Pediatric Post-Acute Care Hospital Transitions: An Evaluation of Current Practice
Objectives: After discharge from an acute care hospital, some children require ongoing care at a post–acute care hospital. Care transitions occur at both admission to the post–acute care hospital and again at discharge to the home/community. Our objective was to report the current practices used during the admission to and discharge from 7 pediatric post–acute care hospitals in the United States.
Methods: Participants from 7 pediatric post–acute care hospitals completed a survey and rated the frequency of use of 20 practices to prepare and support children and their families during both admission to the hospital and at time of discharge to the home/community. For consistency with existing literature, practices were grouped into 4 previously reported categories: assessment, communication, education, and logistics. Descriptive statistics were used to report the frequency of use within practices and between hospitals.
Results: Only 2 of 10 admission practices and 3 of 10 discharge practices were reportedly “always” used by all hospitals. Assessment and communication practices were reported to be more frequently used (57%–100% of the time) than education and logistic procedures. Between hospitals, only the reported frequency of use of the discharge practices was statistically significantly different (P = .03).
Conclusions: Variability exists in transition practices among 7 post–acute care pediatric hospitals. This report is the first known to detail the frequency of use of admission and discharge practices for pediatric post–acute care hospitals in the United States.
Pediatric post–acute care hospitals, also known as pediatric specialty hospitals, pediatric rehabilitation hospitals, and pediatric long-term acute care hospitals, provide services to infants, children, and youth who need additional time, medical care, and rehabilitative services for recuperation and recovery after discharge from an acute care hospital.1–3 Previous research found that children admitted to post–acute care hospitals often have complex medical conditions, including brain injury, spinal cord injury, neuromuscular diseases, multiple congenital anomalies, and chronic lung disease/respiratory failure after premature birth. These children are often dependent on tracheostomy and ventilator support, tube feedings, central lines, and an array of therapeutic services from an interdisciplinary team.1–4 Offering a less restrictive, multispecialty, and developmentally appropriate environment, pediatric post–acute care hospitals can provide care at a lower cost than acute care hospitals.3
Transitions between health care settings and providers have been reported as a time of risk5–13 and uncertainty.10,11 Success of transition is often evaluated in terms of patient satisfaction,14 patient/family readiness,15 and frequency of readmission to an acute care hospital within 30 days of discharge.16–18 Effective transition practices are needed to ensure patient safety5–9,19 and patient/family readiness for admission to a post–acute care hospital or discharge to the community from a post–acute care hospital.9–12
Practices for transition include assessment, communication, education, and logistics.4–12,14,19–25 Reports of transition practices for adults transferring to inpatient rehabilitation programs7 and for infants being discharged after care in a NICU are available.20,21 In addition, recommendations have been made for discharge planning for children who require mechanical ventilation.4,9,14 These recommendations include a comprehensive assessment of medical and service needs; comprehensive training; and timely and thorough communication of information to the child, family, and the accepting care providers.4,6,8,9,14,19–21
Although children requiring post–acute care are a vulnerable population, no evidence-based management guidelines exist for transitioning to and from post–acute care. The identification of current practice is a critical first step in this process. Thus, the purpose of the present article was to report current practices used during the admission and discharge transitions to and from 7 pediatric post–acute care hospitals in the United States.
The present evaluation was conducted through the Specialized Pediatric Applied Research Consortium (SPARC), a 7-center research consortium of post–acute care hospitals in the northeastern United States. SPARC was founded in 2001 to support and conduct evidence-based research in pediatric post–acute care. All 7 SPARC centers participated in this evaluation. Surveys were completed by the principal SPARC investigator at each hospital; all of these investigators have both clinical and administrative responsibilities at their hospital (eg, chief of pediatrics, medical director, program director). Descriptive information about each SPARC hospital is reported in Table 1.
Procedures and Analysis
Based on a comprehensive literature review and published reports from the Institute for Healthcare Improvement,22,23 all transition practices relevant to pediatric post–acute care were identified by the study authors and compiled in a 2-part electronic survey. This process included rewording to make items brief for inclusion in a survey and applicable to pediatrics (eg, changed “self” and “spouse” to “child” and “family”). Twenty specific transition practices were identified and included in the survey: 10 described practices for admission to post–acute care from an acute care hospital (part 1) and 10 described discharge practices from a post–acute care hospital to the community/home (part 2). Tables 2 and 3 list all of the practices included in the survey.
The survey instrument was in table format, with the practices listed in the first column and 4 columns titled with a response option. Investigators rated the frequency of use of each of the practices at their hospital according to the following scale: “always,” “frequently but not consistently,” “occasionally but not usually,” and “never.” Perceptions regarding the effectiveness of the practices were not solicited. One survey per hospital was completed.
Surveys were distributed via e-mail to participating sites and returned to the primary author by e-mail for compilation and analysis. The adjacent frequently and occasionally responses were combined into a “sometimes” category to reduce the low-frequency responses in the presentation of the results. Consistent with previous transitional literature,4–12,14,19–25 we present the clinical practices in 4 categories: assessment, communication, education, and logistics.
Descriptive statistics were used to report the variations in use within practices and between hospitals. Frequencies were calculated for each response option within each of the 10 admission and discharge practices. Practices were then grouped according to category (assessment, communication, education, and logistics) to display the results. Differences in the reported total responses for frequency of use (always, sometimes, and never) for all admission and all discharge practices between hospitals were examined by using Fisher’s exact test and SAS Version 9.3 (SAS Institute, Inc, Cary, NC). Statistical significance was set at P < .05.
Frequency of use varied within the surveyed admission and discharge practices. Two of 10 admission practices and 3 of 10 discharge practices were reportedly always used by all hospitals. The only 2 admission practices reportedly always used by all 7 participating post–acute hospitals were “nurse obtains medical information from acute care hospital” and “printed informational materials given to family.” The only never response was for the practice of “family liaison greets the patient/family upon admission.” Table 2 lists the frequency of use for each of the 10 identified transition practices at admission.
The always response was chosen ≥71% (n = 5) of the time for all of the discharge practices, with the exception of having a nurse call the family at home at regularly scheduled intervals after discharge. “Assess discharge needs with family,” “patient/family education,” and “provide medication list” were the 3 discharge practices reported as always being used by all of the hospitals (100%, n = 7). Table 3 lists the frequency of use for each of the 10 identified transition practices at discharge.
At both admission and discharge, each practice category (assessment, communication, education, and logistics) included 2 or 3 transition practices. No one category was more prevalent at admission or discharge; however, in general, assessment and communication practices were reported to be more frequently used (57%–100% of the time) than education (14%–100%) and logistic procedures (57%–71%).
Between hospitals, differences in the reported total frequency of use (always, sometimes, and never) for all admission practices was not significantly different. The reported total frequency of use (always, sometimes, and never) for all discharge practices was statistically significantly different (P = .03) (Table 4).
The identification of current practice is the first step in both defining best practices as well as addressing potential gaps between best practice and current practice. Thus, the purpose of the present study was to report current practices used during the admission and discharge transitions to and from 7 pediatric post–acute care hospitals. To the best of our knowledge, this report is the first known to detail the types of admission and discharge practices and the variation in use for pediatric post–acute care hospitals in the United States.
The 2 consistent admission practices used across post–acute care hospitals were: (1) a nurse obtaining medical information from the acute care hospital; and (2) printed materials being given to families before admission. In general, all of the post–acute hospitals reported using all of the practices at least sometimes, with only 1 hospital lacking a family liaison to greet the patient and family upon arrival to the post–acute care hospital. O’Brien et al6 suggested elements of a minimum data set that could be used for the transfer of medical information between hospitals. Although information exchange was reported as a consistent practice, this study did not examine the specific medical information communicated between the acute care and post–acute care settings nor the means used to confirm the accuracy and completeness of information.
Only 1 post–acute care hospital reported having a nurse call the family at regularly scheduled intervals after discharge. This factor is a key point because the use of follow-up telephone calls to adult patients after hospital discharge has been evaluated as an effective intervention to decrease 30-day unplanned hospital readmissions.24,25 It can be speculated that all children discharged from a pediatric post–acute care hospital receive either home health care, outpatient rehabilitation, close follow-up by primary care providers in the community, or some combination of these services. Given these factors, post–acute hospitals may be more reliant on the community service providers and thus do not feel a need to perform postdischarge follow-up. There are no data available from this survey, or from the literature, to indicate whether regular postdischarge contact is unnecessary when community service providers are involved or whether such contacts continue to be of benefit even in these circumstances.
Differences in state licensing regulations and variation in the classification of pediatric post–acute care hospitals have prohibited the accurate identification of the number of hospitals and the number of admissions to pediatric post–acute care hospitals across the United States. Depending on the criteria selected, there could be up to 40 pediatric post–acute care hospitals in the United States, according to the Children’s Hospital Association (www.childrenshospitals.org). As such, our sample of 7 pediatric post–acute hospitals may be considered a limitation of this study, although we hope that providing the annual number of admissions and discharges to the participating facilities in Table 1 helped provide some context.
This study was also limited by its self-report design. Although there were a number of clinical practices reported and their use was somewhat consistent across hospitals, additional participants and a more detailed data collection tool may educate practitioners to other approaches and factors that could influence clinical practice, decrease unplanned hospital readmissions, and ultimately improve patient satisfaction, safety, and quality of care. In addition, internal reliability and content validity threats exist because survey responses were not tested nor confirmed beyond the survey responses submitted.
Future research should include examination of the effectiveness of these admission and discharge transition practices. For example, discharge interventions that could benefit from a study of effectiveness might include the use of a follow-up telephone call after the child has been discharged from the hospital and/or an “in-house leave of absence” in which a family assumes full responsibility for all of the child’s care in the hospital for a designated time period before discharge. The effectiveness of these interventions could be evaluated based on the number of emergency department visits, the number of unplanned hospitalizations within the first 30 days postdischarge, and/or any reduction in overall health care costs. In addition, family-centered outcomes, including caregiver satisfaction and caregiver readiness for discharge, could be evaluated and results incorporated into future transition planning.
This study describes the transition practices of 7 post–acute care pediatric hospitals in the United States. Variation exists in the frequency of use within each of the admission and discharge practices. Between hospitals, only the reported frequency of use of the discharge practices was statistically significantly different. Identification of current practice can provide the variables to measure the clinical effectiveness and the impact on satisfaction for post–acute care transitions.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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- Copyright © 2014 by the American Academy of Pediatrics