Sarah C. McBride

A Framework of Pediatric Hospital Discharge Care Informed by Legislation, Research, and Practice

To our knowledge, no widely used pediatric standards for hospital discharge care exist, despite nearly 10 000 pediatric discharges per day in the United States. This lack of standards undermines the quality of pediatric hospital discharge, hinders quality-improvement efforts, and adversely affects the health and well-being of children and their families after they leave the hospital. In this article, we first review guidance regarding the discharge process for adult patients, including federal law within the Social Security Act that outlines standards for hospital discharge; a variety of toolkits that aim to improve discharge care; and the research evidence that supports the discharge process. We then outline a framework within which to organize the diverse activities that constitute discharge care to be executed throughout the hospitalization of a child from admission to the actual discharge. In the framework, we describe processes to (1) initiate pediatric discharge care, (2) develop discharge care plans, (3) monitor discharge progress, and (4) finalize discharge. We contextualize these processes with a clinical case of a child undergoing hospital discharge. Use of this narrative review will help pediatric health care professionals (eg, nurses, social workers, and physicians) move forward to better understand what works and what does not during hospital discharge for children, while steadily improving their quality of care and health outcomes.

Preventable Adverse Events in Infants Hospitalized With Bronchiolitis

Objective. To determine the incidence of preventable adverse events (AEs) and near misses (NMs) among infants hospitalized for bronchiolitis at a pediatric tertiary care hospital and the impact of these errors on hospital length of stay (LOS). Methods. We studied 143 infants with bronchiolitis, ages 0 to 12 months, admitted from December 2002 to April 2003. Using prospective chart review and staff reports, we captured medical errors and AEs. Each event was classified as a (1) preventable AE, (2) nonpreventable AE, (3) intercepted NM, (4) nonintercepted NM, or (5) error with little or no potential for harm. Results. Of 143 patients, 15 (10%) suffered an AE or NM. The incidence of preventable AEs was 10 per 100 admissions. We found a higher incidence of preventable AEs and NMs among critically ill patients (CIPs) compared with non-CIPs (68 vs 5 per 100 admissions, respectively), making the absolute risk of an AE or NM 14 times more likely in CIPs. Mean LOS was significantly longer for CIPs with at least 1 AE (9.1 ± 8.8 days) than for CIPs without AEs (2.9 ± 1.5 days). Mean LOS was not significantly different between non-CIPs who did (3.8 ± 2.6 days) and did not (4.2 ± 5.0 days) experience an AE. Conclusions. Preventable AEs occur frequently among patients admitted for bronchiolitis, especially those who are critically ill. CIPs who suffer AEs during their hospitalization have longer hospital LOSs. Future studies should investigate error-prevention strategies with a focus on those patients with severe disease.

Nursing-led Home Visits Post-hospitalization for Children with Medical Complexity

Purpose Hospital discharge for children with medical complexity (CMC) can be challenging for families. Home visits could potentially benefit CMC and their families after leaving the hospital. We assessed the utility of post‐discharge home visits to identify and address health problems for recently hospitalized CMC. Design and Methods A prospective study of 36 CMC admitted to a childrens hospital from 4/15/2015 to 4/14/2016 identified with a possible high risk of hospital readmission and offered a post‐discharge home visit within 72 h of discharge. The visit was staffed by a hospital nurse familiar with the childs admission. The home visit goals were to reinforce education of the discharge plan, assess the childs home environment, and identify and address any problems or issues that emerged post‐discharge. Results The childrens median age was 6 years [interquartile range (IQR) 2–18]. The median distance from hospital to their home was 38 miles (IQR 8–78). All (n = 36) children had multiple chronic conditions; 89% (n = 32) were assisted with medical technology. The nurse identified and helped with a post‐discharge problem during every (n = 36) visit. Of the 147 problems identified, 26.5% (n = 39) pertained to social/family issues (e.g., financial instability), 23.8% (n = 35) medications (e.g., wrong dose), 20.4% (n = 30) durable medical equipment (e.g., insufficient supply or faulty function), 20.4% (n = 30) childs home environment (e.g., unsafe sleeping arrangement), and 8.8% (n = 13) childs health (e.g., unresolved health problem). Conclusions Home visits helped identify and address post‐discharge issues that occurred for discharged CMC. Practical Implications Hospitals should consider home visits when optimizing discharge care for CMC. HighlightsAn inpatient nurse visited children with medical complexity at home post‐discharge.Nurse identified and assisted with post‐discharge problems for every visit.Most visits identified 3 or more post‐discharge problems.Social/family, medication, and equipment issues were the most common problems.Families and healthcare providers perceived value in the home visit.

Management of parapneumonic effusions in pediatrics: current practice.

Pneumonia with associated complex pleural disease is a cause of significant morbidity among hospitalized children. The management of this patient population continues to be a challenge and varies even among single institutions. The article presented here reviews the management goals for pediatric patients hospitalized with complex parapneumonic effusions and provides updated summaries of both medical and surgical therapies.

Issues Identified by Postdischarge Contact after Pediatric Hospitalization: A Multisite Study

BACKGROUND Many hospitals are considering contacting hospitalized patients soon after discharge to help with issues that arise. OBJECTIVES To (1) describe the prevalence of contact-identified postdischarge issues (PDI) and (2) assess characteristics of children with the highest likelihood of having a PDI. DESIGN, SETTING, AND PATIENTS A retrospective analysis of hospital-initiated follow-up contact for 12,986 children discharged from January 2012 to July 2015 from 4 US children’s hospitals. Contact was made within 14 days of discharge by hospital staff via telephone call, text message, or e-mail. Standardized questions were asked about issues with medications, appointments, and other PDIs. For each hospital, patient characteristics were compared with the likelihood of PDI by using logistic regression. RESULTS Median (interquartile range) age of children at admission was 4.0 years (0a 11); 59.9% were non-Hispanic white, and 51.0% used Medicaid. The most common reasons for admission were bronchiolitis (6.3%), pneumonia (6.2%), asthma (5.1%), and seizure (4.9%). Twenty-five percent of hospitalized children (n = 3263) reported a PDI at contact (hospital range: 16.0%–62.8%). Most (76.3%) PDIs were related to follow-up appointments (eg, difficulty getting one); 20.8% of PDIs were related to medications (eg, problems filling a prescription). Patient characteristics associated with the likelihood of PDI varied across hospitals. Older age (age 10–18 years vs <1 year) was significantly (P < .001) associated with an increased likelihood of PDI in 3 of 4 hospitals. CONCLUSIONS PDIs were identified often through hospital-initiated follow-up contact. Most PDIs were related to appointments. Hospitals caring for children may find this information useful as they strive to optimize their processes for follow-up contact after discharge.

Comparison of Empiric Antibiotics for Acute Osteomyelitis in Children

OBJECTIVES Broad-spectrum antibiotics are commonly used for the empiric treatment of acute hematogenous osteomyelitis and often target methicillin-resistant Staphylococcus aureus (MRSA) with medication-associated risk and unknown treatment benefit. We aimed to compare clinical outcomes among patients with osteomyelitis who did and did not receive initial antibiotics used to target MRSA. METHODS A retrospective cohort study of 974 hospitalized children 2 to 18 years old using the Pediatric Health Information System database, augmented with clinical data. Rates of hospital readmission, repeat MRI and 72-hour improvement in inflammatory markers were compared between treatment groups. RESULTS Repeat MRI within 7 and 180 days was more frequent among patients who received initial MRSA coverage versus methicillin-sensitive S aureus (MSSA)-only coverage (8.6% vs 4.1% within 7 days [P = .02] and 12% vs 5.8% within 180 days [P < .01], respectively). Ninety- and 180-day hospital readmission rates were similar between coverage groups (9.0% vs 8.7% [P = .87] and 10.9% vs 11.2% [P = .92], respectively). Patients with MRSA- and MSSA-only coverage had similar rates of 72-hour improvement in C-reactive protein values, but patients with MRSA coverage had a lower rate of 72-hour white blood cell count normalization compared with patients with MSSA-only coverage (4.2% vs 16.4%; P = .02). CONCLUSIONS In this study of children hospitalized with acute hematogenous osteomyelitis, early antibiotic treatment used to target MRSA was associated with a higher rate of repeat MRI compared with early antibiotic treatment used to target MSSA but not MRSA. Hospital readmission rates were similar for both treatment groups.

Office laboratory procedures, office economics, parenting and parent education, and urinary tract infection.

Four areas of pediatric office practice are again reviewed: office laboratory procedures, office economics, parenting and parent education, and urinary tract infection. Screening for celiac disease and the use of rapid antigen testing for extrapharyngeal group A Streptococcus infections are included in office laboratory procedures. Utilization of health care among patients with public insurance, electronic medical records, billing among pediatric residents, and satisfaction surveys are reviewed in office economics. Challenges related to breastfeeding, obesity management and timely immunizations are covered within parenting and parent education. Finally, the use of an augmented urinalysis and a discussion of imaging for first febrile urinary tract infections are included in the area of urinary tract infection.