Statile Angela M, Schondelmeyer Amanda C, Thomson Joanna E, Brower Laura H, Davis Blair, Redel Jacob, Hausfeld Julie, Tucker Karen, White Denise L, White Christine M
Division of Hospital Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
Division of Hospital Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio James M. Anderson Center for Health Systems Excellence.
Pediatrics. 2016 Aug;138(2). doi: 10.1542/peds.2015-3832. Epub 2016 Jul 13.
Children with medical complexity have unique needs when facilitating transitions from hospital to home. Defining readiness for discharge is challenging, and preparation requires coordination of family, education, equipment, and medications. Our multidisciplinary team aimed to increase the percentage of medically complex hospital medicine patients discharged within 2 hours of meeting medical discharge goals from 50% to 80%.
We used quality improvement methods to identify key drivers and inform interventions. Medical discharge goals were defined on admission for each patient. Interventions included implementation of a complex care inpatient team with electronic admission order set, weekly care coordination rounds, needs assessment tool, and medication pathway. The primary measure, percentage of patients discharged within 2 hours of meeting medical discharge goals, was followed on a run chart. The secondary measures, pre- and post-intervention length of stay and 30-day readmission rate, were compared by using Wilcoxon rank-sum and χ(2) tests, respectively.
The percentage of medically complex patients discharged within 2 hours of meeting medical discharge goals improved from 50% to 88% over 17 months and sustained for 6 months. In preintervention-postintervention comparison, median length of stay did not change (3.1 days [interquartile range, 1.8-7.0] vs 2.9 days [interquartile range, 1.7-6.1]; P = .67) and 30-day readmission rate was not impacted (30.7% vs 26.4%; P = .51).
Efficient discharge for medically complex patients requires support of a multidisciplinary team to proactively address discharge needs, ensuring patients are ready for discharge when medical goals are met.
患有复杂疾病的儿童在从医院过渡到家庭的过程中有独特的需求。确定出院准备情况具有挑战性，且准备工作需要家庭、教育、设备和药物的协调配合。我们的多学科团队旨在将达到医疗出院目标后2小时内出院的患有复杂疾病的医院内科患者比例从50%提高到80%。
我们采用质量改进方法来确定关键驱动因素并为干预措施提供依据。每位患者入院时确定医疗出院目标。干预措施包括组建一个配备电子入院医嘱集的复杂护理住院团队、每周进行护理协调查房、使用需求评估工具以及采用药物治疗路径。主要指标是达到医疗出院目标后2小时内出院的患者比例，通过运行图进行跟踪。次要指标，即干预前后的住院时间和30天再入院率，分别采用Wilcoxon秩和检验和χ²检验进行比较。
在17个月的时间里，达到医疗出院目标后2小时内出院的患有复杂疾病的患者比例从50%提高到了88%，并持续了6个月。在干预前与干预后的比较中，中位住院时间没有变化（3.1天[四分位间距，1.8 - 7.0]对2.9天[四分位间距，1.7 - 6.1]；P = 0.67），30天再入院率也未受影响（30.7%对26.4%；P = 0.51）。
患有复杂疾病的患者实现高效出院需要多学科团队的支持，以积极主动地满足出院需求，确保患者在达到医疗目标时做好出院准备。
