Improving transitions of care for complex pediatric trauma patients from inpatient rehabilitation to home: an observational pilot study

Abstract

BackgroundPatients requiring inpatient pediatric rehabilitation following trauma or disabling illness often require complex care after hospital discharge. The patients and their families are at risk for loss of continuity of care and increased stress which can adversely affect functional and medical outcomes. This pilot study assesses the complexity of need and difficulty with obtaining services at the time of transition from inpatient to outpatient care for pediatric rehabilitation. Additionally we explored the intervention of a post discharge phone call from an experienced rehabilitation nurse to address any issues identified in this period.MethodsA rehabilitation nurse made scripted post discharge phone calls to patients and families 1–2 weeks after discharge from inpatient pediatric rehabilitation inquiring about medical appointments, medications, therapies, adaptive equipment and transition back to school. Results were recorded by the nurse then analyzed and tabulated by a rehabilitation physician.ResultsEighty two percent of patients had needs in 4–5 of the areas assessed as part of their discharge recommendations. Eighty four percent of those families contacted had difficulty with at least one area at discharge. In all cases of confusion or difficulty with the recommendations, the nurse was able to provide needed guidance to ameliorate the situation.ConclusionsThis pilot study indicates that pediatric rehabilitation patient require complex care as they transition to an outpatient setting. There is significant confusion and families often have difficulty obtaining necessary care in an efficient and effective way during this transition. A post discharge phone call from an experienced rehabilitation nurse could address most of the issues that arise during the transition. This pilot study indicates a need for more investigation into interventions to improve the transition process for pediatric rehabilitation patients and suggests a post discharge phone call program could be useful intervention for pediatric rehabilitation patients and other patient populations requiring complex care such as polytrauma patients.

Stress, Trauma, Sepsis, Inflammation, Management in Asthma

“…A recent pilot study by Biffl assessed the complexity of need and diffi culty with obtaining services at the time of transition from inpatient to outpatient care for pediatric rehabilitation [18]. Current developments on the implementation of trauma informed care in a variety of service systems call for the surveillance of trauma, resiliency and health impact.…”

Scoping review of the literature to ascertain how follow-up care is provided to major trauma patients post discharge from acute care

“… 27 In both studies the advanced qualifications were specific to the psychologists involved in the team. In relation to the nursing roles, studies described educational levels in terms of the position title or experience: nurses were described as experienced 35 having additional qualifications such as a nurse practitioner 38 43 44 or advanced practice nurse. 37 …”

“… 37 Almost half of paediatric trauma patients reported no difficulties in accessing ongoing services, but this was due to established structured follow-up support based on their injuries (ie, TBI). 35 …”

“…37 Almost half of paediatric trauma patients reported no difficulties in accessing ongoing services, but this was due to established structured follow-up support based on their injuries (ie, TBI). 35 The majority of patients were satisfied with the follow-up service provided with one study reporting 90% of patients surveyed found the follow-up appointment helpful. 44 For patients who used telehealth to access follow-up care, 100% stated they thought this delivery method made it easier to access care.…”

“…The resources required to provide follow-up included physical clinic space, phone and text messaging capability and telehealth equipment; seven articles reported using a mixture of resources. 27-31 33 34 To deliver follow-up care, the resources reported included the use of a script to deliver a phone call [34][35][36] or a scripted algorithm incorporating specific topic related questions pertaining to general well-being, pain control and complications. 6 37 Protocols and guidelines were followed to deliver the care to patients 38 39 although no description of the content of these were provided.…”