OBJECTIVES:

The transition period from hospitalization to outpatient care can be high risk for pediatric patients. Our aim was to profile the use of a “safety net” for families through provision of specific inpatient provider contact information for urgent issues post discharge.

METHODS:

In this prospective study, we implemented an updated after-visit summary that directed families to call the hospital operator and specifically ask for the pediatric hospital medicine attending on call if they were unable to reach their primary care provider (PCP) with an urgent postdischarge concern. Education for nursing staff, operators, and pediatric hospital medicine providers was completed, and contact information was automatically populated into the after-visit summary. Information collected included the number of calls, the topic, time spent, whether the family contacted the PCP first, and the time of day. Descriptive statistics and Fisher’s exact test were used to summarize findings.

RESULTS:

Over a 13-month period, of 5145 discharges, there were 47 postdischarge phone calls, which averaged to 3.6 calls per month. The average length of time spent on a call was 21 minutes. For 30% of calls, families had tried contacting their PCPs first, and 55% of calls occurred at night. Topics of calls included requesting advice about symptoms, time line for reevaluation, and assistance with medications.

CONCLUSIONS:

This safety net provided families with real-time problem-solving for an urgent need post discharge, which included triaging patient symptoms at home, counseling on medication questions, information about the time line of illness recovery, and provision of additional resources.

Care of the pediatric patient does not end after the family exits the hospital doors. The transition from hospitalization to outpatient care can be high risk. Studies reveal that 1 in 5 pediatric patients experience postdischarge problems, one-third of which require further intervention by a provider.13  Common postdischarge problems encountered by families include obtaining prescriptions in pediatric formulations, questions about symptoms, and obstacles to follow-up care.

Postdischarge issues can lead to significant consternation for families, unnecessary risk to the patient, and reuse of health care resources. The role of the pediatric hospital medicine (PHM) team is to prepare families for this transition,4  yet some unanticipated postdischarge issues are unavoidable and lead to suboptimal care. Additionally, families may have unique transition needs, and improvement efforts should address this variability.5 

At discharge, care must be transitioned from the inpatient team to the primary care provider (PCP). The time between discharge and PCP follow-up appointment can be a vulnerable period because the patient is no longer receiving direct care from their inpatient provider. Although some PCPs practice inpatient medicine, allowing for better continuity of care, the expanding role of the hospitalist has increased the transfer of care from hospital-based providers to PCPs.6 

Postdischarge follow-up phone calls have been employed to assist with the transition, and although they can serve as a vital resource, they may not address issues that arise before or after the phone call.7,8  In our experience, although many PCPs have answering services for their patients, families may not have knowledge of this service, may feel reluctant to call when the issue is related to hospitalization, or have yet to establish care with a new PCP postdischarge. Additionally, when families call the general hospital phone number with questions, they may become frustrated by operators forwarding them to providers or units who cannot help.

Our goal for this intervention was to improve the discharge transition by including PHM provider contact information on the after-visit summary (AVS) as an additional means of support, specifically when families cannot reach their PCPs after discharge. By creating this two-tier approach, or “safety net,” for families, we can minimize care gaps while also balancing time constraints and increased workload of the PHM team for long-term sustainability.9  This intervention addresses the difference in directionality of contact post discharge and provides real-time access to an attending provider post discharge when the family has an urgent need. We therefore aimed to profile the use of this safety net intervention.

This is a single-center, noncontrolled prospective study performed at our freestanding, 300-bed academic quaternary care pediatric hospital in the Midwest. The PHM section is composed of 33 physicians and 10 advanced practice practitioners and receives >5000 admissions annually. In April 2019, we added specific PHM contact information on the AVS for PHM patients. This study was approved by our institutional review board as non–human subjects research.

Nursing education was provided to align discharge teaching for contacting providers with the new AVS. During discharge teaching, families were counseled via verbal and written instructions that the use of PHM contact information was for urgent situations when the family could not reach the PCP.

Hospital operator education was completed to standardize scripting of pages to the PHM attending, including caller name, number, and message: “[name] is calling re: recent hospitalization of [child, date of birth, phone number].” This allowed for expedited chart review before returning the call.

Feedback sessions were held with PHM providers to discuss how to balance addressing this safety gap while not infringing on the PCP-patient relationship and how to streamline this process for sustainability. As part of our discharge transition process, all discharge summaries are routed to the PCP, and calls are made for any patient with specific follow-up needs. To promote the PCP-patient relationship, the AVS was visually arranged so families would see the PCP’s contact information first. PCP information was followed by discharge instructions with disease-specific information for home care, and finally the phrase “if you cannot reach your primary care provider [with PCP contact info provided again] and have urgent questions about your child’s recent hospital stay, call [hospital operator number]. Ask to talk to the hospitalist provider on call.” Use of the word “urgent” was included to specifically remind families of appropriate use.

We used informatics tools within our electronic health record (EHR) to integrate this process into our discharge workflow. The contact phrase was added to all discharge order sets, and a rule was built into the EHR to only appear for patients with PHM as the discharging service.

We collected data over a 13-month period from April 2019 to April 2020. Phone call–specific questions were added to a PHM survey that attending physicians complete at shift conclusion. Information collected included the number of calls, the topic, time spent, whether the PCP was contacted first, and whether the call occurred during a day or night shift. As a means of quality assurance, we used the EHR workbench report to pull all PHM attending telephone encounters and postdischarge phone calls.

Descriptive statistics and Fisher’s exact test were used to analyze data.

Over a 13-month period, of 5145 discharges, there were a total of 47 phone calls (0.9% of discharges) from families (44 unique family calls because 3 families called twice), averaging 3.6 calls per month (range 0–10 calls). Patient characteristics are described in Table 1. The highest number of calls was in January, likely reflecting a higher census during respiratory season. The average length of time spent on a call was 21 minutes (range 5–60 minutes). The total time spent on phone calls during this 13-month period was 15 hours. Of the 47 phone calls, 14 (30%) were made by families who had tried contacting their PCPs first, whereas 29 (62%) were made by families who had not, and for 4 (8%) families, it wase unknown whether they had tried contacting their PCPs first (Table 2). Of the 47 phone calls, 26 (55%) occurred during the night shift (5:30 pm to 7:30 am). There was a significant difference in whether callers contacted PCPs first between nighttime and daytime calls (17% vs 53%, respectively; P = .021) Thirty-six calls occurred during weekdays (77%), but there was no significant difference in whether callers contacted PCPs before the hospitalist between weekdays and weekends (P = .755) (Tables 2 and 3). Ninety-four percent (4836) of discharges had PHM provider contact information included, with the remaining 6% not included because of incorrect order set usage. The most common reasons for calls were requesting advice about new and ongoing symptoms. The 3 most common discharge diagnoses were pneumonia, bronchiolitis, and toxic shock syndrome (see Supplemental Table 4 for a list of all diagnoses). Real-time problem-solving with families during calls included triaging patients for continued observation at home versus seeking care, strategies for difficult medication administration, reassurance about the time line of illness recovery, and provision of additional resources, such as hospital case management and social work.

TABLE 1

Patient Demographics (N = 47)

Value
Sex, n (%)  
 Female 25 (58) 
 Male 18 (42) 
Insurance type, n (%)  
 Private 23 (53) 
 Public 20 (47) 
Race and/or ethnicity, n (%)  
 White 37 (79) 
 Black or African American 5 (11) 
 Asian 1 (2) 
 Unknown 4 (8) 
Age by group, y, n (%)  
 <1 11 (26) 
 1–2 7 (16) 
 3–6 8 (19) 
 7–12 8 (19) 
 13–18 9 (21) 
Age, median (IQR), range 4 y (1–11 y), 13 d to 17 y 
Chronic conditions, n (%)  
 Yes 18 (42) 
 No 25 (58) 
Hospital length of stay, h, mean (SD), range 88.8 (75.4), 18–393 
Discharge time, n (%)  
 Day (6:00 am to 5:30 pm37 (86) 
 Night (5:31 pm to 5:59 am6 (14) 
Value
Sex, n (%)  
 Female 25 (58) 
 Male 18 (42) 
Insurance type, n (%)  
 Private 23 (53) 
 Public 20 (47) 
Race and/or ethnicity, n (%)  
 White 37 (79) 
 Black or African American 5 (11) 
 Asian 1 (2) 
 Unknown 4 (8) 
Age by group, y, n (%)  
 <1 11 (26) 
 1–2 7 (16) 
 3–6 8 (19) 
 7–12 8 (19) 
 13–18 9 (21) 
Age, median (IQR), range 4 y (1–11 y), 13 d to 17 y 
Chronic conditions, n (%)  
 Yes 18 (42) 
 No 25 (58) 
Hospital length of stay, h, mean (SD), range 88.8 (75.4), 18–393 
Discharge time, n (%)  
 Day (6:00 am to 5:30 pm37 (86) 
 Night (5:31 pm to 5:59 am6 (14) 

Percentages are based on the total N available for that item. Because of incomplete provider-reported data, Ns are not equal across certain items.

TABLE 2

Call Details (N = 47)

n%
Reason for call   
 Wanted advice regarding new symptoms 17 36 
 Wanted advice regarding ongoing symptoms 17 36 
 Wanted advice regarding return of symptoms 13 
 Assistance with medications 
 Assistance with missing supplies after discharge 
 Assistance with follow-up appointment 
 Assistance with laboratory test results 
Daytime or nighttime call   
 Daytime 21 45 
 Nighttime 26 55 
Weekday or weekend call   
 Weekday 36 77 
 Weekend 11 23 
Contacted PCP first   
 No 29 62 
 Yes 14 30 
 Unknown 
n%
Reason for call   
 Wanted advice regarding new symptoms 17 36 
 Wanted advice regarding ongoing symptoms 17 36 
 Wanted advice regarding return of symptoms 13 
 Assistance with medications 
 Assistance with missing supplies after discharge 
 Assistance with follow-up appointment 
 Assistance with laboratory test results 
Daytime or nighttime call   
 Daytime 21 45 
 Nighttime 26 55 
Weekday or weekend call   
 Weekday 36 77 
 Weekend 11 23 
Contacted PCP first   
 No 29 62 
 Yes 14 30 
 Unknown 
TABLE 3

Secondary Analyses of Calls to Hospitalist or PCP (N = 43)

Contacted PCP First, n (%)Did Not Contact PCP, n (%)P
Time of calls   .021 
 Daytime call 10 (53) 9 (47) — 
 Nighttime call 4 (17) 20 (83) — 
Day of calls   .755 
 Weekday call 10 (31) 22 (69) — 
 Weekend call 4 (36) 7 (64) — 
Contacted PCP First, n (%)Did Not Contact PCP, n (%)P
Time of calls   .021 
 Daytime call 10 (53) 9 (47) — 
 Nighttime call 4 (17) 20 (83) — 
Day of calls   .755 
 Weekday call 10 (31) 22 (69) — 
 Weekend call 4 (36) 7 (64) — 

—, not applicable.

Although inpatient teams work hard to prepare for discharge, this study highlights the need for provision of additional support for families. There have been previous studies in which discharge follow-up phone calls2,3  and home nurse visits have been evaluated,10  but this work reveals a simple intervention for when families encounter issues, especially during nighttime hours. Given there were, on average, only 3.6 calls per month, this safety net is an opportunity for improved care transition without a significant time burden placed on inpatient providers. This number is lower than predicted on the basis of previous literature13  regarding the number of postdischarge issues and is likely due to the two-tier nature of this intervention, with both the PCP and PHM contact information provided.

There are caregiver-reported measures to assess discharge transition as well as standardized evaluation of the quality of transitions in the pediatric population.1113  Our future work will include applying validated measurement tools to this intervention and continuing to track calls for ongoing characterization and potential financial impact to the institution. With additional data, we may be able to better categorize information requested by families to help identify themes and specific transition gaps for future quality improvement. Furthermore, our data suggests that families are hesitant to contact their PCPs at night, and we can provide education about after-hours answering services their PCPs provide. There are several limitations of this study. We relied on attending documentation of calls, which may underestimate our numbers, and we acknowledge that some data fields were not filled out to completion. Additionally, our sample size was small, limiting our ability to make generalizable conclusions on specific situations in which families might use the PHM contact information or our ability to assess the impact of our intervention.

A safety net for families can help augment care during a vulnerable time as patients transition from inpatient to outpatient care. PHM providers triage issues in real time with families, including filling a need after hours, and provide active problem-solving through counseling and assessing the need for reevaluation. Hospitalization of a child is stressful for families, and PHM providers play a crucial role not only in coordination of care before discharge but also during transition back to the patient’s medical home.

We thank Fatima Anibaba, MS, for help collecting data.

Dr Yale conceptualized and designed the study, conducted analyses, interpreted the data, and drafted the initial manuscript; Dr Bauer designed the informatics implementation, conducted analyses, interpreted the data, and critically reviewed and revised the manuscript; Dr Stephany conceptualized and designed the study and critically reviewed and revised the manuscript; Ms Porada conducted analyses, interpreted the data, and critically reviewed and revised the manuscript; Dr Liljestrom conceptualized and designed the study, conducted analyses and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.

FUNDING: No external funding.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.