Mangione-Smith), Seattle, Wash
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12
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Yale S, Bauer SC, Stephany A, Porada K, Liljestrom T. One Call Away: Addressing a Safety Gap for Urgent Issues Post Discharge. Hosp Pediatr 2021; 11:632-635. [PMID: 34045321 DOI: 10.1542/hpeds.2020-003418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVES The transition period from hospitalization to outpatient care can be high risk for pediatric patients. Our aim was to profile the use of a "safety net" for families through provision of specific inpatient provider contact information for urgent issues post discharge. METHODS In this prospective study, we implemented an updated after-visit summary that directed families to call the hospital operator and specifically ask for the pediatric hospital medicine attending on call if they were unable to reach their primary care provider (PCP) with an urgent postdischarge concern. Education for nursing staff, operators, and pediatric hospital medicine providers was completed, and contact information was automatically populated into the after-visit summary. Information collected included the number of calls, the topic, time spent, whether the family contacted the PCP first, and the time of day. Descriptive statistics and Fisher's exact test were used to summarize findings. RESULTS Over a 13-month period, of 5145 discharges, there were 47 postdischarge phone calls, which averaged to 3.6 calls per month. The average length of time spent on a call was 21 minutes. For 30% of calls, families had tried contacting their PCPs first, and 55% of calls occurred at night. Topics of calls included requesting advice about symptoms, time line for reevaluation, and assistance with medications. CONCLUSIONS This safety net provided families with real-time problem-solving for an urgent need post discharge, which included triaging patient symptoms at home, counseling on medication questions, information about the time line of illness recovery, and provision of additional resources.
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Affiliation(s)
- Sarah Yale
- Children's Wisconsin, Milwaukee, Wisconsin;
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Sarah Corey Bauer
- Children's Wisconsin, Milwaukee, Wisconsin
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | | | - Kelsey Porada
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Tracey Liljestrom
- Children's Wisconsin, Milwaukee, Wisconsin
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
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13
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Abstract
OBJECTIVES The need for high-quality discharge summaries is critical to ensure safe transitions of care. Deficits may lead to lapses in communication and poor outcomes. In this study, we sought to characterize the completeness, accuracy, and quality of pediatric discharge summaries. METHODS A retrospective chart review of 200 discharge summaries of patients discharged from the general pediatrics service from July 2016 to October 2017 was conducted. These summaries were audited for 7 elements: admission date, discharge date, discharge diagnosis, medications, immunizations, pending laboratory tests, and follow-up appointments. Accuracy was verified through chart review. Quality of hospital course and patient instructions was evaluated by using a modified validated discharge summary evaluation tool. Additional data collected included medical complexity of the patient and the number of authors. Analysis of variance, χ2 tests, and Pearson correlations were used to analyze data. RESULTS Discharge diagnosis, medications, and follow-up appointments had the lowest rates of completion and accuracy. The quality of the hospital course and patient instructions was variable, with no statistical significance seen in quality scores on the basis of the number of authors or medical complexity. There were more inaccuracies in discharge medications for patients with baseline chronic conditions than those without chronic conditions (63% vs 35%; P < .001). CONCLUSIONS Content and quality of discharge summary documentation are inconsistent and have implications for patient outcomes after discharge. This study highlights areas of opportunity to improve pediatric discharge summaries. Future work should be focused on educational and systems-based interventions to improve documentation.
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Affiliation(s)
- Divya Lakhaney
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Sumeet L Banker
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
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14
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A Quality Improvement Intervention Bundle to Reduce 30-Day Pediatric Readmissions. Pediatr Qual Saf 2020; 5:e264. [PMID: 32426630 PMCID: PMC7190252 DOI: 10.1097/pq9.0000000000000264] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 01/30/2020] [Indexed: 02/02/2023] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: Pediatric hospital readmissions can represent gaps in care quality between discharge and follow-up, including social factors not typically addressed by hospitals. This study aimed to reduce the 30-day pediatric readmission rate on 2 general pediatric services through an intervention to enhance care spanning the hospital stay, discharge, and follow-up process. Methods: A multidisciplinary team developed an intervention bundle based on a needs assessment and evidence-based models of transitional care. The intervention included pre-discharge planning with a transition coordinator, screening and intervention for adverse social determinants of health (SDH), medication reconciliation after discharge, communication with the primary care provider, access to a hospital-based transition clinic, and access to a 24-hour direct telephone line staffed by hospital attending pediatricians. These were implemented sequentially from October 2013 to February 2017. The primary outcome was the readmission rate within 30 days of index discharge. The length of stay was a balancing measure. Results: During the intervention, the included services discharged 4,853 children. The pre-implementation readmission rate of 10.3% declined to 7.4% and remained stable during a 4-month post-intervention observation period. Among 1,394 families screened for adverse SDH, 48% reported and received assistance with ≥ 1 concern. The length of stay increased from 4.10 days in 2013 to 4.30 days in 2017. Conclusions: An intervention bundle, including SDH, was associated with a sustained reduction in readmission rates to 2 general pediatric services. Transitional care that addresses multiple domains of family need during a child’s health crisis can help reduce pediatric readmissions.
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15
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Desai AD, Zhou C, Simon TD, Mangione-Smith R, Britto MT. Validation of a Parent-Reported Hospital-to-Home Transition Experience Measure. Pediatrics 2020; 145:e20192150. [PMID: 31969474 PMCID: PMC6993281 DOI: 10.1542/peds.2019-2150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The Pediatric Transition Experience Measure (P-TEM) is an 8-item, parent-reported measure that globally assesses hospital-to-home transition quality from discharge through follow-up. Our goal was to examine the convergent validity of the P-TEM with existing, validated process and outcome measures of pediatric hospital-to-home transitions. METHODS This was a prospective, cohort study of English-speaking parents and legal guardians who completed the P-TEM after their children's discharge from a tertiary children's hospital between January 2016 and October 2016. By using data from 3 surveys, we assessed convergent validity by examining associations between total and domain-specific P-TEM scores (0-100 scale) and 4 pediatric hospital-to-home transition validation measures: (1) Child Hospital Consumer Assessment of Healthcare Providers and Systems Discharge Composite, (2) Center of Excellence on Quality of Care Measures for Children With Complex Needs parent-reported transition measures, (3) change in health-related quality of life from admission to postdischarge, and (4) 30-day emergency department revisits or readmissions. RESULTS P-TEM total scores were 7.5 points (95% confidence interval: 4.6 to 10.4) higher for participants with top-box responses on the Child Hospital Consumer Assessment of Healthcare Providers and Systems Discharge Composite compared with those of participants with lower Discharge Composite scores. Participants with highet P-TEM scores (ie, top-box responses) had 6.3-points-greater improvement (95% confidence interval: 2.8 to 9.8) in health-related quality of life compared with participants who reported lower P-TEM scores. P-TEM scores were not significantly associated with 7- or 30-day reuse. CONCLUSIONS The P-TEM demonstrated convergent validity with existing hospital-to-home process and outcome validation measures in a population of hospitalized children.
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Affiliation(s)
- Arti D Desai
- Department of Pediatrics, University of Washington, Seattle, Washington;
- Seattle Children's Research Institute, Seattle, Washington; and
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington; and
| | - Tamara D Simon
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington; and
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington; and
| | - Maria T Britto
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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16
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Leary JC, Walsh KE, Morin RA, Schainker EG, Leyenaar JK. Quality and Safety of Pediatric Inpatient Care in Community Hospitals: A Scoping Review. J Hosp Med 2019; 14:694-703. [PMID: 31532739 PMCID: PMC6827538 DOI: 10.12788/jhm.3268] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although the majority of children are hospitalized in nonchildren's hospitals, little is known about the quality and safety of pediatric care in community hospitals. OBJECTIVE The aim of this study was to conduct a scoping review and synthesize literature on the quality and safety of pediatric inpatient care in United States community hospitals. METHODS We performed a systematic literature search in October 2016 to identify pediatric studies that reported on safety, effectiveness, efficiency, timeliness, patient-centeredness, or equity set in general, nonuniversity, or nonchildren's hospitals. We extracted data on study design, patient descriptors, and quality outcomes and assessed the risk of bias using modified Newcastle-Ottawa Scales. RESULTS A total of 44 articles met the inclusion criteria. Study designs, patient populations, and quality outcome measures were heterogeneous; only three clinical domains, (1) perinatal regionalization, (2) telemedicine, and (3) imaging radiation, were explored in multiple studies with consistent directionality of results. A total of 30 studies were observational, and 22 studies compared community hospital quality outcomes with other hospital types. The remaining 14 studies reported testing of interventions; 12 showed improved quality of care postintervention. All studies reported an outcome addressing safety, effectiveness, or efficiency, whereas timeliness, patient-centeredness, and equity were infrequently addressed. Risk of bias was moderate or high for 72% of studies. CONCLUSIONS Literature on the inpatient care of children in community hospitals is limited, making it difficult to evaluate healthcare quality. Measures of timeliness, patient-centeredness, and equity are underrepresented. The field would benefit from more multicenter collaborations to facilitate the application of robust study designs and to enable a systematic assessment of individual interventions and community hospital quality outcomes.
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Affiliation(s)
- Jana C Leary
- The Floating Hospital for Children at Tufts Medical Center, Department of Pediatrics, Tufts University School of Medicine, Boston, Massachusetts
- Corresponding Author: Jana C. Leary, MD, MS; E-mail: ; Telephone: 617-636-4624
| | - Kathleen E Walsh
- James M Anderson Center for Health Systems Excellence, Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Rebecca A Morin
- Tufts University, Hirsh Health Sciences Library, Boston, Massachusetts
| | | | - JoAnna K Leyenaar
- The Dartmouth Institute for Health Policy & Clinical Practice and Department of Pediatrics, Children’s Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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17
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Desai AD, Starmer AJ. Process Metrics and Outcomes to Inform Quality Improvement in Pediatric Hospital Medicine. Pediatr Clin North Am 2019; 66:725-737. [PMID: 31230619 DOI: 10.1016/j.pcl.2019.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article provides an overview of the selection, development, and use of process and outcome measures for pediatric hospital medicine quality improvement initiatives. It reviews commonly used categories of process and outcome measures and provides a list of common sources and repositories of previously validated measures. It also provides a blueprint for the development of novel measures. The relative merits of various data collection methods are discussed (eg, medical record abstraction, administrative, surveys), along with guiding principles for disseminating the results of quality improvement evaluations on a local and national level.
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Affiliation(s)
- Arti D Desai
- University of Washington, Seattle Children's Research Institute, 2001 8th Avenue, Suite 400, Seattle, WA 98121, USA.
| | - Amy J Starmer
- Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
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18
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McDaniel CE, Jennings R, Schroeder AR, Paciorkowski N, Hofmann M, Leyenaar J. Aligning Inpatient Pediatric Research With Settings of Care: A Call to Action. Pediatrics 2019; 143:peds.2018-2648. [PMID: 31018987 DOI: 10.1542/peds.2018-2648] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
- Corrie E McDaniel
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Washington;
| | - Rebecca Jennings
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Washington
| | - Alan R Schroeder
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, California
| | | | - Michelle Hofmann
- Department of Pediatrics, School of Medicine, The University of Utah, Salt Lake City, Utah; and
| | - JoAnna Leyenaar
- Department of Pediatrics, The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
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19
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Martens A, DeLucia M, Leyenaar JK, Mallory LA. Foster Caregiver Experience of Pediatric Hospital-to-Home Transitions: A Qualitative Analysis. Acad Pediatr 2018; 18:928-934. [PMID: 30401467 DOI: 10.1016/j.acap.2018.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 06/01/2018] [Accepted: 06/16/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Children entering foster care after discharge from the hospital are at risk for adverse events associated with the hospital-to-home transition. Education of foster caregivers regarding transitional care needs is key. However, little is known about the unique needs of foster caregivers as they transition from hospital to home with a new foster child or how hospital-based health care teams can better support foster caregivers. We aimed to examine the experiences and preferences of foster caregivers' regarding hospital-to-home transitions of children newly discharged into their care and to identify opportunities for inpatient providers to improve outcomes for these children. METHODS We conducted semistructured telephone interviews of foster caregivers who newly assumed care of a child at the time of hospital discharge between May 2016 and June 2017. Interviews were continued until thematic saturation was reached. Interviews were audio recorded, transcribed, and analyzed to identify themes using a general inductive approach. RESULTS Fifteen interviews were completed. All subjects were female, 87% were Caucasian, and 73% were first-time foster caregivers. Thirteen themes were identified and grouped into the following domains: 1) knowing the child, 2) medicolegal issues, 3) complexities of multistakeholder communication, and 4) postdischarge preparation and support. CONCLUSIONS Caregivers of children newly entering foster care following hospital discharge face unique challenges and may benefit from enhanced care processes to facilitate successful transitions. Hospitalization provides an opportunity for information gathering and sharing, clarification of custodial status, and facilitation of communication among multistakeholders, including child protective services and biological parents.
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Affiliation(s)
- Anna Martens
- Tufts University School of Medicine (A Martens and M DeLucia), Boston, Mass
| | - Michael DeLucia
- Tufts University School of Medicine (A Martens and M DeLucia), Boston, Mass
| | - JoAnna K Leyenaar
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center and Dartmouth Institute for Health Policy and Clinical Practice (JK Leyenaar), Lebanon, NH
| | - Leah A Mallory
- Department of Pediatrics, The Barbara Bush Children's Hospital at Maine Medical Center (LA Mallory), Portland, Me.
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20
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Desai AD, Simon TD, Leyenaar JK, Britto MT, Mangione-Smith R. Utilizing Family-Centered Process and Outcome Measures to Assess Hospital-to-Home Transition Quality. Acad Pediatr 2018; 18:843-846. [PMID: 30077673 PMCID: PMC6598693 DOI: 10.1016/j.acap.2018.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/13/2018] [Accepted: 07/28/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Arti D Desai
- Department of Pediatrics (AD Desai, TD Simon, and R Mangione-Smith), University of Washington, Seattle; Seattle Children's Research Institute (AD Desai, TD Simon, and R Mangione-Smith).
| | - Tamara D Simon
- Department of Pediatrics (AD Desai, TD Simon, and R Mangione-Smith), University of Washington, Seattle; Seattle Children's Research Institute (AD Desai, TD Simon, and R Mangione-Smith)
| | - JoAnna K Leyenaar
- Department of Pediatrics & The Dartmouth Institute for Health Policy and Clinical Practice (JK Leyenaar), Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Maria T Britto
- James M. Anderson Center for Health Systems Excellence (MT Britto), Cincinnati Children's Hospital Medical Center, Ohio
| | - Rita Mangione-Smith
- Department of Pediatrics (AD Desai, TD Simon, and R Mangione-Smith), University of Washington, Seattle; Seattle Children's Research Institute (AD Desai, TD Simon, and R Mangione-Smith)
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21
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Hamline MY, Speier RL, Vu PD, Tancredi D, Broman AR, Rasmussen LN, Tullius BP, Shaikh U, Li STT. Hospital-to-Home Interventions, Use, and Satisfaction: A Meta-analysis. Pediatrics 2018; 142:e20180442. [PMID: 30352792 PMCID: PMC6317574 DOI: 10.1542/peds.2018-0442] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2018] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Hospital-to-home transitions are critical opportunities to promote patient safety and high-quality care. However, such transitions are often fraught with difficulties associated with increased health care use and poor patient satisfaction. OBJECTIVE In this review, we determine which pediatric hospital discharge interventions affect subsequent health care use or parental satisfaction compared with usual care. DATA SOURCES We searched 7 bibliographic databases and 5 pediatric journals. STUDY SELECTION Inclusion criteria were: (1) available in English, (2) focused on children <18 years of age, (3) pediatric data reported separately from adult data, (4) not focused on normal newborns or pregnancy, (5) discharge intervention implemented in the inpatient setting, and (6) outcomes of health care use or caregiver satisfaction. Reviews, case studies, and commentaries were excluded. DATA EXTRACTION Two reviewers independently abstracted data using modified Cochrane data collection forms and assessed quality using modified Downs and Black checklists. RESULTS Seventy one articles met inclusion criteria. Although most interventions improved satisfaction, interventions variably reduced use. Interventions focused on follow-up care, discharge planning, teach back-based parental education, and contingency planning were associated with reduced use across patient groups. Bundled care coordination and family engagement interventions were associated with lower use in patients with chronic illnesses and neonates. LIMITATIONS Variability limited findings and reduced generalizability. CONCLUSIONS In this review, we highlight the utility of a pediatric discharge bundle in reducing health care use. Coordinating follow-up, discharge planning, teach back-based parental education, and contingency planning are potential foci for future efforts to improve hospital-to-home transitions.
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Affiliation(s)
| | | | - Paul Dai Vu
- School of Aerospace Medicine, Wright-Patterson Air Force Base, United States Air Force, Dayton, Ohio
| | | | - Alia R Broman
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon; and
| | | | - Brian P Tullius
- Department of Pediatric Hematology, Oncology, and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio
| | - Ulfat Shaikh
- Department of Pediatrics
- School of Medicine, University of California, Davis, Sacramento, California
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22
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Herbst LA, Desai S, Benscoter D, Jerardi K, Meier KA, Statile AM, White CM. Going back to the ward-transitioning care back to the ward team. Transl Pediatr 2018; 7:314-325. [PMID: 30460184 PMCID: PMC6212378 DOI: 10.21037/tp.2018.08.01] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Transition of care from the intensive care unit (ICU) to the ward is usually an indication of the patient's improving clinical status, but is also a time when patients are particularly vulnerable. The transition between care teams poses a higher risk of medical error, which can be mitigated by safe and complete patient handoff and medication reconciliation. ICU readmissions are associated with increased mortality as well as ICU and hospital length of stay (LOS); however tools to accurately predict ICU readmission risk are limited. While there are many mechanisms in place to carefully identify patients appropriate for transfer to the ward, the optimal timing of transfer can be affected by ICU strain, limited resources such as ICU beds, and overall hospital capacity and flow leading to suboptimal transfer times or delays in transfer. The patient and family perspectives should also be considered when planning for transfer from the ICU to the ward. During times of transition, families will meet a new care team, experience uncertainty of future care plans, and adjust to a different daily routine which can lead to increased stress and anxiety. Additionally, a subset of patients, such as those with new technology, require additional multidisciplinary support, education and care coordination which can contribute to longer hospital LOS if not addressed proactively early in the hospitalization while the patient remains in the ICU. In this review article, we describe key components of the transfer from ICU to the ward, discuss current strategies to optimize timing of patient transfers, explore strategies to partner with patients and families during the transfer process, highlight patient populations where additional considerations are needed, and identify future areas of exploration which could improve the care transition from the ICU to the ward.
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Affiliation(s)
- Lori A Herbst
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA.,Geriatrics & Palliative Care Division, Department of Family & Community Medicine, UC College of Medicine, Cincinnati, OH, USA
| | - Sanyukta Desai
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA
| | - Dan Benscoter
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA
| | - Karen Jerardi
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA
| | - Katie A Meier
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA
| | - Angela M Statile
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA
| | - Christine M White
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA
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23
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Leyenaar JK, Andrews CB, Tyksinski ER, Biondi E, Parikh K, Ralston S. Facilitators of interdepartmental quality improvement: a mixed-methods analysis of a collaborative to improve pediatric community-acquired pneumonia management. BMJ Qual Saf 2018; 28:215-222. [PMID: 30100566 DOI: 10.1136/bmjqs-2018-008065] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 06/22/2018] [Accepted: 07/22/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Emergency medicine and paediatric hospital medicine physicians each provide a portion of the initial clinical care for the majority of hospitalised children in the USA. While these disciplines share goals to increase quality of care, there are scant data describing their collaboration. Our national, multihospital learning collaborative, which aimed to increase narrow-spectrum antibiotic prescribing for paediatric community-acquired pneumonia, provided an opportunity to examine factors influencing the success of quality improvement efforts across these two clinical departments. OBJECTIVE To identify barriers to and facilitators of interdepartmental quality improvement implementation, with a particular focus on increasing narrow-spectrum antibiotic use in the emergency department and inpatient settings for children hospitalised with pneumonia. METHODS We used a mixed-methods design, analysing interviews, written reports and quality measures. To describe hospital characteristics and quality measures, we calculated medians/IQRs for continuous variables, frequencies for categorical variables and Pearson correlation coefficients. We conducted in-depth, semistructured interviews by phone with collaborative site leaders; interviews were transcribed verbatim and, with progress reports, analysed using a general inductive approach. RESULTS 47 US-based hospitals were included in this analysis. Qualitative analysis of 35 interview transcripts and 142 written reports yielded eight inter-related domains that facilitated successful interdepartmental quality improvement: (1) hospital leadership and support, (2) quality improvement champions, (3) evidence supporting the intervention, (4) national health system influences, (5) collaborative culture, (6) departments' structure and resources, (7) quality improvement implementation strategies and (8) interdepartmental relationships. CONCLUSIONS The conceptual framework presented here may be used to identify hospitals' strengths and potential barriers to successful implementation of quality improvement efforts across clinical departments.
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Affiliation(s)
- JoAnna K Leyenaar
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Christine B Andrews
- Department of Pediatrics, Hasbro Children's Hospital, Providence, Rhode Island, USA
| | - Emily R Tyksinski
- Department of Nursing, Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Eric Biondi
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, Maryland, USA
| | - Kavita Parikh
- Division of Hospitalist Medicine, Children's National Health System, Washington, District of Columbia, USA
| | - Shawn Ralston
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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DeLucia M, Martens A, Leyenaar J, Mallory LA. Improving Hospital-to-Home Transitions for Children Entering Foster Care. Hosp Pediatr 2018; 8:465-470. [PMID: 30042218 DOI: 10.1542/hpeds.2017-0221] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
| | - Anna Martens
- School of Medicine, Tufts University, Boston, Massachusetts
| | - JoAnna Leyenaar
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; and
| | - Leah A Mallory
- Department of Pediatrics, The Barbara Bush Children's Hospital, Maine Medical Center, Portland, Maine
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25
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Rosenthal JL, Li STT, Hernandez L, Alvarez M, Rehm RS, Okumura MJ. Familial Caregiver and Physician Perceptions of the Family-Physician Interactions During Interfacility Transfers. Hosp Pediatr 2018; 7:344-351. [PMID: 28546453 DOI: 10.1542/hpeds.2017-0017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Children with special health care needs (CSHCN) have frequent hospitalizations and high specialty care utilization. If they initially present to a medical facility not capable of providing their definitive care, these children often experience an interfacility transfer. This transition has potential to impose hardships on familial caregivers. The goal of this study was to explore family-physician interactions during interfacility transfers from the perspectives of referring and accepting physicians and familial caregivers, and then develop a conceptual model for effective patient- and family-centered interfacility transfers that leverages the family-physician interaction. METHODS This single-center qualitative study used grounded theory methods. Interviews were conducted with referring and accepting physicians and the familial caregivers of CSHCN. Four researchers coded the data. The research team reached consensus on the major categories and developed a conceptual model. RESULTS Eight referring physicians, 9 accepting physicians, and 8 familial caregivers of 25 CSHCN were interviewed. All participants stated that family-physician interactions during transfers should be improved. Three main categories were developed: shared decision-making, provider awareness of families' resource needs, and communication. The conceptual model showed that 2-way communication allows providers to gain awareness of families' needs, which can facilitate shared decision-making, ultimately enhancing effective coordination and patient- and family-centered transfers. CONCLUSIONS Shared decision-making, provider awareness of families' resource needs, and communication are perceived as integral aspects of the family-physician interaction during interfacility transfers. Transfer systems should be reengineered to optimize family-physician interactions to make interfacility transfers more patient- and family-centered.
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Affiliation(s)
- Jennifer L Rosenthal
- Department of Pediatrics, University of California, Davis, Sacramento, California;
| | - Su-Ting T Li
- Department of Pediatrics, University of California, Davis, Sacramento, California
| | | | - Michelle Alvarez
- American University of Antigua, College of Medicine, St. John's, Antigua and Barbuda
| | | | - Megumi J Okumura
- Pediatrics and Internal Medicine, University of California, San Francisco, San Francisco, California; and
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26
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Pordes E, Gordon J, Sanders LM, Cohen E. Models of Care Delivery for Children With Medical Complexity. Pediatrics 2018; 141:S212-S223. [PMID: 29496972 DOI: 10.1542/peds.2017-1284f] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2017] [Indexed: 11/24/2022] Open
Abstract
Children with medical complexity (CMC) are a subset of children and youth with special health care needs with high resource use and health care costs. Novel care delivery models in which care coordination and other services to CMC are provided are a focus of national and local health care and policy initiatives. Current models of care for CMC can be grouped into 3 main categories: (1) primary care-centered models, (2) consultative- or comanagement-centered models, and (3) episode-based models. Each model has unique advantages and disadvantages. Evaluations of these models have demonstrated positive outcomes, but most studies have limited generalizability for broader populations of CMC. A lack of standardized outcomes and population definitions for CMC hinders assessment of the comparative effectiveness of different models of care and identification of which components of the models lead to positive outcomes. Ongoing challenges include inadequate support for family caregivers and threats to the sustainability of models of care. Collaboration among key stakeholders (patients, families, providers, payers, and policy makers) is needed to address the gaps in care and create best practice guidelines to ensure the delivery of high-value care for CMC.
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Affiliation(s)
- Elisabeth Pordes
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John Gordon
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lee M Sanders
- Lucile Packard Children's Hospital and Center for Policy, Outcomes and Prevention (CPOP), Stanford University, Palo Alto, California; and
| | - Eyal Cohen
- Department of Pediatrics, The Hospital for Sick Children and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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27
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Leyenaar JK, Rizzo PA, O'Brien ER, Lindenauer PK. Paediatric hospital admission processes and outcomes: a qualitative study of parents' experiences and priorities. BMJ Qual Saf 2018; 27:790-798. [PMID: 29453197 DOI: 10.1136/bmjqs-2017-007442] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 12/28/2017] [Accepted: 01/28/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Hospital admission, like hospital discharge, represents a transition of care associated with changes in setting, healthcare providers and clinical management. While considerable efforts have focused on improving the quality and safety of hospital-to-home transitions, there has been little focus on transitions into hospital. OBJECTIVES Among children hospitalised with ambulatory care sensitive conditions, we aimed to characterise families' experiences as they transitioned from outpatient to inpatient care, identify hospital admission processes and outcomes most important to families and determine how parental perspectives differed between children admitted directly and through emergency departments (ED). METHODS We conducted semistructured interviews with parents of hospitalised children at four structurally diverse hospitals. We inquired about preadmission healthcare encounters, how hospital admission decisions were made and parents' preferences regarding hospital admission processes and outcomes. Interviews were transcribed verbatim and analysed using a general inductive approach. RESULTS We conducted 48 interviews. Participants were predominantly mothers (74%); 45% had children with chronic illnesses and 52% were admitted directly. Children had a median of two (IQR 1-3) healthcare encounters in the week preceding hospital admission, with 44% seeking care in multiple settings. Patterns of healthcare utilisation were influenced by (1) disease acuity and healthcare access; (2) past experiences; and (3) varied perspectives about primary care and ED roles as hospital gatekeepers. Participants' hospital admission priorities included: (1) effective clinical care; (2) efficient admission processes; (3) safety and security; (4) timeliness; and (5) patient and family-centred processes of care. CONCLUSIONS Families received preadmission care in several settings and described varying degrees of care coordination during their admission processes. This research can guide improvements in hospitals' admission systems, necessary to achieve health system integration and continuity of care.
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Affiliation(s)
- JoAnna K Leyenaar
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA.,Graduate Program in Clinical and Translational Science, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Paul A Rizzo
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Emily R O'Brien
- Department of Nursing, Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Peter K Lindenauer
- Department of Internal Medicine, Baystate Medical Center, Springfield, Massachusetts, USA.,Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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28
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Leyenaar JK, Rizzo PA, Khodyakov D, Leslie LK, Lindenauer PK, Mangione-Smith R. Importance and Feasibility of Transitional Care for Children With Medical Complexity: Results of a Multistakeholder Delphi Process. Acad Pediatr 2018; 18:94-101. [PMID: 28739535 PMCID: PMC5756674 DOI: 10.1016/j.acap.2017.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 07/14/2017] [Accepted: 07/18/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Children with medical complexity (CMC) account for disproportionate hospital utilization and adverse outcomes after discharge, and several gaps exist regarding the quality of hospital to home transitional care for this population. We conducted an expert elicitation process to identify important and feasible hospital to home transitional care interventions for CMC from the perspectives of parents and health care professionals. METHODS We conducted a 2-round electronic Delphi process to identify important and feasible transitional care interventions. Panelists included parents of CMC and multidisciplinary health care professionals. In the first round, panelists rated the importance and feasibility of 39 transitional care interventions on a 9-point Likert scale; agreement between panelists was defined according to RAND/UCLA Appropriateness Methods. The second round of data collection evaluated 16 interventions that panelists did not agree on in the first round and 8 new or revised interventions, accompanied by quantitative and qualitative data summaries. RESULTS A total of 29 parents of CMC and 37 health care professionals participated in the Delphi process (response rate 75%). Both stakeholder panels endorsed most interventions as important; health care professionals were less likely to rate several interventions as feasible compared with the parent panel. Over 2 rounds of data collection, the 2 stakeholder panels endorsed 25 interventions as important as well as feasible. These interventions related to family engagement during the hospitalization, care coordination and social support assessment, predischarge education, and written materials. CONCLUSIONS Parents and health care professionals considered several transitional care interventions important as well as feasible. This research might inform hospitals' transitional care programs and policies.
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Affiliation(s)
- JoAnna K Leyenaar
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Tufts University School of Medicine, Boston, Mass.
| | | | | | - Laurel K Leslie
- Departments of Medicine and Pediatrics, Tufts Medical Center, Boston, Mass; Department of Research, American Board of Pediatrics, Chapel Hill, NC
| | - Peter K Lindenauer
- Department of Quantitative Health Sciences, University of Massachusetts Medial School, Worcester; Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle Children's Research Institute, Seattle
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29
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Foster CC, Jacob-Files E, Arthur KC, Hillman SA, Edwards TC, Mangione-Smith R. Provider Perspectives of High-Quality Pediatric Hospital-to-Home Transitions for Children and Youth With Chronic Disease. Hosp Pediatr 2017; 7:649-659. [PMID: 29038132 DOI: 10.1542/hpeds.2017-0031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The objective of this study was to describe health care providers' and hospital administrators' perspectives on how to improve pediatric hospital-to-home transitions for children and youth with chronic disease (CYCD). METHODS Focus groups and key informant interviews of inpatient attending physicians, primary care physicians, pediatric residents, nurses, care coordinators, and social workers were conducted at a tertiary care children's hospital. Key informant interviews were performed with hospital administrators. Semistructured questions were used to elicit perceptions of transitional care quality and to identify key structures and processes needed to improve transitional care outcomes. Transcripts of discussions were coded to identify emergent themes. RESULTS Participants (N = 22) reported that key structures needed to enhance transitional care were a multidisciplinary team, inpatient provider-patient continuity, hospital resource availability, an interoperative electronic health record, and availability of community resources. Key processes needed to achieve high-quality transitional care included setting individualized transition goals, involving parents in care planning, establishing parental competency with home care tasks, and consistently communicating with primary care physicians. Providers identified a lack of reliable roles and processes, insufficient assessment of patient and/or family psychosocial factors, and consistent 2-way communication with community providers as elements to target to improve transitional care outcomes for CYCD. CONCLUSIONS Many key structures and processes of care perceived as important to achieving high-quality transitional care outcomes for CYCD have the opportunity for improvement at the institution studied. Engaging key stakeholders in designing quality improvement interventions to address these deficits in the current care model may improve transitional care outcomes for this vulnerable population.
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Affiliation(s)
- Carolyn C Foster
- Departments of Pediatrics and .,Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington; and
| | - Elizabeth Jacob-Files
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington; and
| | - Kimberly C Arthur
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington; and
| | - Stephanie A Hillman
- Department of Patient and Family Experience, Seattle Children's Hospital, Seattle, Washington
| | - Todd C Edwards
- Health Services, University of Washington, Seattle, Washington
| | - Rita Mangione-Smith
- Departments of Pediatrics and.,Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington; and
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30
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Rosenthal JL, Romano PS, Kokroko J, Gu W, Okumura MJ. Receiving Providers' Perceptions on Information Transmission During Interfacility Transfers to General Pediatric Floors. Hosp Pediatr 2017; 7:335-343. [PMID: 28559362 DOI: 10.1542/hpeds.2016-0152] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pediatric patients can present to a medical facility and subsequently be transferred to a different hospital for definitive care. Interfacility transfers require a provider handoff across facilities, posing risks that may affect patient outcomes. OBJECTIVES The goal of this study was to describe the thoroughness of information transmission between providers during interfacility transfers, to describe perceived errors in care at the posttransfer facility, and to identify potential associations between thoroughness of information transmission and perceived errors in care. METHODS We performed an exploratory prospective cohort study on communication practices and patient outcomes during interfacility transfers to general pediatric floors. Data were collected from provider surveys and chart review. Descriptive statistics were used to summarize survey responses. Logistic regression was used to analyze the association of communication deficits with odds of having a perceived error in care. RESULTS A total of 633 patient transfers were reviewed; 218 transport command physician surveys and 217 frontline provider surveys were completed. Transport command physicians reported higher proportions of key elements being included in the verbal handoff compared with frontline providers. The written key element transmitted with the lowest frequency was a summary document (65.2%), and 13% of transfers had at least 1 perceived error in care. Transfers with many deficits were associated with higher odds of having a perceived error in care. CONCLUSIONS Information transmission during pediatric transfers is perceived to be inconsistently complete. Deficits in the verbal and written information transmission are associated with odds of having a perceived error in care.
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Affiliation(s)
| | - Patrick S Romano
- Departments of Pediatrics and.,Internal Medicine, and.,Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California; and
| | | | | | - Megumi J Okumura
- Department of Pediatrics and Internal Medicine, University of California, San Francisco, San Francisco, California
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31
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Parast L, Burkhart Q, Desai AD, Simon TD, Allshouse C, Britto MT, Leyenaar JK, Gidengil CA, Toomey SL, Elliott MN, Schneider EC, Mangione-Smith R. Validation of New Quality Measures for Transitions Between Sites of Care. Pediatrics 2017; 139:peds.2016-4178. [PMID: 28557755 PMCID: PMC9534578 DOI: 10.1542/peds.2016-4178] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Assessing and improving the quality of transitions to home from the emergency department (ED) or hospital is critical for patient safety. Our objective was to validate 8 newly developed caregiver-reported measures of transition quality. METHODS This prospective observational study included 1086 caregiver survey respondents whose children had an ED visit (n = 523) or hospitalization (n = 563) at Seattle Children's Hospital in 2014. Caregivers were contacted to complete 2 surveys. The first survey included the newly developed transition quality measures and multiple validation measures including modified versions of Child Hospital Consumer Assessments of Healthcare Providers and Systems (HCAHPS) composites, assessing communication and discharge planning. The second survey (administered 30 days later) included questions about follow-up appointments and ED return visits and readmissions. Using multivariate regression, we examined associations between the newly developed transition quality measures and each validation measure. RESULTS All transition quality measures were significantly associated with ≥1 validation measures. The hospital-to-home transition measure assessing whether discharge instructions were easy to understand, were useful, and contained necessary follow-up information had the largest association with the Child HCAHPS nurse-parent and doctor-parent communication composites (β = 55.6; 95% confidence interval, 43 to 68.3; and β = 48.3; 95% confidence interval, 36.3 to 60.3, respectively, scaled to reflect change associated with a 0 to 100 change in the transition measure score). CONCLUSIONS Newly developed quality measures for pediatric ED- and hospital-to-home transitions were significantly and positively associated with previously validated measures of caregiver experience. These new measures may be useful for assessing and improving on the quality of ED- and hospital-to-home transitions.
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Affiliation(s)
| | | | - Arti D. Desai
- Seattle Children’s Research Institute, Seattle, Washington,Department of Pediatrics, University of Washington, Seattle, Washington
| | - Tamara D. Simon
- Seattle Children’s Research Institute, Seattle, Washington,Department of Pediatrics, University of Washington, Seattle, Washington
| | | | - Maria T. Britto
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | | | - Courtney A. Gidengil
- RAND Corporation, Boston, Massachusetts,Boston Children’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Sara L. Toomey
- Boston Children’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | | | | | - Rita Mangione-Smith
- Seattle Children’s Research Institute, Seattle, Washington,Department of Pediatrics, University of Washington, Seattle, Washington
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32
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Unaka NI, Statile A, Haney J, Beck AF, Brady PW, Jerardi KE. Assessment of readability, understandability, and completeness of pediatric hospital medicine discharge instructions. J Hosp Med 2017; 12:98-101. [PMID: 28182805 PMCID: PMC6327837 DOI: 10.12788/jhm.2688] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The average American adult reads at an 8th-grade level. Discharge instructions written above this level might increase the risk of adverse outcomes for children as they transition from hospital to home. We conducted a cross-sectional study at a large urban academic children's hospital to describe readability levels, understandability scores, and completeness of written instructions given to families at hospital discharge. Two hundred charts for patients discharged from the hospital medicine service were randomly selected for review. Written discharge instructions were extracted and scored for readability (Fry Readability Scale [FRS]), understandability (Patient Education Materials Assessment Tool [PEMAT]), and completeness (5 criteria determined by consensus). Descriptive statistics enumerated the distribution of readability, understandability, and completeness of written discharge instructions. Of the patients included in the study, 51% were publicly insured. Median age was 3.1 years, and median length of stay was 2.0 days. The median readability score corresponded to a 10th-grade reading level (interquartile range, 8-12; range, 1-13). Median PEMAT score was 73% (interquartile range, 64%-82%; range, 45%-100%); 36% of instructions scored below 70%, correlating with suboptimal understandability. The diagnosis was described in only 33% of the instructions. Although explicit warning signs were listed in most instructions, 38% of the instructions did not include information on the person to contact if warning signs developed. Overall, the readability, understandability, and completeness of discharge instructions were subpar. Efforts to improve the content of discharge instructions may promote safe and effective transitions home. Journal of Hospital Medicine 2017;12:98-101.
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Affiliation(s)
- Ndidi I. Unaka
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Address for correspondence and reprint requests: Ndidi I. Unaka, MD, MEd, Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, ML 5018, Cincinnati, OH 45229; Telephone: 513-636-8354; Fax: 513-636-7905;
| | - Angela Statile
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Julianne Haney
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Andrew F. Beck
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Patrick W. Brady
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Karen E. Jerardi
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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33
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Desai AD, Burkhart Q, Parast L, Simon TD, Allshouse C, Britto MT, Leyenaar JK, Gidengil CA, Toomey SL, Elliott MN, Schneider EC, Mangione-Smith R. Development and Pilot Testing of Caregiver-Reported Pediatric Quality Measures for Transitions Between Sites of Care. Acad Pediatr 2016; 16:760-769. [PMID: 27495373 PMCID: PMC9534576 DOI: 10.1016/j.acap.2016.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 07/26/2016] [Accepted: 07/26/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Few measures exist to assess pediatric transition quality between care settings. The study objective was to develop and pilot test caregiver-reported quality measures for pediatric hospital and emergency department (ED) to home transitions. METHODS On the basis of an evidence review, we developed draft caregiver-reported quality measures for transitions between sites of care. Using the RAND-UCLA Modified Delphi method, a multistakeholder panel endorsed measures for further development. Measures were operationalized into 2 surveys, which were administered to caregivers of patients (n = 2839) discharged from Seattle Children's Hospital between July 1 and September 1, 2014. Caregivers were randomized to mail or telephone survey mode. Measure scores were computed as a percentage of eligible caregivers who endorsed receiving the indicated care. Differences in scores were examined according to survey mode and caregiver characteristics. RESULTS The Delphi panel endorsed 6 of 8 hospital to home transition measures and 2 of 3 ED to home transitions measures. Scores differed significantly according to mode for 1 measure. Caregivers with lower levels of educational attainment and/or Spanish-speaking caregivers reported significantly higher scores on 3 of the measures. The largest difference was reported for the measure that assessed whether caregivers received assistance with scheduling follow-up appointments; 92% score for caregivers with lower educational attainment versus 79% for caregivers with higher educational attainment (P < .001). CONCLUSIONS We developed 8 new, evidence-based quality measures to assess transition quality from the perspective of caregivers. Pilot testing of these measures in a single institution yielded valuable insights for future testing and implementation of these measures.
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Affiliation(s)
- Arti D. Desai
- Department of Pediatrics, University of Washington, Seattle Children’s Research Institute, Seattle, WA
| | | | | | - Tamara D. Simon
- Department of Pediatrics, University of Washington, Seattle Children’s Research Institute, Seattle, WA
| | | | - Maria T. Britto
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | | | - Courtney A. Gidengil
- RAND Corporation, Division of Infectious Diseases, Boston Children’s Hospital, Harvard Medical School, Boston, Mass
| | | | | | | | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle Children’s Research Institute, Seattle, WA
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