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Rodriguez VA, Boggs EF, Verre MC, Siebenaler MK, Wicks JS, Castiglioni C, Palac H, Garfield CF. Hospital Discharge Instructions: Characteristics, Accessibility, and National Guideline Adherence. Hosp Pediatr 2022; 12:959-970. [PMID: 36195675 DOI: 10.1542/hpeds.2021-006493] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Victoria A Rodriguez
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Elizabeth F Boggs
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Aurora, Colorado
| | - Michael C Verre
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mary Katherine Siebenaler
- HSHS St. John's Children's Hospital, Springfield, Illinois.,Southern Illinois University School of Medicine, Springfield, Illinois; and
| | - Jennifer S Wicks
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Cynthia Castiglioni
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Hannah Palac
- Independent Statistical Consultant, Wauwatosa, Wisconsin
| | - Craig F Garfield
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Northwestern University Feinberg School of Medicine, Chicago, Illinois
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2
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Leyenaar JK, Esporas M, Mangione-Smith R. How Does Pediatric Quality Measure Development Reflect the Real World Needs of Hospitalized Children? Acad Pediatr 2022; 22:S70-S72. [PMID: 35339245 PMCID: PMC9614710 DOI: 10.1016/j.acap.2021.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/14/2021] [Accepted: 01/31/2021] [Indexed: 12/25/2022]
Affiliation(s)
- JoAnna K. Leyenaar
- The Department of Pediatrics and The Dartmouth Institute of Health Policy & Clinical Practice, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03755
| | - Megan Esporas
- Children’s Hospital Association, 600 13th Street, NW, Suite 500, Washington, DC 20005
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3
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Yale S, Bauer SC, Stephany A, Porada K, Liljestrom T. One Call Away: Addressing a Safety Gap for Urgent Issues Post Discharge. Hosp Pediatr 2021; 11:632-635. [PMID: 34045321 DOI: 10.1542/hpeds.2020-003418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVES The transition period from hospitalization to outpatient care can be high risk for pediatric patients. Our aim was to profile the use of a "safety net" for families through provision of specific inpatient provider contact information for urgent issues post discharge. METHODS In this prospective study, we implemented an updated after-visit summary that directed families to call the hospital operator and specifically ask for the pediatric hospital medicine attending on call if they were unable to reach their primary care provider (PCP) with an urgent postdischarge concern. Education for nursing staff, operators, and pediatric hospital medicine providers was completed, and contact information was automatically populated into the after-visit summary. Information collected included the number of calls, the topic, time spent, whether the family contacted the PCP first, and the time of day. Descriptive statistics and Fisher's exact test were used to summarize findings. RESULTS Over a 13-month period, of 5145 discharges, there were 47 postdischarge phone calls, which averaged to 3.6 calls per month. The average length of time spent on a call was 21 minutes. For 30% of calls, families had tried contacting their PCPs first, and 55% of calls occurred at night. Topics of calls included requesting advice about symptoms, time line for reevaluation, and assistance with medications. CONCLUSIONS This safety net provided families with real-time problem-solving for an urgent need post discharge, which included triaging patient symptoms at home, counseling on medication questions, information about the time line of illness recovery, and provision of additional resources.
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Affiliation(s)
- Sarah Yale
- Children's Wisconsin, Milwaukee, Wisconsin;
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Sarah Corey Bauer
- Children's Wisconsin, Milwaukee, Wisconsin
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | | | - Kelsey Porada
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Tracey Liljestrom
- Children's Wisconsin, Milwaukee, Wisconsin
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
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Abstract
OBJECTIVES The need for high-quality discharge summaries is critical to ensure safe transitions of care. Deficits may lead to lapses in communication and poor outcomes. In this study, we sought to characterize the completeness, accuracy, and quality of pediatric discharge summaries. METHODS A retrospective chart review of 200 discharge summaries of patients discharged from the general pediatrics service from July 2016 to October 2017 was conducted. These summaries were audited for 7 elements: admission date, discharge date, discharge diagnosis, medications, immunizations, pending laboratory tests, and follow-up appointments. Accuracy was verified through chart review. Quality of hospital course and patient instructions was evaluated by using a modified validated discharge summary evaluation tool. Additional data collected included medical complexity of the patient and the number of authors. Analysis of variance, χ2 tests, and Pearson correlations were used to analyze data. RESULTS Discharge diagnosis, medications, and follow-up appointments had the lowest rates of completion and accuracy. The quality of the hospital course and patient instructions was variable, with no statistical significance seen in quality scores on the basis of the number of authors or medical complexity. There were more inaccuracies in discharge medications for patients with baseline chronic conditions than those without chronic conditions (63% vs 35%; P < .001). CONCLUSIONS Content and quality of discharge summary documentation are inconsistent and have implications for patient outcomes after discharge. This study highlights areas of opportunity to improve pediatric discharge summaries. Future work should be focused on educational and systems-based interventions to improve documentation.
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Affiliation(s)
- Divya Lakhaney
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Sumeet L Banker
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
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5
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Desai AD, Zhou C, Simon TD, Mangione-Smith R, Britto MT. Validation of a Parent-Reported Hospital-to-Home Transition Experience Measure. Pediatrics 2020; 145:e20192150. [PMID: 31969474 PMCID: PMC6993281 DOI: 10.1542/peds.2019-2150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The Pediatric Transition Experience Measure (P-TEM) is an 8-item, parent-reported measure that globally assesses hospital-to-home transition quality from discharge through follow-up. Our goal was to examine the convergent validity of the P-TEM with existing, validated process and outcome measures of pediatric hospital-to-home transitions. METHODS This was a prospective, cohort study of English-speaking parents and legal guardians who completed the P-TEM after their children's discharge from a tertiary children's hospital between January 2016 and October 2016. By using data from 3 surveys, we assessed convergent validity by examining associations between total and domain-specific P-TEM scores (0-100 scale) and 4 pediatric hospital-to-home transition validation measures: (1) Child Hospital Consumer Assessment of Healthcare Providers and Systems Discharge Composite, (2) Center of Excellence on Quality of Care Measures for Children With Complex Needs parent-reported transition measures, (3) change in health-related quality of life from admission to postdischarge, and (4) 30-day emergency department revisits or readmissions. RESULTS P-TEM total scores were 7.5 points (95% confidence interval: 4.6 to 10.4) higher for participants with top-box responses on the Child Hospital Consumer Assessment of Healthcare Providers and Systems Discharge Composite compared with those of participants with lower Discharge Composite scores. Participants with highet P-TEM scores (ie, top-box responses) had 6.3-points-greater improvement (95% confidence interval: 2.8 to 9.8) in health-related quality of life compared with participants who reported lower P-TEM scores. P-TEM scores were not significantly associated with 7- or 30-day reuse. CONCLUSIONS The P-TEM demonstrated convergent validity with existing hospital-to-home process and outcome validation measures in a population of hospitalized children.
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Affiliation(s)
- Arti D Desai
- Department of Pediatrics, University of Washington, Seattle, Washington;
- Seattle Children's Research Institute, Seattle, Washington; and
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington; and
| | - Tamara D Simon
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington; and
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington; and
| | - Maria T Britto
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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6
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Desai AD, Starmer AJ. Process Metrics and Outcomes to Inform Quality Improvement in Pediatric Hospital Medicine. Pediatr Clin North Am 2019; 66:725-737. [PMID: 31230619 DOI: 10.1016/j.pcl.2019.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article provides an overview of the selection, development, and use of process and outcome measures for pediatric hospital medicine quality improvement initiatives. It reviews commonly used categories of process and outcome measures and provides a list of common sources and repositories of previously validated measures. It also provides a blueprint for the development of novel measures. The relative merits of various data collection methods are discussed (eg, medical record abstraction, administrative, surveys), along with guiding principles for disseminating the results of quality improvement evaluations on a local and national level.
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Affiliation(s)
- Arti D Desai
- University of Washington, Seattle Children's Research Institute, 2001 8th Avenue, Suite 400, Seattle, WA 98121, USA.
| | - Amy J Starmer
- Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
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7
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Freed GL, deJong N, Macy ML, Van KD, Leslie LK. Pediatricians' Participation in Quality Improvement at the Time of Enrollment in MOC. Pediatrics 2018; 142:peds.2018-0712. [PMID: 30301817 DOI: 10.1542/peds.2018-0712] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Although national bodies have proclaimed the importance of incorporating quality improvement (QI) into the daily fabric of clinical care, the actual proportion of practicing pediatricians who participate in QI activities on an annual basis is unknown. Correspondingly little is known about pediatrician motivations for, attitudes about, and support received for QI participation. METHODS Pediatric diplomates enrolling in the American Board of Pediatrics' Maintenance of Certification program during calendar year 2016 were provided with the opportunity to complete a brief survey. A portion of the survey was focused on issues related to participation in QI programs. RESULTS Survey responses were received from 8714 of the 11 890 diplomates who enrolled in Maintenance of Certification in 2016 (response rate: 73.3%). Overall, 86.6% of respondents reported participation in at least 1 QI project in the previous year. There was variation in previous-year participation in a QI project by practice affiliation categories, ranging from 79.9% for nonacademic generalists to 92.4% for academic specialists. The extrinsic requirement for QI to maintain board certification was the dominant motivator among all respondents (50.7%), followed by 2 intrinsic factors: identify gaps in practice and implement change (40.3%) and opportunity to collaborate with others (36.9%). CONCLUSIONS Although the results are encouraging, despite almost 2 decades of national attention to the quality of health care and efforts to embed continual QI in health care delivery activities, ∼1 in 5 nonacademic pediatricians and 1 in 10 academic pediatricians did not report participating in any QI activities in the previous year.
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Affiliation(s)
- Gary L Freed
- Division of General Pediatrics, Department of Pediatrics and Communicable Diseases, .,Department of Health Management and Policy, School of Public Health, and.,Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
| | - Neal deJong
- Division of General Pediatrics and Adolescent Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michelle L Macy
- Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan.,Division of Pediatric Emergency Medicine, Department of Emergency Medicine, School of Medicine
| | - Kenton D Van
- Division of General Pediatrics, Department of Pediatrics and Communicable Diseases.,Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
| | - Laurel K Leslie
- American Board of Pediatrics, Chapel Hill, North Carolina; and.,School of Medicine, Tufts University, Boston, Massachusetts
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Desai AD, Simon TD, Leyenaar JK, Britto MT, Mangione-Smith R. Utilizing Family-Centered Process and Outcome Measures to Assess Hospital-to-Home Transition Quality. Acad Pediatr 2018; 18:843-846. [PMID: 30077673 PMCID: PMC6598693 DOI: 10.1016/j.acap.2018.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/13/2018] [Accepted: 07/28/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Arti D Desai
- Department of Pediatrics (AD Desai, TD Simon, and R Mangione-Smith), University of Washington, Seattle; Seattle Children's Research Institute (AD Desai, TD Simon, and R Mangione-Smith).
| | - Tamara D Simon
- Department of Pediatrics (AD Desai, TD Simon, and R Mangione-Smith), University of Washington, Seattle; Seattle Children's Research Institute (AD Desai, TD Simon, and R Mangione-Smith)
| | - JoAnna K Leyenaar
- Department of Pediatrics & The Dartmouth Institute for Health Policy and Clinical Practice (JK Leyenaar), Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Maria T Britto
- James M. Anderson Center for Health Systems Excellence (MT Britto), Cincinnati Children's Hospital Medical Center, Ohio
| | - Rita Mangione-Smith
- Department of Pediatrics (AD Desai, TD Simon, and R Mangione-Smith), University of Washington, Seattle; Seattle Children's Research Institute (AD Desai, TD Simon, and R Mangione-Smith)
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9
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Desai AD, Jacob-Files EA, Lowry SJ, Opel DJ, Mangione-Smith R, Britto MT, Howard WJ. Development of a Caregiver-Reported Experience Measure for Pediatric Hospital-to-Home Transitions. Health Serv Res 2018; 53 Suppl 1:3084-3106. [PMID: 29740810 DOI: 10.1111/1475-6773.12864] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To develop and test a caregiver-reported experience measure for pediatric hospital-to-home transitions. DATA SOURCES/STUDY SETTING Primary data were collected between 07/2014 and 05/2015 from caregivers within 2-8 weeks of their child's discharge from a tertiary care children's hospital. STUDY DESIGN/DATA COLLECTION We used a step-wise approach to developing the measure that included drafting de novo survey items based on caregiver interviews (n = 18), pretesting items using cognitive interviews (n = 18), and pilot testing revised items among an independent sample of caregivers (n = 500). Item reduction statistics and confirmatory factor analysis (CFA) were performed on a test sample of the pilot data to refine the measure, followed by CFA on the validation sample to test the final measure model fit. PRINCIPAL FINDINGS Of 46 initial survey items, 19 were removed after pretesting and 19 were removed after conducting item statistics and CFA. This resulted in an eight-item measure with two domains: transition preparation (four items) and transition support (four items). Survey items assess the quality of discharge instructions, access to needed support and resources, care coordination, and follow-up care. Practical fit indices demonstrated an acceptable model fit: χ2 = 28.3 (df = 19); root-mean-square error of approximation = 0.04; comparative fit index = 0.99; and Tucker-Lewis index = 0.98. CONCLUSIONS An eight-item caregiver-reported experience measure to evaluate hospital-to-home transition outcomes in pediatric populations demonstrated acceptable content validity and psychometric properties.
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Affiliation(s)
- Arti D Desai
- Department of Pediatrics, University of Washington, Seattle Children's Research Institute, Seattle, WA
| | | | | | - Douglas J Opel
- Department of Pediatrics, University of Washington, Seattle Children's Research Institute, Seattle, WA
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle Children's Research Institute, Seattle, WA
| | - Maria T Britto
- Department of Pediatrics, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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10
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Leyenaar JK, Rizzo PA, O'Brien ER, Lindenauer PK. Paediatric hospital admission processes and outcomes: a qualitative study of parents' experiences and priorities. BMJ Qual Saf 2018; 27:790-798. [PMID: 29453197 DOI: 10.1136/bmjqs-2017-007442] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 12/28/2017] [Accepted: 01/28/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Hospital admission, like hospital discharge, represents a transition of care associated with changes in setting, healthcare providers and clinical management. While considerable efforts have focused on improving the quality and safety of hospital-to-home transitions, there has been little focus on transitions into hospital. OBJECTIVES Among children hospitalised with ambulatory care sensitive conditions, we aimed to characterise families' experiences as they transitioned from outpatient to inpatient care, identify hospital admission processes and outcomes most important to families and determine how parental perspectives differed between children admitted directly and through emergency departments (ED). METHODS We conducted semistructured interviews with parents of hospitalised children at four structurally diverse hospitals. We inquired about preadmission healthcare encounters, how hospital admission decisions were made and parents' preferences regarding hospital admission processes and outcomes. Interviews were transcribed verbatim and analysed using a general inductive approach. RESULTS We conducted 48 interviews. Participants were predominantly mothers (74%); 45% had children with chronic illnesses and 52% were admitted directly. Children had a median of two (IQR 1-3) healthcare encounters in the week preceding hospital admission, with 44% seeking care in multiple settings. Patterns of healthcare utilisation were influenced by (1) disease acuity and healthcare access; (2) past experiences; and (3) varied perspectives about primary care and ED roles as hospital gatekeepers. Participants' hospital admission priorities included: (1) effective clinical care; (2) efficient admission processes; (3) safety and security; (4) timeliness; and (5) patient and family-centred processes of care. CONCLUSIONS Families received preadmission care in several settings and described varying degrees of care coordination during their admission processes. This research can guide improvements in hospitals' admission systems, necessary to achieve health system integration and continuity of care.
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Affiliation(s)
- JoAnna K Leyenaar
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA.,Graduate Program in Clinical and Translational Science, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Paul A Rizzo
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Emily R O'Brien
- Department of Nursing, Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Peter K Lindenauer
- Department of Internal Medicine, Baystate Medical Center, Springfield, Massachusetts, USA.,Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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