Nurse Support for Children and Their Parents Returning Home From the Hospital—The H2O Study [Internet]

Excerpt

Background: The transition from hospital to home is a vulnerable time, especially for pediatric patients and their families.

Objectives: We sought to improve outcomes of hospital-to-home transitions for hospitalized children aged < 18 years old through the following aims:

1. Aim 1: Develop a comprehensive understanding of hospital-to-home transitions.

2. Aim 2: Adapt a home nurse intervention to address challenges and improve patient- and family-defined outcomes of transitions.

3. Aim 3: Determine if a single nurse-led home visit after pediatric discharge decreases 30-day urgent reutilization and enhances transitions.

4. Aim 4/supplement: Determine if a single nurse-led phone call after pediatric discharge decreases 30-day urgent reutilization and enhances transitions. Post hoc analysis: Interpret aim 3 trial results from the stakeholder perspective.

Methods:

1. Study setting: The study took place in a large freestanding pediatric tertiary care hospital.

2. Aim 1: We held focus groups with caregivers of recently discharged children. We analyzed qualitative data using an inductive, thematic approach.

3. Aim 2: We incorporated feedback from families and nurses to optimize the nurse home visit intervention using iterative improvement science methods.

4. Aim 3: We randomized 1500 children to either a nurse-led home visit or standard discharge. Our primary outcome was 30-day unplanned health care reutilization (readmission, emergency department, or urgent care revisit). Secondary outcomes included parental postdischarge coping, days until return to normal routine, and caregiver-recalled number of clinical warning signs (“red flags”; see Figure 2 for examples).

5. Aim 4: We randomly assigned 966 children to either a postdischarge phone call or standard discharge. We analyzed outcomes for aims 3 and 4 using regression analyses adjusted for stratification variables.

6. Post hoc analysis: We conducted stakeholder interviews and focus groups.

Results:

1. Aim 1: Four main concepts resulted: (1) “In a fog” (barriers to processing and acting on information); (2) “What I wish I had” (desired information and suggestions for improvement); (3) “Am I ready to go home?” (discharge readiness); and (4) “I'm home, now what?”(confidence and postdischarge care).

2. Aim 2: We addressed postdischarge barriers through iteratively adapting the intervention using feedback from nurses and families from 301 consecutive nurse visits.

3. Aim 3: “The 30-day reuse rate was 17.8% in the intervention group and 14.0% in the control group. In intention-to-treat analysis, children randomly assigned to the intervention group had higher odds of 30-day health care use (odds ratio = 1.33; 95% CI, 1.003-1.76).” “Postdischarge coping scores and number of days until returning to a normal routine were similar between groups. Parents in the intervention group recalled more red flags at 14 days (mean = 1.9 vs 1.6; P < .01).”

4. Aim 4: “Children in the intervention and control arms had similar rates of 30-day urgent health care services (intervention group, 77 [15.9%]; control group, 63 [13.1%]; P = 0.21). Parents of children in the intervention group recalled more clinical warning signs at 14 days (mean = 1.8; [95% CI, 1.7-2.0] in the intervention group; 1.5 [95% CI, 1.4-1.6] in the control group; ratio of intervention to control, 1.2 [95% CI, 1.1-1.3]).”

5. Post hoc Analysis: Many factors influenced reutilization. Parents valued the reassurance and education that the nurse visit provided.

Conclusions: Families articulate many unmet needs during transitions from the hospital to home. Children randomly assigned to an in-home nurse visit had higher rates of reutilization than children randomly assigned to the control; children randomly assigned to a postdischarge phone call had similar rates of reutilization. Postdischarge nurse contact does bolster caregiver knowledge. Further study is needed to understand the effect of this gained knowledge on family-centered outcomes.

Note for readers: Throughout the report there are long quotations that reflect text taken verbatim from our previously published manuscripts. Although the Final Research Report is intended to be a complete account of all activities of the Hospital to Home Outcomes (H2O) study, the level of detail provided here is limited due to word count and the vast amount of information generated by this work. Please refer to the “Related Publications” section for further detailed information.