Multi-stakeholder informed guidelines to support direct admission for hospitalized children
Leyenaar, JoAnna.
2018
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Abstract:
Introduction: One-quarter of all unplanned pediatric hospitalizations in the Unites
States begin as direct admissions, defined as hospital admission without first receiving
care in the hospital's emergency department. Direct admissions for children may have
several advantages over admissions through emergency departments, including improved
continuity of care, decreased risk of ... read morenosocomial infection, and reduced resource
utilization. However, studies in adults have raised concerns about the safety of this
admission approach. Previous research has shown that direct admission rates are highly
variable across hospitals, and we know very little about the perspectives and priorities
of the multiple stakeholders involved in direct admission processes or how to optimize
pediatric direct admission processes. The work summarized in this thesis aimed to
address these gaps through three complementary studies: (i) a qualitative study
characterizing patterns of pre-admission acute care for children and parents' priorities
regarding their child's hospital admission processes and outcomes: (ii) a retrospective
cohort study examining hospital and community characteristics associated with pediatric
direct admission to hospital; and (iii) deliberative methods and a modified Delphi
process to develop direct admission guidelines for hospitalized children. Methods: The
work summarized in this thesis applied mixed methods, including semi-structured
interviews with parents of hospitalized children, hierarchical regression modeling to
determine the proportion of variation in hospitals' risk-adjusted direct admission rates
that may be attributed to observed hospital and community characteristics, and pairing
of deliberative methods and a modified Delphi process to engage multiple stakeholders in
the direct admission process to develop pediatric direct admission guidelines. Results:
We conducted 48 interviews with parents of hospitalized children at four hospitals.
Children had a median of 2 [interquartile range 1-3] healthcare encounters in the week
preceding hospital admission, with 44% seeking care in multiple settings. Participants'
hospital admission priorities included: (i) effective clinical care; (ii) efficient
admission processes; (iii) safety and security; (iv) timeliness; and (v) patient- and
family-centered processes of care. In our retrospective cohort study of 211,458 children
discharged from 933 hospitals and 26 states, 20.2% were admitted directly. One-fifth of
the variance in risk-adjusted direct admission rates was attributed to observed hospital
and community factors. The greatest proportion of this explained variance was related to
ED volume (37%), volume of pediatric hospitalizations (27%), and size of the
pediatrician workforce (12%). Through a modified Delphi process, panelists endorsed 71
direct admission best practices and 13 outcomes to evaluate hospital admission
processes. Conclusions: These three papers expand our knowledge about factors associated
with direct admission to hospital, and characterize diverse perspectives of key
stakeholders in this admission approach. The direct admission guidelines resulting from
this work can be adapted by hospitals and health systems to inform hospital admission
policies and protocols, providing best practices to standardize approaches to care for
hospitalized children.
Thesis (Ph.D.)--Tufts University, 2018.
Submitted to the Dept. of Clinical & Translational Science.
Advisor: Peter Lindenauer.
Keyword: Health sciences.read less - ID:
- h702qk04h
- Component ID:
- tufts:25426
- To Cite:
- TARC Citation Guide EndNote
