Parental Management of Discharge Instructions: A Systematic Review

Pediatrician perspectives on barriers and facilitators to discharge instruction comprehension and adherence for parents of children with medical complexity

BACKGROUND

High rates of posthospitalization errors are observed in children with medical complexity (CMC). Poor parent comprehension of and adherence to complex discharge instructions can contribute to errors. Pediatrician views on common barriers and facilitators to parent comprehension and adherence are understudied.

OBJECTIVE

To examine pediatrician perspectives on barriers and facilitators experienced by parents in comprehension of and adherence to inpatient discharge instructions for CMC.

DESIGN, SETTINGS, AND PARTICIPANTS

We conducted a qualitative, descriptive study of attending pediatricians (n = 20) caring for CMC in inpatient settings (United States and Canada) and belonging to listservs for pediatric hospitalists/complex care providers. We used purposive/maximum variation sampling to ensure heterogeneity (e.g., hospital, region).

MAIN OUTCOME AND MEASURES

A multidisciplinary team designed and piloted a semistructured interview guide with pediatricians who care for CMC. Team members conducted semistructured interviews via phone or video call. Interviews were audiorecorded and transcribed. We analyzed transcripts using content analysis; codes were derived a priori from a conceptual framework (based on the Pediatric Self-Management Model) and a preliminary transcript analysis. We applied codes and identified emerging themes.

RESULTS

Pediatricians identified three themes as barriers and facilitators to discharge instruction comprehension and adherence: (1) regimen complexity, (2) access to the healthcare team (e.g., inpatient team, outpatient pediatrician, home nursing) and resources (e.g., medications, medical equipment), and (3) need for a family centered and health literacy-informed approach to discharge planning and education. Next steps include the assessment of parent perspectives on barriers and facilitators to discharge instruction comprehension and adherence for prents of CMC and the development of intervention strategies.

Parents' understanding of medication at discharge and potential harm in children with medical complexity

OBJECTIVE

Children with medical complexity (CMC) are among the most vulnerable patient groups. This study aimed to evaluate their prevalence and risk factors for medication misunderstanding and potential harm (PH) at discharge.

DESIGN AND SETTING

Cross-sectional study at a tertiary care centre.

STUDY POPULATION

CMC admitted at Medical University of Vienna between May 2018 and January 2019.

INTERVENTION

CMC and caregivers underwent a structured interview at discharge; medication understanding and PH for adverse events were assessed by a hybrid approach.

MAIN OUTCOME MEASURES

Medication misunderstanding rate; PH.

RESULTS

For 106 included children (median age 9.6 years), a median number of 5.0 (IQR 3.0-8.0) different medications were prescribed. 83 CMC (78.3%) demonstrated at least one misunderstanding, in 33 CMC (31.1%), potential harm was detected, 5 of them severe. Misunderstandings were associated with more medications (r=0.24, p=0.013), new prescriptions (r=0.23, p=0.019), quality of medication-related communication (r=-0.21, p=0.032), low level of education (p=0.013), low language skills (p=0.002) and migratory background (p=0.001). Relative risk of PH was 2.27 times increased (95% CI 1.23 to 4.22) with new medications, 2.14 times increased (95% CI 1.10 to 4.17) with migratory background.

CONCLUSION

Despite continuous care at a tertiary care centre and high level of subjective satisfaction, high prevalence of medication misunderstanding with relevant risk for PH was discovered in CMC and their caregivers. This demonstrates the need of interventions to improve patient safety, with stratification of medication-related communication for high-risk groups and a restructured discharge process focusing on detection of misunderstandings ('unknown unknowns').

Health Literacy-Informed Communication to Reduce Discharge Medication Errors in Hospitalized Children: A Randomized Clinical Trial

Importance

Inadequate communication between caregivers and clinicians at hospital discharge contributes to medication dosing errors in children. Health literacy-informed communication strategies during medication counseling can reduce dosing errors but have not been tested in the pediatric hospital setting.

Objective

To test a health literacy-informed communication intervention to decrease liquid medication dosing errors compared with standard counseling in hospitalized children.

Design, Setting, and Participants

This parallel, randomized clinical trial was performed from June 22, 2021, to August 20, 2022, at a tertiary care, US children's hospital. English- and Spanish-speaking caregivers of hospitalized children 6 years or younger prescribed a new, scheduled liquid medication at discharge were included in the analysis.

Interventions

Permuted block (n = 4) randomization (1:1) to a health literacy-informed discharge medication communication bundle (n = 99) compared with standard counseling (n = 99). A study team member delivered the intervention consisting of a written, pictogram-based medication instruction sheet, teach back (caregivers state information taught), and demonstration of dosing with show back (caregivers show how they would draw the liquid medication in the syringe).

Main Outcome and Measures

Observed dosing errors, assessed using a caregiver-submitted photograph of their child's medication-filled syringe and expressed as the percentage difference from the prescribed dose. Secondary outcomes included caregiver-reported medication knowledge. Outcome measurements were blinded to participant group assignment.

Results

Among 198 caregivers randomized (mean [SD] age, 31.4 [6.5] years; 186 women [93.9%]; 36 [18.2%] Hispanic or Latino and 158 [79.8%] White), the primary outcome was available for 151 (76.3%). The observed mean (SD) percentage dosing error was 1.0% (2.2 percentage points) among the intervention group and 3.3% (5.1 percentage points) among the standard counseling group (absolute difference, 2.3 [95% CI, 1.0-3.6] percentage points; P < .001). Twenty-four of 79 caregivers in the intervention group (30.4%) measured an incorrect dose compared with 39 of 72 (54.2%) in the standard counseling group (P = .003). The intervention enhanced caregiver-reported medication knowledge compared with the standard counseling group for medication dose (71 of 76 [93.4%] vs 55 of 69 [79.7%]; P = .03), duration of administration (65 of 76 [85.5%] vs 49 of 69 [71.0%]; P = .04), and correct reporting of 2 or more medication adverse effects (60 of 76 [78.9%] vs 13 of 69 [18.8%]; P < .001). There were no differences in knowledge of medication name, indication, frequency, or storage.

Conclusions and Relevance

A health literacy-informed discharge medication communication bundle reduced home liquid medication administration errors and enhanced caregiver medication knowledge compared with standard counseling. Routine use of these standardized strategies can promote patient safety following hospital discharge.

Trial Registration

ClinicalTrials.gov Identifier: NCT05143047.

Management of Discharge Instructions for Children With Medical Complexity: A Systematic Review

CONTEXT

Children with medical complexity (CMC) are at risk for adverse outcomes after discharge. Difficulties with comprehension of and adherence to discharge instructions contribute to these errors. Comprehensive reviews of patient-, caregiver-, provider-, and system-level characteristics and interventions associated with discharge instruction comprehension and adherence for CMC are lacking.

OBJECTIVE

To systematically review the literature related to factors associated with comprehension of and adherence to discharge instructions for CMC.

DATA SOURCES

PubMed/Medline, Embase, Cochrane Central Register of Controlled Trials, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, Web of Science (database initiation until March 2023), and OAIster (gray literature) were searched.

STUDY SELECTION

Original studies examining caregiver comprehension of and adherence to discharge instructions for CMC (Patient Medical Complexity Algorithm) were evaluated.

DATA EXTRACTION

Two authors independently screened titles/abstracts and reviewed full-text articles. Two authors extracted data related to study characteristics, methodology, subjects, and results.

RESULTS

Fifty-one studies were included. More than half were qualitative or mixed methods studies. Few interventional studies examined objective outcomes. More than half of studies examined instructions for equipment (eg, tracheostomies). Common issues related to access, care coordination, and stress/anxiety. Facilitators included accounting for family context and using health literacy-informed strategies.

LIMITATIONS

No randomized trials met inclusion criteria. Several groups (eg, oncologic diagnoses, NICU patients) were not examined in this review.

CONCLUSIONS

Multiple factors affect comprehension of and adherence to discharge instructions for CMC. Several areas (eg, appointments, feeding tubes) were understudied. Future work should focus on design of interventions to optimize transitions.

Pediatric Resident Communication of Hospital Discharge Instructions

OBJECTIVE

Suboptimal provider-parent communication contributes to poor parent comprehension of pediatric discharge instructions, which can lead to adverse outcomes. Residency is a critical window to acquire and learn to utilize key communication skills, potentially supported by formal training programs or visual reminders. Few studies have examined resident counseling practices or predictors of counseling quality. Our objectives were to (1) examine pediatric resident counseling practices and (2) determine how formal training and presence of discharge templates with domain-specific prompts are associated with counseling.

METHODS

We conducted a cross-sectional survey of a convenience sample of residents in the American Academy of Pediatrics Section on Pediatric Trainees. Outcomes included resident self-report of frequency of (1) counseling in domains of care and (2) use of health literacy-informed counseling strategies (pictures, demonstration, Teach Back, Show Back) (6-point scales; frequent = often/usually/always). Predictor variables were (1) formal discharge-related training (e.g., lectures) and (2) hospital discharge instruction template with space for individual domains. Logistic regression analyses, utilizing generalized estimating equations when appropriate to account for multiple domains (adjusting for resident gender, postgraduate year), were performed.

KEY RESULTS

Few residents (N = 317) (13.9%) reported formal training. Over 25% of residents infrequently counsel on side effects, diagnosis, and restrictions. Resident reported use of communication strategies was infrequent: drawing pictures (24.1%), demonstration (15.8%), Teach Back (36.8%), Show Back (11.4%). Designated spaces in instruction templates for individual domains were associated with frequent domain-specific counseling (adjusted odds ratio [aOR] 4.1 [95% confidence interval: 3.5-4.8]). Formal training was associated with frequent Teach Back (aOR 2.6 [1.4-5.1]) and Show Back (aOR 2.7 [1.2-6.2]).

CONCLUSIONS

Lack of formal training and designated space for domain-specific instructions are associated with suboptimal counseling at discharge by pediatric residents. Future research should focus on determining the best mechanisms for teaching trainees communication skills and optimizing written instruction templates to support verbal counseling. [HLRP: Health Literacy Research and Practice. 2023;7(4):e178-e186.].

Factors Influencing Parents' Perception of Their Infants' Transition From a 6-Bed Pod to Single Family Room in a Mixed-Room Neonatal Intensive Care Unit

BACKGROUND

While hospitalized in the neonatal intensive care unit (NICU), infants and their families undergo multiple transitions, and these have been found to be a source of stress for families. Although mixed-room NICU designs allow for infants to benefit from different room types as their needs evolve during their stay, these can necessitate a transfer from one room type to another, which represents a transition for families. As some NICUs change to mixed-room designs, there is a need to better understand the factors impacting these particular transitions from the perception of parents.

PURPOSE

Examine parent perceptions of factors affecting the transition from a 6-bed pod to single family room in a mixed-room design NICU.

METHODS

Using a qualitative descriptive design, semistructured interviews were conducted with 17 parents whose infant had transitioned from a 6-bed pod to single family room. Interviews were transcribed verbatim and then analyzed using content analysis.

RESULTS

Four categories of factors were identified: (1) framing, timing, and comprehensiveness of information provided by staff regarding the transition; (2) parents' perception of advantages and disadvantages of the new space; (3) parent's own well-being and quality of support from staff; and (4) parent's previous NICU and parenting experience.

IMPLICATIONS FOR PRACTICE

Staff should frame the information they provide about this transition in a positive way to help parents adjust. A family-centered approach should also be used to provide tailored information and support to individual families.

IMPLICATIONS FOR RESEARCH

Future studies are needed into intraunit transfers including sources of support for parents, as well as staff perceptions of these transitions.

Parent Perceptions of Transitioning From a 6-Bed Pod to a Single Family Room in a Mixed-Room Design NICU

BACKGROUND

As some neonatal intensive care units (NICUs) shift toward mixed-room designs, with different room types available throughout family's stays, there is a need to better understand parent perceptions of this transition.

METHODS

This study used a qualitative descriptive design to describe parent perceptions of transitioning from a 6-bed pod to a single family room in a mixed-room design NICU. Purposive sampling was used to recruit 10 mothers and 7 fathers who were regularly present on the unit before and after the transition. Semistructured telephone interviews were conducted a minimum of 2 days after the transition occurred. Interviews were transcribed and then analyzed using reflexive thematic analysis.

FINDINGS

Four themes were identified: going into the unknown; approaching the finish line; becoming comfortable in the new reality and seeing the benefits; and gaining autonomy and confidence in parenting.

CONCLUSION

These results further our understanding of the transition process from a 6-bed pod to a single-family room for parents in the NICU. Staff should be sensitized to this experience to provide tailored information and support for parents throughout the transition.

A Quality Improvement Initiative to Improve Pediatric Discharge Medication Safety and Efficiency

Medication errors are a leading safety concern, especially for families with limited English proficiency and health literacy, and patients discharged on multiple medications with complex schedules. Integration of a multilanguage electronic discharge medication platform may help decrease medication errors. This quality improvement (QI) project's primary aim (process measure) was to increase utilization in the electronic health record (EHR) of the integrated MedActionPlanPro (MAP) for cardiovascular surgery and blood and marrow transplant patients at hospital discharge and for the first clinic follow-up visit to 80% by July 2021.

Methods

This QI project occurred between August 2020 and July 2021 on 2 subspecialty pediatric acute care inpatient units and respective outpatient clinics. An interdisciplinary team developed and implemented interventions, including integration of MAP within EHR; the team tracked and analyzed outcomes for discharge medication matching, and efficacy and safety MAP integration occurred with a go-live date of February 1, 2021. Statistical process control charts tracked progress.

Results

Following the implementation of the QI interventions, there was an increase from 0% to 73% in the utilization of the integrated MAP in the EHR across the acute care cardiology unit-cardiovascular surgery/blood and marrow transplant units. The average user hours per patient (outcome measure) decreased 70% from the centerline of 0.89 hours during the baseline period to 0.27 hours. In addition, the medication matching between Cerner inpatient and MAP inpatient increased significantly from baseline to postintervention by 25.6% (P < 0.001).

Conclusion

MAP integration into the EHR was associated with improved inpatient discharge medication reconciliation safety and provider efficiency.

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

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

Implementing a Post-Discharge Telemedicine Service Pilot to Enhance the Hospital to Home Transition

OBJECTIVES

The objectives of this study are to (1) describe our postdischarge telemedicine program and (2) evaluate program implementation.

METHODS

At our single-center tertiary care children's hospital, we launched our postdischarge telemedicine program in April 2020. We used the Template for Intervention Description and Replication framework to describe our pilot program and Proctor's conceptual framework to evaluate implementation over a 9-month period. Retrospective chart review was conducted. Descriptive analyses were used to compare demographics and health care reutilization rates across patients. Implementation outcomes included adoption (rate of scheduled visits) and feasibility (rate of completed visits). Effectiveness outcomes included the rate of postdischarge issues and unscheduled healthcare utilization.

RESULTS

We established a postdischarge telemedicine program for a general pediatric population that ensured follow-up at a time when in-person evaluation was limited because of the coronavirus disease 2019 pandemic. For implementation evaluation, we included all 107 patients in the pilot program. Adoption was 100% and feasibility was 58%. Eighty-two percent of patients completing a visit reported one or more postdischarge issues. There was no difference in health system reutilization between those who completed a visit and those who did not.

CONCLUSIONS

Implementation of a postdischarge telemedicine service is achievable and promotes early detection of failures in the hospital to home transition. Directions for future study will include rigorous program evaluation via telemedicine program assessment tools and sustainability efforts that build upon known implementation and health service outcomes.

A sequential, multiple assignment randomized trial comparing web-based education to mobile video interpreter access for improving provider interpreter use in primary care clinics: the mVOCAL hybrid type 3 study protocol

BACKGROUND

Individuals who use a language other than English for medical care are at risk for disparities related to healthcare safety, patient-centered care, and quality. Professional interpreter use decreases these disparities but remains underutilized, despite widespread access and legal mandates. In this study, we compare two discrete implementation strategies for improving interpreter use: (1) enhanced education targeting intrapersonal barriers to use delivered in a scalable format (interactive web-based educational modules) and (2) a strategy targeting system barriers to use in which mobile video interpreting is enabled on providers' own mobile devices.

METHODS

We will conduct a type 3 hybrid implementation-effectiveness study in 3-5 primary care organizations, using a sequential multiple assignment randomized trial (SMART) design. Our primary implementation outcome is interpreter use, calculated by matching clinic visits to interpreter invoices. Our secondary effectiveness outcome is patient comprehension, determined by comparing patient-reported to provider-documented visit diagnosis. Enrolled providers (n = 55) will be randomized to mobile video interpreting or educational modules, plus standard interpreter access. After 9 months, providers with high interpreter use will continue as assigned; those with lower use will be randomized to continue as before or add the alternative strategy. After another 9 months, both strategies will be available to enrolled providers for 9 more months. Providers will complete 2 surveys (beginning and end) and 3 in-depth interviews (beginning, middle, and end) to understand barriers to interpreter use, based on the Theoretical Domains Framework. Patients who use a language other than English will be surveyed (n = 648) and interviewed (n = 75) following visits with enrolled providers to understand their experiences with communication. Visits will be video recorded (n = 100) to assess fidelity to assigned strategies. We will explore strategy mechanism activation to refine causal pathway models using a quantitative plus qualitative approach. We will also determine the incremental cost-effectiveness of each implementation strategy from a healthcare organization perspective, using administrative and provider survey data.

DISCUSSION

Determining how these two scalable strategies, alone and in sequence, perform for improving interpreter use, the mechanisms by which they do so, and at what cost, will provide critical insights for addressing a persistent cause of healthcare disparities.

TRIAL REGISTRATION

NCT05591586.

Using Comic-Based Concussion Discharge Instructions to Address Caregiver Health Literacy in the Emergency Department

INTRODUCTION

This study compared the effectiveness of comic-based with text-based concussion discharge instructions on improving caregiver knowledge. This study also examined the role of social determinants of health on comprehension instructions.

METHODS

This was an observational study of the caregivers of pediatric concussion patients. Caregivers' health literacy and demographics related socioeconomic factors were obtained. After the patients' evaluation in the emergency department, caregivers were given printed comic-based concussion discharge instructions. Caregivers were contacted 3 days later and tested overall knowledge of discharge instructions' content. These survey results were compared with historical controls who received text-based instructions.

RESULTS

A total of 120 participants were recruited, and 86 participants completed follow-up procedures. When comparing the caregivers' recall ability with a comic-based vs traditional text-based instructions, caregivers with comic-based content were more likely to accurately recall overall discharge instructions (77.5% vs 44%, P < .001), particularly physical rest and activity restrictions (86.5% vs 63%, P < .001). Caregivers also were less likely to misidentify a red flag symptom (7.5% vs 19%, P < .04). Comic-based instructions did not increase recall of cognitive rest instructions or postconcussive symptoms. When examining demographic factors, caregivers who could not recall 3 postconcussive symptoms were more likely to be Hispanic or Black, less likely to be college educated, and more likely to have low health literacy.

DISCUSSION

Novel methods should be explored to adequately prepare caregivers for continuing postconcussive care at home. Discharge instructions must be tailored to address caregivers' baseline health literacy and how caregivers digest and retain information.

Risk factors associated with 31-day unplanned hospital readmission in newborns: a systematic review

The purpose of this study is to synthesize evidence on risk factors associated with newborn 31-day unplanned hospital readmissions (UHRs). A systematic review was conducted searching CINAHL, EMBASE (Ovid), and MEDLINE from January 1st 2000 to 30th June 2021. Studies examining unplanned readmissions of newborns within 31 days of discharge following the initial hospitalization at the time of their birth were included. Characteristics of the included studies examined variables and statistically significant risk factors were extracted from the inclusion studies. Extracted risk factors could not be pooled statistically due to the heterogeneity of the included studies. Data were synthesized using content analysis and presented in narrative and tabular form. Twenty-eight studies met the eligibility criteria, and 17 significant risk factors were extracted from the included studies. The most frequently cited risk factors associated with newborn readmissions were gestational age, postnatal length of stay, neonatal comorbidity, and feeding methods. The most frequently cited maternal-related risk factors which contributed to newborn readmissions were parity, race/ethnicity, and complications in pregnancy and/or perinatal period.

CONCLUSION

This systematic review identified a complex and diverse range of risk factors associated with 31-day UHR in newborn. Six of the 17 extracted risk factors were consistently cited by studies. Four factors were maternal (primiparous, mother being Asian, vaginal delivery, maternal complications), and two factors were neonatal (male infant and neonatal comorbidities). Implementation of evidence-based clinical practice guidelines for inpatient care and individualized hospital-to-home transition plans, including transition checklists and discharge readiness assessments, are recommended to reduce newborn UHRs.

WHAT IS KNOWN

• Attempts have been made to identify risk factors associated with newborn UHRs; however, the results are inconsistent.

WHAT IS NEW

• Six consistently cited risk factors related to newborn 31-day UHRs. Four maternal factors (primiparous, mother being Asian, vaginal delivery, maternal complications) and 2 neonatal factors (male infant and neonatal comorbidities). • The importance of discharge readiness assessment, including newborn clinical fitness for discharge and parental readiness for discharge. Future research is warranted to establish standardised maternal and newborn-related variables which healthcare providers can utilize to identify newborns at greater risk of UHRs and enable comparison of research findings.

Retention of discharge instructions using an interdisciplinary model for at-risk children with cancer: A quality improvement initiative

PURPOSE

We sought to improve caregiver retention of critical initial hospital discharge instructions using a multidisciplinary, team-based intervention for newly diagnosed pediatric cancer patients at high risk for unfavorable outcomes.

MATERIALS AND METHODS

A multidisciplinary team of pediatric residents, nurses, social workers, pharmacists and hematology/oncology faculty implemented practices to optimize teaching of key discharge material as part of four Plan-Do-Study-Act intervention cycles. An 11-question survey distributed at the first post-discharge clinic visit assessed the efficacy of the intervention, as defined by caregiver retention of critical home instructions.

RESULTS

Thirty-nine caregivers of pediatric cancer patients in an urban academic tertiary-care children's hospital took part in this project. Overall retention of key discharge information was greater in the post-intervention cohort compared to the baseline cohort (median total scores: 89 and 63, respectively; p = .001). Improvements in the proportions of correct responses post-intervention were also observed across all subject matters: from 0.57 to 0.88 for fever guidelines (p = .059), from 0.71 to 0.78 for signs of sepsis (p = .65), from 0.57 to 1.00 for accurate choice of on-call number (p = .004), and from 0.71 to 0.94 for antiemetic management (p = .14).

CONCLUSION

Initiation of our comprehensive cancer-specific program to improve caregiver retention of discharge instructions at the first post-hospitalization clinic visit has been successful and sustainable. This project demonstrated that a multi-disciplinary collaborative team effort increases caregiver retention of critical health information, and this has potential to lead to improved outcomes for patients.

Development and use of an innovative Gap Finding Tool to create a Pharmaceutical Care Model within a paediatric oncology setting

INTRODUCTION

A paediatric cancer ward is a setting where pharmacists participate in direct patient care, acting as coordinators between the patient, caregivers and healthcare professionals. The aim of the study was to develop a Gap Finding Tool to support the setting up of a pharmaceutical care model at a Paediatric-Adolescent Cancer Ward.

METHODS

The Standards of Practice for Clinical Pharmacy Services by the Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Clinical Pharmacy (2013), the American College of Clinical Pharmacy (2014) and the European Association of Hospital Pharmacists (2014) were used to compile the Gap Finding Tool. The developed Tool was tested for content validity by a panel of experts and subsequently implemented over 2 months.

RESULTS

The Gap Finding Tool comprised of nine sections with an average of eight statements each about pharmacy services that should be provided at ward level. For each statement, the rater indicates whether these contributions are provided. When the Tool was implemented at the Paediatric-Adolescent Cancer Ward, four major gaps were identified, namely, absence of a clinical pharmacist, lack of medicines information, vetting of chemotherapy prescriptions by pharmacist with limited access to patient data and lack of pharmacist-input on medicines availability. Processes requiring optimisation included discharge medication advice and documentation processes.

CONCLUSION

The developed Gap Finding Tool is an innovative tool which is versatile and can be used in ward or ambulatory clinical settings to identify gaps in pharmaceutical processes and services and compare national or regional practices to international standards.

Parental Factors Affecting Pediatric Medication Management in Underserved Communities

BACKGROUND

Medication errors and adverse drug events are common in the pediatric population. Limited English proficiency and low health literacy have been associated with decreased medication adherence, increased medication errors, and worse health outcomes. This study explores parental factors affecting medication management in underserved communities.

METHODS

Using qualitative methods, we identified factors believed to affect medication management among parents. We conducted focus group discussions between December 2019 and September 2020. We recruited parents and health care professionals from local community partners and a tertiary care children's hospital. Sessions were recorded and transcribed. Three investigators created the coding scheme. Two investigators independently coded each focus group and organized results into themes using thematic analysis.

RESULTS

Eleven focus groups were held (n = 45): 4 English-speaking parent groups (n = 18), 3 Spanish-speaking parent groups (n = 11), and 4 health care professional groups (n = 16). We identified 4 main factors that could impact medication delivery: 1) limited health literacy among parents and feeling inadequate at medication administration (knowledge/skill gap), 2) poor communication between caregivers (regarding medication delivery, dosage, frequency, and purpose) and between providers (regarding what has been prescribed), 3) lack of pediatric medication education resources, and 4) personal attitudes and beliefs that influence one's medication-related decisions.

CONCLUSIONS

The compounding effect of these factors - knowledge, communication, resource, and personal belief - may put families living in underserved communities at greater risk for medication errors and suboptimal health outcomes. These findings can be used to guide future interventions and may help optimize medication delivery for pediatric patients.

Nurses' Experiences Implementing e PED : An iPad Application to Guide Quality Discharge Teaching

Quality discharge teaching prepares patients and families to transition safely from hospital to home. Technology can enhance and support quality discharge teaching by promoting patient family engagement during the transition. The purpose of this mixed methods study was to explore clinical nurses' experience with using Engaging Parents in Education for Discharge, an iPad application to guide quality discharge teaching. Twelve nurses at a large Midwestern Children's Hospital participated in small focus groups after use of the Engaging Parents in Education for Discharge application and completed a questionnaire on their perception of the acceptability and feasibility of the app. Findings revealed three themes: (1) development and deployment issues focused on the importance of training and support by the study team during implementation; (2) workflow integration centered on the importance of incorporating use of the app into current workflows and to preserve effective communication strategies with parents to optimize use in the healthcare setting; and (3) nurses perceived value in the use of the Engaging Parents in Education for Discharge app for beneficial scripting, questions on discharge topics often forgotten, and guidance for complex patients. Results of this study offer insight into key components for consideration when implementing and integrating technology to aid nursing practice.

Hospital Discharge Instructions: Characteristics, Accessibility, and National Guideline Adherence

OBJECTIVES

The content of pediatric hospital discharge instructions is highly variable. This study aimed to describe the characteristics, accessibility per patient literacy level and language, and national guideline adherence of pediatric hospital discharge instructions.

METHODS

This retrospective study assessed discharge instructions at a tertiary children's hospital. Patient and instruction characteristics, including patient health literacy level, grade level of instructions, patient language preference, and language of instructions were collected via chart review and electronic medical record query. Standard admission processes assessed health literacy via Brief Health Literacy Screening. The association between demographic and clinical characteristics and adherence to Solutions for Patient Safety guidelines was analyzed by using unadjusted and adjusted analysis methods.

RESULTS

Of 240 discharge instructions, 25% were missing at least 1 recommended content area: signs of worsening, where to seek help, or medication reconciliation. A patient health literacy deficit was identified in 15%; the mean grade level of instructions was 10.1. Limited English proficiency was reported among 17% one quarter of whom received language concordant instructions. Use of discharge instruction templates and discharge services were associated with improved guideline adherence (P <.001). Almost one-half of the study population had a complex medical history, which was associated with decreased guideline adherence (P = .04).

CONCLUSIONS

One-quarter of discharge instructions for this predominantly medically complex population failed to meet national standards. Accessibility was often limited by the reading grade level or discordant language of instructions. Templates may be a valuable tool for improving discharge instruction content, accessibility, and adherence to national guidelines.

Prognostic factors influencing parental empowerment after discharge of their hospitalized child: A cross-sectional study

PURPOSE

There is a growing number of children with medical complexity (CMC). After hospitalization, care often has to be continued at home, making transitional care very important. However, many parents do not feel empowered in their role as caregiver for the child. To move forward in this field, we explored prognostic factors associated with parental empowerment after discharge of hospitalized children.

DESIGN AND METHODS

In a cross-sectional study, we collected data on potential prognostic factors found in the literature and on parental empowerment by means of the Family Empowerment Scale (FES). Linear regression analyses were performed to explore the associations between the prognostic factors and the FES.

RESULTS

Data from 228 patients and their parents were analyzed. Out of twelve factors included in the study, three showed significant associations with parental empowerment. Parents of CMC felt more empowered compared to parents of children with less complex conditions (β = 0.20, p = 0.00). We found a positive association between the age of the child and parental empowerment (β = 0.01, p = 0.00). Employed couples felt more empowered compared to unemployed couples (β = 0.30, p = 0.00). These three variables explained 11% of variance in the FES scores.

CONCLUSIONS

Parental empowerment is associated with the patient's age, child's medical complexity, and parental employment status.

PRACTICE IMPLICATIONS

Attention should be paid to the discharge preparation of parents of children with less medical complexity. Awareness is required for parents of younger children and parental employment status, because they are at risk for lower parental empowerment.

Pain management communication between parents and nurses after pediatric outpatient surgery

PURPOSE

The purpose of this study was to explore parent-nurse pain management communication during a child's discharge process following pediatric outpatient surgery.

DESIGN AND METHODS

Thirty-two clinical encounters at discharge between parents (N = 40) and nurses (N = 25) at BC Children's Hospital were audio recorded and transcribed verbatim. Content analysis was applied on the audio recordings and corresponding transcripts using MAXQDA qualitative research software and Microsoft Excel.

RESULTS

Overall, nurses delivered pain management instructions at an average sixth grade readability level and frequently used communication elements of reassurance, optimism, and question-asking. Less consistent communication elements included open-ended questions, interruptions, and promotion of parental decision-making. Parents most frequently asked one to five questions, with pain medication being the most inquired topic.

CONCLUSIONS

Several strengths of the nurse communication approach were identified, and parent questions highlighted a need for greater understanding around pain medication.

PRACTICE IMPLICATIONS

These findings will help guide effective pain management communication and care for young patients and their families.

Electronic Discharge Communication Tools Used in Pediatric Emergency Departments: Systematic Review

BACKGROUND

Electronic discharge communication tools (EDCTs) are increasingly common in pediatric emergency departments (EDs). These tools have been shown to improve patient-centered communication, support postdischarge care at home, and reduce unnecessary return visits to the ED.

OBJECTIVE

This study aimed to map and assess the evidence base for EDCTs used in pediatric EDs according to their functionalities, intended purpose, implementation context features, and outcomes.

METHODS

A systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) procedures for identification, screening, and eligibility. A total of 7 databases (EBSCO, MEDLINE, CINAHL, PsycINFO, EMBASE Scopus, and Web of Science) were searched for studies published between 1989 and 2021. Studies evaluating discharge communication-related outcomes using electronic tools (eg, text messages, videos, and kiosks) in pediatric EDs were included. In all, 2 researchers independently assessed the eligibility. Extracted data related to study identification, methodology, settings and demographics, intervention features, outcome implementation features, and practice, policy, and research implications. The Mixed Method Appraisal Tool was used to assess methodological quality. The synthesis of results involved structured tabulation, vote counting, recoding into common metrics, inductive thematic analysis, descriptive statistics, and heat mapping.

RESULTS

In total, 231 full-text articles and abstracts were screened for review inclusion with 49 reports (representing 55 unique tools) included. In all, 70% (26/37) of the studies met at least three of five Mixed Method Appraisal Tool criteria. The most common EDCTs were videos, text messages, kiosks, and phone calls. The time required to use the tools ranged from 120 seconds to 80 minutes. The EDCTs were evaluated for numerous presenting conditions (eg, asthma, fracture, head injury, fever, and otitis media) that required a range of at-home care needs after the ED visit. The most frequently measured outcomes were knowledge acquisition, caregiver and patient beliefs and attitudes, and health service use. Unvalidated self-report measures were typically used for measurement. Health care provider satisfaction or system-level impacts were infrequently measured in studies. The directionality of primary outcomes pointed to positive effects for the primary measure (44/55, 80%) or no significant difference (10/55, 18%). Only one study reported negative findings, with an increase in return visits to the ED after receiving the intervention compared with the control group.

CONCLUSIONS

This review is the first to map the broad literature of EDCTs used in pediatric EDs. The findings suggest a promising evidence base, demonstrating that EDCTs have been successfully integrated across clinical contexts and deployed via diverse technological modalities. Although caregiver and patient satisfaction with EDCTs is high, future research should use robust trials using consistent measures of communication quality, clinician experience, cost-effectiveness, and health service use to accumulate evidence regarding these outcomes.

TRIAL REGISTRATION

PROSPERO CRD42020157500; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=157500.

Implementation of a Meds to Beds Medication Use Program and Parent Experience at the Time of Transition From a Neonatal Intensive Care Unit to Home

OBJECTIVE

This study aims to describe the overall experience of the neonatal intensive care unit (NICU) parent at time of transition home related to discharge medication use, following implementation of a Meds to Beds program.

METHODS

A descriptive, qualitative study was used to explore parent experiences around medication use during transition home. Eleven parents whose infants required medications at the time of transition home from the NICU participated in a semi-structured telephone interview post-discharge. The data were coded and analyzed for themes.

RESULTS

Major themes nested within the key stages of medication use in preparation for transition home from the NICU were identified: in-hospital preparation (practice early and often, Meds to Beds, and relationship with clinical pharmacist), transition home (schedule and routine, strategies for medication administration) and post-discharge (refills and long-term medication management). Strategies based on parent experiences to improve the process and ameliorate anxiety are presented.

CONCLUSIONS

Parents expressed how effective the Meds to Beds program was on the transition home by increasing parental confidence and knowledge around medications and reducing stress around the acquisition of medications for home. They also reported comfort in having a relationship with the NICU clinical pharmacist, providing a tailored approach to coordinating care both in hospital and during the transition home. Regardless of implementation of a Meds to Beds program, great opportunities remain to refine the transition home. Implementing the suggested improvement strategies could provide significant positive effects with respect to patient care and parental stress during the transition home.

"When the surgery was over, I felt like the worst part had passed": experiences of parents of children with craniosynostosis

PURPOSE

Parents of children scheduled for surgery often experience emotional distress and anxiety. This study aimed to explore parents' experiences of hospital care after their child's craniosynostosis surgery and their perception of support during the year after discharge.

DESIGN AND METHODS

A purposive sample of 19 parents of 12 children with nonsyndromic craniosynostosis, who had undergone surgery, was recruited from one of two national centers in Sweden. An interview was conducted ~1 year after the child's surgery, from September 2017 to August 2018. The interviews followed a semistructured interview guide, were recorded, transcribed verbatim, and analyzed using inductive content analysis.

RESULTS

The analysis yielded six categories with subcategories as follows: (1) cared for and confident: the hospital staff was perceived as kind, professional, and reliable. (2) Alone and abandoned: sometimes, parents found it hard to initiate contact with professionals during hospitalization and after discharge. (3) The importance of information: thorough information was perceived as essential and the need for information varied during postsurgery period. (4) Feelings of worry: some parents remained worried about risks during recovery and were concerned about comorbidities and development. (5) Alright after all: parents felt that the worst part had been before surgery. (6) The need for support: parents were generally satisfied with the support offered and they often received support from family and friends, or other parents through social media/online forums.

PRACTICE IMPLICATIONS

Healthcare professionals must be responsive to what support parents need at different stages in the care process and be aware that parents sometimes hesitate to initiate contact and ask for help and support. Support from healthcare professionals to everyone in the follow-up program, as a default, might be more accessible or acceptable for some parents. Providing online support from professionals should be considered and caregivers could also facilitate peer support among parents, either face-to-face or online.

Improving Health Literacy Knowledge, Behaviors, and Confidence with Interactive Training

BACKGROUND

Ensuring that health care professionals are knowledgeable about the influence limited health literacy has on health outcomes and how to apply health literate strategies is crucial to transform quality and safety in care settings. Although many organizational efforts to address health literacy have focused on hospital settings, few have focused on primary care. The designation of a patient-centered medical home requires the need to address integrating health literacy and the training needs of primary care settings. Brief description of activity: An interactive health literacy training intervention was developed, implemented, and evaluated for 25 primary care clinics. This included an online educational module, in-person application activities, and a sustainability plan to continue skill building, reinforce behaviors, and support practice.

IMPLEMENTATION

Using a descriptive pre- and post-training design, three survey measures were used to rate health literacy knowledge, behaviors, and confidence levels of more than 475 primary care staff. A pre-training survey was completed prior to completion of an interactive online health literacy module and attendance at an in-person training session which followed. A post-training survey was then completed. Sustainment activities, including lunch and learns, and reinforcement activities by clinic leaders, were initiated to promote use of the strategies in practice. A 1-year follow-up survey was then administered to measure sustainability.

RESULTS

The interactive training intervention improved primary care staff's knowledge, behaviors, and confidence in using health literacy strategies with patients and families. Common barriers and facilitators around the use of these strategies were also identified.

LESSONS LEARNED

Careful consideration should be taken when developing health literacy training to ensure it will be effective, efficient, and sustainable. Using elements that facilitate the transfer of training to practice will help improve success. Addressing barriers and promoting facilitators, as well as integrating and connecting health literacy strategies with existing organizational goals and initiatives offer additional ways to reinforce and sustain the practice change. [HLRP: Health Literacy Research and Practice. 2022;6(2):e113-e120.] Plain Language Summary: Clinic staff can improve how they provide information and education to children and families. Interactive training about health literacy led clinic staff to (1) know more about health literacy, (2) use health literacy strategies more, and (3) feel more confident using health literacy strategies. Training over time, supporting staff, and connecting to organizational goals are important for sustainment.

Efficacy of Digital Health Tools for a Pediatric Patient Registry: Semistructured Interviews and Interface Usability Testing With Parents and Clinicians

Background

Acute respiratory infection (ARI) in childhood is common, but more knowledge on the burden and natural history of ARI in the community is required. A better understanding of ARI risk factors, treatment, and outcomes will help support parents to manage their sick child at home. Digital health tools are becoming more widely adopted in clinical care and research and may assist in understanding and managing common pediatric diseases, including ARI, in hospitals and in the community. We integrated 2 digital tools—a web-based discharge communication system and the REDCap (Research Electronic Data Capture) platform—into the Pragmatic Adaptive Trial for Acute Respiratory Infection in Children to enhance parent and physician engagement around ARI discharge communication and our patient registry.

Objective

The objective of this study is to determine the efficacy and usability of digital tools integrated into a pediatric patient registry for ARI.

Methods

Semistructured interviews and software interface usability testing were conducted with 11 parents and 8 emergency department physicians working at a tertiary pediatric hospital and research center in Perth, Western Australia, in 2019. Questions focused on experiences of discharge communication and clinical trial engagement. Responses were analyzed using the qualitative Framework Method. Participants were directly observed using digital interfaces as they attempted predetermined tasks that were then classified as success, failure, software failure, or not observed. Participants rated the interfaces using the System Usability Scale (SUS).

Results

Most parents (9/11, 82%) indicated that they usually received verbal discharge advice, with some (5/11, 45%) recalling receiving preprinted resources from their physician. Most (8/11, 73%) would also like to receive discharge advice electronically. Most of the physicians (7/8, 88%) described their usual practice as verbal discharge instructions, with some (3/8, 38%) reporting time pressures associated with providing discharge instructions. The digital technology option was preferred for engaging in research by most parents (8/11, 73%). For the discharge communication digital tool, parents gave a mean SUS score of 94/100 (SD 4.3; A grade) for the mobile interface and physicians gave a mean usability score of 93/100 (SD 4.7; A grade) for the desktop interface. For the research data management tool (REDCap), parents gave a mean usability score of 78/100 (SD 11.0; C grade) for the mobile interface.

Conclusions

Semistructured interviews allowed us to better understand parent and physician experiences of discharge communication and clinical research engagement. Software interface usability testing methods and use of the SUS helped us gauge the efficacy of our digital tools with both parent and physician users. This study demonstrates the feasibility of combining qualitative research methods with software industry interface usability testing methods to help determine the efficacy of digital tools in a pediatric clinical research setting.

Nurse’s performance in the hospital discharge process of children with chronic disease

ABSTRACT Objective: To analyze the nurse’s performance in the hospital discharge process of children with chronic disease. Method: Qualitative research conducted from May to August/2019 with ten nurses working in a pediatric unit of a public hospital. The data, collected through semi-structured interviews, were submitted to inductive thematic analysis. Results: In the preparation for hospital discharge, nurses recognize health education as their attribution, valuing family knowledge in the training regarding home care. Nevertheless, their practice is weakened by the little articulation among the multiprofessional team, reduced nursing sizing and disarticulation in the health care network. Conclusion: There is a paradox between the report and the practice of the hospital discharge process accomplished by nurses. Although they have theoretical knowledge, their work process is influenced by the disarticulated way in which the multiprofessional team interacts, and the conditions provided by the institution to work in the preparation for hospital discharge of these children.

Atuação da enfermeira no processo de alta hospitalar de criança com doença crônica

RESUMO Objetivo: Analisar a atuação da enfermeira no processo de alta hospitalar de crianças com doença crônica. Método: Pesquisa qualitativa realizada de maio a agosto/2019 com dez enfermeiras de unidade pediátrica de hospital público. Os dados, coletados por meio de entrevistas semiestruturadas, foram submetidos à análise temática indutiva. Resultados: No preparo para alta hospitalar, as enfermeiras reconhecem como sua atribuição a educação em saúde, valorizando o saber familiar na capacitação quanto aos cuidados domiciliares. Entretanto, sua prática é fragilizada pela pouca articulação entre a equipe multiprofissional, dimensionamento de enfermagem reduzido e desarticulação na rede de atenção à saúde. Conclusão: Evidencia-se paradoxo entre o relato e a prática do processo de alta hospitalar efetivado pelas enfermeiras. Embora possuam conhecimento teórico, seu processo de trabalho sofre influência do modo desarticulado como a equipe multiprofissional interage e das condições disponibilizadas pela instituição para atuarem no preparo para alta hospitalar dessas crianças.

Disconnection in Information Exchange During Pediatric Trauma Transfers: A Qualitative Study

Pediatric patients experiencing an emergency department (ED) visit for a traumatic injury often transfer from the referring ED to a pediatric trauma center. This qualitative study sought to evaluate the experience of information exchange during pediatric trauma visits to referring EDs from the perspectives of parents and referring and accepting clinicians through semi-structured interviews. Twenty-five interviews were conducted (10 parents and 15 clinicians) and analyzed through qualitative thematic analysis. A 4-person team collaboratively identified codes, wrote memos, developed major themes, and discussed theoretical concepts. Three interdependent themes emerged: (1) Parents’ and clinicians’ distinct experiences result in a disconnect of information exchange needs; (2) systems factors inhibit effective information exchange and amplify the disconnect; and (3) situational context disrupts the flow of information contributing to the disconnect. Individual-, situational-, and systems-level factors contribute to disconnects in the information exchanged between parents and clinicians. Understanding how these factors’ influence information disconnect may offer avenues for improving patient–clinician communication in trauma transfers.

Preventing Home Medication Administration Errors

Medication administration errors that take place in the home are common, especially when liquid preparations are used and complex medication schedules with multiple medications are involved; children with chronic conditions are disproportionately affected. Parents and other caregivers with low health literacy and/or limited English proficiency are at higher risk for making errors in administering medications to children in their care. Recommended strategies to reduce home medication errors relate to provider prescribing practices; health literacy-informed verbal counseling strategies (eg, teachback and showback) and written patient education materials (eg, pictographic information) for patients and/or caregivers across settings (inpatient, outpatient, emergency care, pharmacy); dosing-tool provision for liquid medication measurement; review of medication lists with patients and/or caregivers (medication reconciliation) that includes prescription and over-the-counter medications, as well as vitamins and supplements; leveraging the medical home; engaging adolescents and their adult caregivers; training of providers; safe disposal of medications; regulations related to medication dosing tools, labeling, packaging, and informational materials; use of electronic health records and other technologies; and research to identify novel ways to support safe home medication administration.

Communication, Veterinary-Client-Patient Relationship, and Teledentistry

Communication is the basis of any relationship. Communication can help strengthen the relationship between veterinarians, their clients, and their colleagues throughout the profession. Different models of communication have been demonstrated including the directive model, consumerism model, and relationship-centered model. When veterinarians refer to a specialist, they view the referral as an extension of the care they provide. Therefore, developing a relationship with the specialist is an important facet of patient care. Creating an appropriate veterinary-client-patient relationship (VCPR) helps the patient receive the best care possible. This needs to be considered when offering telemedicine or teledentistry to clients or referring veterinarians.

Improving Discharge Instructions for Hospitalized Children With Limited English Proficiency

BACKGROUND AND OBJECTIVES

Patients with limited English proficiency (LEP) have increased risk of adverse events after hospitalization. At our institution, LEP families did not routinely receive translated discharge instructions in their preferred language. Our objective for this study was to increase the percentage of patients with LEP on the hospital medicine (HM) service receiving translated discharge instructions from 12% to 80%.

METHODS

Following the Model for Improvement, we convened an interdisciplinary team that included HM providers, pediatric residents, language access services staff, and nurses to design and test interventions aimed at key drivers through multiple plan-do-study-act cycles. Interventions addressed the translation request process, care team education, standardizing discharge instructions for common conditions, and identification and mitigation of failures. We used established rules for analyzing statistical process control charts to evaluate the percentage of patients with translated discharge instructions for all languages and for Spanish.

RESULTS

During the study period, 540 patients with LEP were discharged from the HM service. Spanish was the preferred language for 66% of patients with LEP. The percentage of patients with LEP who received translated discharge instructions increased from 12% to 50% in 3 months and to 77% in 18 months. For patients whose preferred language was Spanish, the percentage increased from 16% to 69% in 4 months and to 96% in 18 months.

CONCLUSIONS

Interventions targeting knowledge of the translation process and standardized Spanish discharge instructions were associated with an increased percentage of families receiving translated discharge instructions. Future work will be used to assess the impact of these interventions on postdischarge disparities, including emergency department revisits and readmissions.

A natural language processing pipeline to synthesize patient-generated notes toward improving remote care and chronic disease management: a cystic fibrosis case study

Objectives

Patient-generated health data (PGHD) are important for tracking and monitoring out of clinic health events and supporting shared clinical decisions. Unstructured text as PGHD (eg, medical diary notes and transcriptions) may encapsulate rich information through narratives which can be critical to better understand a patient’s condition. We propose a natural language processing (NLP) supported data synthesis pipeline for unstructured PGHD, focusing on children with special healthcare needs (CSHCN), and demonstrate it with a case study on cystic fibrosis (CF).

Materials and Methods

The proposed unstructured data synthesis and information extraction pipeline extract a broad range of health information by combining rule-based approaches with pretrained deep-learning models. Particularly, we build upon the scispaCy biomedical model suite, leveraging its named entity recognition capabilities to identify and link clinically relevant entities to established ontologies such as Systematized Nomenclature of Medicine (SNOMED) and RXNORM. We then use scispaCy’s syntax (grammar) parsing tools to retrieve phrases associated with the entities in medication, dose, therapies, symptoms, bowel movements, and nutrition ontological categories. The pipeline is illustrated and tested with simulated CF patient notes.

Results

The proposed hybrid deep-learning rule-based approach can operate over a variety of natural language note types and allow customization for a given patient or cohort. Viable information was successfully extracted from simulated CF notes. This hybrid pipeline is robust to misspellings and varied word representations and can be tailored to accommodate the needs of a specific patient, cohort, or clinician.

Discussion

The NLP pipeline can extract predefined or ontology-based entities from free-text PGHD, aiming to facilitate remote care and improve chronic disease management. Our implementation makes use of open source models, allowing for this solution to be easily replicated and integrated in different health systems. Outside of the clinic, the use of the NLP pipeline may increase the amount of clinical data recorded by families of CSHCN and ease the process to identify health events from the notes. Similarly, care coordinators, nurses and clinicians would be able to track adherence with medications, identify symptoms, and effectively intervene to improve clinical care. Furthermore, visualization tools can be applied to digest the structured data produced by the pipeline in support of the decision-making process for a patient, caregiver, or provider.

Conclusion

Our study demonstrated that an NLP pipeline can be used to create an automated analysis and reporting mechanism for unstructured PGHD. Further studies are suggested with real-world data to assess pipeline performance and further implications.

Detecting Hearing Loss in Infants With a Syndrome or Craniofacial Abnormalities Following the Newborn Hearing Screen

Purpose The current Joint Committee on Infant Hearing guidelines recommend that infants with syndromes or craniofacial abnormalities (CFAs) who pass the universal newborn hearing screening (UNHS) undergo audiological assessment by 9 months of age. However, emerging research suggests that children with these risk factors are at increased risk of early hearing loss despite passing UNHS. To establish whether earlier diagnostic audiological assessment is warranted for all infants with a syndrome or CFA, regardless of screening outcome, this study compared audiological outcomes of those who passed UNHS and those who referred. Method A retrospective analysis was performed on infants with a syndrome or CFA born between July 1, 2012, and June 30, 2017 who participated in Queensland, Australia's state-wide UNHS program. Results Permanent childhood hearing loss (PCHL) yield was higher among infants who referred on newborn hearing screening (51.20%) than in those who passed. Nonetheless, 27.47% of infants who passed were subsequently diagnosed with hearing loss (4.45% PCHL, 23.02% transient conductive), but PCHL was generally milder in this cohort. After microtia/atresia, the most common PCHL etiologies were Trisomy 21, other syndromes, and cleft palate. Of the other syndromes, Pierre Robin sequence featured prominently among infants who passed the hearing screen and were subsequently diagnosed with PCHL, whereas there was a broader mix of other syndromes that caused PCHL in infants who referred on screening. Conclusion Children identified with a syndrome or CFA benefit from early diagnostic audiological assessment, regardless of their newborn hearing screening outcome.

Nurse-Caregiver Communication of Hospital-To-Home Transition Information at a Tertiary Pediatric Hospital in Western Australia: A Multi-Stage Qualitative Descriptive Study

PURPOSE

To observe and describe nurse-caregiver communication of hospital-to-home transition information at the time of discharge at a tertiary children's hospital of Western Australia.

DESIGN AND METHODS

A multi-stage qualitative descriptive design involved 31 direct clinical observations of hospital-to-home transition experiences, and semi-structured interviews with 20 caregivers and 12 nurses post-discharge. Eleven caregivers were re-interviewed 2-4 weeks post-discharge. Transcripts of audio recordings and field notes were analyzed using content analysis. Medical records were examined to determine patients' usage of hospital services within 30 days of discharge.

RESULTS

Four themes emerged from the content analysis: structure of hospital-to-home transition information; transition information delivery; readiness for discharge; and recovery experience post-hospital discharge. Examination of medical records found seven patients presented to the Emergency Department within 2-19 days post-discharge, of which three were readmitted. Primary caregivers of three readmitted patients all had limited English proficiency.

CONCLUSION

The study affirmed the complexity of transitioning pediatric patients from hospital to home. Inconsistent content and delivery of information impacted caregivers' perception of readiness for discharge and the recovery experience.

PRACTICE IMPLICATIONS

Nurses need to assess readiness for discharge to identify individual needs using a validated tool. Inclusion of education on hospital-to-home transition information and discharge planning/process is required in the orientation program for junior and casual staff to ensure consistency of information delivery. Interpreter services should be arranged for caregivers with limited language proficiency throughout the hospital stay especially when transition information is being provided. Nurses should apply teach-back techniques to improve caregivers' comprehension of information.

Parent Perceptions and Experiences Regarding Medication Education at Time of Hospital Discharge for Children With Medical Complexity

BACKGROUND

Children with medical complexity (CMC) often require complex medication regimens. Medication education on hospital discharge should provide a critical safety check before medication management transitions from hospital to family. Current discharge processes may not meet the needs of CMC and their families. The objective of this study is to describe parent perspectives and priorities regarding discharge medication education for CMC.

METHODS

We performed a qualitative, focus-group-based study, using ethnography. Parents of hospitalized CMC were recruited to participate in 1 of 4 focus groups; 2 were in Spanish. Focus groups were recorded, transcribed, and then coded and organized into themes by using thematic analysis.

RESULTS

Twenty-four parents participated in focus groups, including 12 native English speakers and 12 native Spanish speakers. Parents reported a range of 0 to 18 medications taken by their children (median 4). Multiple themes emerged regarding parental ideals for discharge medication education: (1) information quality, including desire for complete, consistent information, in preferred language; (2) information delivery, including education timing, and delivery by experts; (3) personalization of information, including accounting for literacy of parents and level of information desired; and (4) self-efficacy, or education resulting in parents' confidence to conduct medical plans at home.

CONCLUSIONS

Parents of CMC have a range of needs and preferences regarding discharge medication education. They share a desire for high-quality education provided by experts, enabling them to leave the hospital confident in their ability to care for their children once home. These perspectives could inform initiatives to improve discharge medication education for all patients, including CMC.

Health Literacy-Related Safety Events: A Qualitative Study of Health Literacy Failures in Patient Safety Events

Introduction

Communication failures are the leading root cause of safety events. Although much communication research focuses on the healthcare team, there is little focus on communication with patients and families. It is not known what deficits in health literate patient communication lead to patient safety events. We aimed to identify themes of health literacy-related safety events to describe the impact of health literate communication on patient safety.

Methods

The safety events were entered into a system-wide self-reported safety event collection database. A patient safety specialist trained in health literacy prospectively tagged events for health literacy. The authors retrospectively queried the database for all health literacy tagged events during 9 months (September 2017-May 2018). The authors reviewed and independently coded health literacy-associated safety events. Qualitative content analysis of events facilitated by software (NVivo) was completed to identify the health literacy-related safety event themes.

Results

Health literacy events comprised 4% (152/3911) of self-reported safety events during the 9 months. Main themes of the health literacy safety events related to (1) medication; (2) system processes; and (3) discharge/transition. Subthemes of each of the events further described the event types. Health literacy-associated safety events encompass all safety event outcomes (near miss, precursor, and serious safety events).

Conclusions

Health literacy-related safety events occur in the healthcare environment. This review characterizing health literacy-related safety events prioritizes areas to implement health literate safety practices. Many opportunities exist to address communication-related safety events around medication, system processes, and discharge using health literate best practices.

Evaluating the Financial Sustainability of the School-Based Telemedicine Asthma Management Program

Using telemedicine to improve asthma management in underserved communities has been shown to be highly effective. However, program operating costs are perceived as the main barrier to dissemination and scaling up. This study evaluated whether a novel, evidence-based School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) program, designed to overcome barriers to care for families of urban school-aged children, can be financially sustainable in real-world urban school settings. Eligible children (n = 400) had physician-diagnosed asthma with persistent or poorly controlled symptoms at baseline. Total costs included the cost of implementing and running the SB-TEAM program, asthma-related health care costs, cost of caregiver lost productivity in wages related to child illness, and school absenteeism fees. Using data from the SB-TEAM study and national data on wages and equipment costs, the authors modeled low, actual, and high-cost scenarios. The actual cost of administering the SB-TEAM program averaged $344 per child. Expenses incurred by families for medical care ($982), caregiver productivity cost ($415), and school absenteeism costs ($284) in SB-TEAM were not different from the costs in the control group ($1594, $492, and $318 [P > 0.05]). The study findings remained robust under sensitivity analyses for various state- and school-specific regulations, staffing requirements, and wages. The authors concluded that the SB-TEAM program operating costs may be offset by the reduction in health care costs, caregiver lost wages, and school absenteeism associated with the program health benefit.

SAFER Care: Improving Caregiver Comprehension of Discharge Instructions

BACKGROUND

One in five pediatric patients suffers from adverse events related to hospital discharge. Current literature lacks evidence on effective interventions to improve caregiver comprehension (CC) of discharge instructions. We examined if a standardized framework for written and verbal discharge counseling was associated with increased CC of key discharge instructions after discharge from a general pediatric inpatient unit.

METHODS

An interprofessional team created the SAFER Care framework to encourage standard, comprehensive discharge counseling. Plan-do-study-act cycles included electronic health record smartphrases, educational initiatives, data feedback, visual aids, and family outreach. Caregivers were surveyed by phone within 4 days of discharge. Our primary outcome was the proportion of caregivers correctly responding to all questions related to discharge care, comparing pre- and postintervention periods. Data were plotted on a statistical process control chart to assess the effectiveness of interventions.

RESULTS

A total of 171 surveys were analyzed in the preintervention period, and 262 surveys were analyzed in the postintervention period. A total of 37% of caregivers correctly responded to all questions in the preintervention period, compared with 62% of caregivers in the postintervention period, meeting rules for special cause variation.

CONCLUSIONS

Development of the SAFER Care framework and its use in written and verbal discharge counseling was associated with significantly improved CC of discharge instructions in a general pediatric inpatient unit. Further studies should be focused on expanding this to other populations, particularly limited-English-proficiency families.

Factors Associated with Pediatric Burn Clinic Follow-up after Emergency Department Discharge

Attrition between emergency department discharge and outpatient follow-up is well documented across a variety of pediatric ailments. Given the importance of outpatient medical care and the lack of related research in pediatric burn populations, we examined sociodemographic factors and burn characteristics associated with outpatient follow-up adherence among pediatric burn patients. A retrospective review of medical records was conducted on patient data extracted from a burn registry database at an urban academic children's hospital over a 2-year period (January 2018-December 2019). All patients were treated in the emergency department and discharged with instructions to follow-up in an outpatient burn clinic within one week. A total of 196 patients (Mage=5.5 years; 54% male) were included in analyses. Average percent total body surface area was 1.9 (SD=1.5%). One-third of pediatric burn patients (33%) did not attend outpatient follow-up as instructed. Older patients (OR=1.00; 95% CI: [.99-1.00], p=.045), patients with superficial burns (OR=9.37; 95% CI: [2.50-35.16], p=.001), patients with smaller percent total body surface area (OR=1.37; 95% CI: [1.07-1.76], p=.014), and patients with Medicaid insurance (OR=.22; 95% CI: [.09-.57], p=.002) or uninsured/unknown insurance (OR=.07; 95% CI: [.02-.26], p=.000) were less likely to follow up, respectively. Patient gender, race, ethnicity, and distance to clinic were not associated with follow-up. Follow-up attrition in our sample suggests a need for additional research identifying factors associated with adherence to follow-up care. Identifying factors associated with follow-up adherence is an essential step in developing targeted interventions to improve health outcomes in this at-risk population.

Disparity in Nurse Discharge Communication for Hospitalized Families Based on English Proficiency

OBJECTIVES

Effective communication is critical for safely discharging hospitalized children, including those with limited English proficiency (LEP), who are at high risk of reuse. Our objective was to describe and compare the safety and family centeredness of nurse communication at hospital discharge for English-proficient (EP) and LEP families.

METHODS

In this single-center, cross-sectional study, we used direct observation of hospital discharges for EP and LEP children. Observers recorded quantitative and qualitative details of nurse-family communication, focusing on 3 domains: safe discharge, family centeredness, and family engagement. Patient characteristics and percentages of encounters in which all components were discussed within each domain were compared between EP and LEP encounters by using Fisher's exact tests. We used field notes to supplement quantitative findings.

RESULTS

We observed 140 discharge encounters; 49% were with LEP families. Nurses discussed all safe discharge components in 31% of all encounters, most frequently omitting emergency department return precautions. Nurses used all family-centered communication components in 11% and family-engagement components in 89% of all encounters. Nurses were more likely to discuss all components of safe discharge in EP encounters when compared with LEP encounters (53% vs 9%; P < .001; odds ratio: 11.5 [95% confidence interval 4.4-30.1]). There were no differences in family centeredness or family engagement between LEP and EP encounters.

CONCLUSIONS

Discharge encounters of LEP patients were less likely to include all safe discharge communication components, compared with EP encounters. Opportunities to improve nurse-family discharge communication include providing written discharge instructions in families' primary language, ensuring discussion of return precautions, and using teach-back to optimize family engagement and understanding.

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Social Factors Predictive of Intensive Care Utilization in Technology-Dependent Children, a Retrospective Multicenter Cohort Study

Objective: Technology-dependent children with medical complexity (CMC) are frequently admitted to the pediatric intensive care unit (PICU). The social risk factors for high PICU utilization in these children are not well described. The objective of this study was to describe the relationship between race, ethnicity, insurance status, estimated household income, and PICU admission following the placement of a tracheostomy and/or gastrostomy (GT) in CMC. Study Design: This was a retrospective multicenter study of children <19 years requiring tracheostomy and/or GT placement discharged from a hospital contributing to the Pediatric Health Information System (PHIS) database between January 2016 and March 2019. Primary predictors included estimated household income, insurance status, and race/ethnicity. Additional predictor variables collected included patient age, sex, number of chronic complex conditions (CCC), history of prematurity, and discharge disposition following index hospitalization. The primary outcome was need for PICU readmission within 30 days of hospital discharge. Secondary outcomes included repeated PICU admissions and total hospital costs within 1 year of tracheostomy and/or GT placement. Results: Patients requiring a PICU readmission within 30 days of index hospitalization for tracheostomy or GT placement accounted for 6% of the 20,085 included subjects. In multivariate analyses, public insurance [OR 1.28 (95% C.I. 1.12-1.47), p < 0.001] was associated with PICU readmission within 30 days of hospital discharge while living below the federal poverty threshold (FPT) was associated with a lower odds of 30-day PICU readmission [OR 0.7 (95% C.I. 0.51-0.95), p = 0.0267]. Over 20% (n = 4,197) of children required multiple (>1) PICU admissions within one year from index hospitalization. In multivariate analysis, Black children [OR 1.20 (95% C.I. 1.10-1.32), p < 0.001] and those with public insurance [OR 1.34 (95% C.I. 1.24-1.46), p < 0.001] had higher odds of multiple PICU admissions. Social risk factors were not associated with total hospital costs accrued within 1 year of tracheostomy and/or GT placement. Conclusions: In a multicenter cohort study, Black children and those with public insurance had higher PICU utilization following tracheostomy and/or GT placement. Future research should target improving healthcare outcomes in these high-risk populations.

Effect of written and video discharge instructions on parental recall of information about analgesics in children: a pre/post-implementation study

OBJECTIVE

The aim of this study was to determine whether written and video instructions improved the recall of how to use analgesics correctly in parents of children discharged following assessment in the emergency department (ED).

METHODS

This was a prospective pre- and post-implementation study set in the EDs of a tertiary teaching hospital and an urban general hospital in the Netherlands. The participants were parents/carers of children under 12-years-old who had been assessed in and subsequently discharged from the ED. The pre-implementation phase involved 165 participants; the post-phase involved 174 participants. In the post-implementation phase, written instructions about correct analgesic use in children and a link to an online video were provided at discharge. Endpoints were measured using a questionnaire designed to ascertain participants' recall of how to use analgesics correctly and their patterns of use, completed 3-5 days following discharge of their child from the ED. Additionally, participants were asked about re-attending healthcare services and their satisfaction with and preferences for information about analgesic use.

RESULTS

Recall of the correct use of analgesics was significantly higher in participants in the post-implementation phase compared to the pre-implementation phase [difference 29%; 95% confidence interval (CI) 19-39%]. In the post-implementation phase, participants represented to healthcare services less frequently (difference -6%; 95% CI -13-0%). Patterns of use of analgesics varied between the pre- and post-phases, with significantly more participants giving analgesics at home (difference 11%; 95% CI 1-20%). Participants in the post-implementation phase were significantly more (highly) satisfied about the analgesic advice they received compared to parents in the pre-implementation phase (difference -13; 95% CI -23% to -3%). Verbal (93%) or written instructions (83%) were the most popular choices for discharge instructions.

CONCLUSION

In our study, we observed that the recall of the correct use of analgesics was increased in participants who had been given written instructions at discharge.

Understanding preparation for preterm infant discharge from parents' and healthcare providers' perspectives: Challenges and opportunities

AIM

To describe the facilitating/inhibiting factors of preparation for preterm infant discharge and recommendations for increasing discharge readiness from parents' and healthcare providers' perspectives based on Meleis's Transitions Theory.

DESIGN

A qualitative cross-sectional descriptive design.

METHODS

We selected a purposive sample of 17 parents (9 fathers and 8 mothers) and 13 healthcare providers (10 nurses and 3 clinicians) from the neonatal intensive care unit of a tertiary hospital in Eastern China. Data were collected between May -July 2018. Data from audio-recorded semi-structured individual interviews were coded with content analysis both inductively and deductively.

RESULTS

The analyses yielded four themes: personal conditions, community conditions, nursing therapeutics, and patterns of response. Parents and healthcare providers had unique opinions about the themes.

CONCLUSION

Meleis's Transitions Theory seems to be an applicable and practicable framework for understanding the discharge preparation of parents with preterm infants and may be used to help healthcare providers to develop appropriate interventions on discharge preparation practice.

IMPACT

To address the lack of discharge readiness of preterm infants in China and countries with a similar clinical context, healthcare providers should help parents play a more active role to promote their engagement in discharge preparation. In a wider global community, healthcare providers should consider parents' personal conditions and their practical needs in performing discharge preparation.

Information Management in the Emergency Department

Information management in the emergency department (ED) is a challenge for all providers. The volume of information required to care for each patient and to keep the ED functioning is immense. It must be managed through varying means of communication and in connection with ED information systems. Management of information in the ED is imperfect; different modes and methods of identification, interpretation, action, and communication can be beneficial or harmful to providers, patients, and departmental flow. This article reviews the state of information management in the ED and proposes recommendations to improve the management of information in the future.

Adherence to follow-up recommendations for babies at risk for pediatric hearing loss

OBJECTIVE

The purpose of this retrospective study was to evaluate the families' compliance with recommendations for continued monitoring of babies with high-risk factors for hearing loss.

METHODS

Hearing screening and follow-up results from 604 babies were tracked across a five-year period. Bivariate analysis, including chi-square analysis, t-tests, and one-way analyses of variance were conducted to test whether various factors predicted likelihood of follow up.

RESULTS

Although 86% of the babies returned for the initial follow-up appointment, few completed the protocol or were diagnosed with hearing loss (10.3%). Excluding the babies who never returned, the average age for initial assessment was near the recommended 3-month target (3.5 months). However, babies were last seen at 9.4 months on average, which is earlier than recommended. Some factors positively predicted follow-up: receipt of ototoxic medication, hyperbilirubinemia requiring transfusion, ECMO, syndromes associated with hearing loss, craniofacial anomalies, and passing the newborn hearing screening. Others were negatively predictive: NICU stay >5 days, younger maternal age, and failing the newborn screening. There was no relationship between the results of the last test and whether the families continued with monitoring. Babies with risks categorized as more likely to be associated with delayed onset hearing loss were more often late to the initial follow up, but also followed up for a longer period of time.

CONCLUSIONS

These results demonstrate the need to focus on the barriers unique to babies with risk factors for late onset/progressive hearing loss in addition to those barriers that generally affect loss to follow up. Tools for parental engagement are recommended.

Using the Engaging Parents in Education for Discharge (ePED) iPad Application to Improve Parent Discharge Experience

PURPOSE

The purpose of this study was to evaluate the use of the Engaging Parents in Education for Discharge (ePED) iPad application on parent experiences of hospital discharge teaching and care coordination. Hypotheses were: parents exposed to discharge teaching using ePED will have 1) higher quality of discharge teaching and 2) better care coordination than parents exposed to usual discharge teaching. The secondary purpose examined group differences in the discharge teaching, care coordination, and 30-day readmissions for parents of children with and without a chronic condition.

DESIGN/METHODS

Using a quasi-experimental design, ePED was implemented on one inpatient unit (n = 211) and comparison group (n = 184) from a separate unit at a pediatric academic medical center. Patient experience outcome measures collected on day of discharge included Quality of Discharge Teaching Scale-Delivery (QDTS-D) and care coordination measured by Care Transition Measure (CTM). Thirty-day readmission was abstracted from records.

RESULTS

Parents taught using ePED reported higher QDTS-D scores than parents without ePED (p = .002). No differences in CTM were found between groups. Correlations between QDTS-D and CTM were small for ePED (r = 0.14, p 0.03) and non-ePED (r = 0.29, p < .001) parent groups. CTM was weakly associated with 30-day readmissions in the ePED group.

CONCLUSION

The use of ePED by the discharging nurse enhances parent-reported quality of discharge teaching.

PRACTICE IMPLICATIONS

The ePED app is a theory-based structured conversation guide to engage parents in discharge preparation. Nursing implementation of ePED contributes to optimizing the patient/family healthcare experience.