Implementing a Best Practice Guideline to Improve Care Transitions for Children with Medical Complexity
Summary
Project Description and Organizational Context
SE Health sought to use the RNAO BPG Toolkit: Knowledge-to-Action process to implement the RNAO Care Transitions Clinical Best Practice Guideline (CBPG) to improve transitions from hospital to home for Children with Medical Complexity (CMC). In many areas across Ontario, SE Health cares for CMC through a variety of services including shift nursing respite, school health nursing, rehab and nursing home visits and palliative care.
As proposed in the fellowship application, the steps in the RNAO best practice guideline implementation toolkit were followed. Proposed outcomes included aligning SE Health policies and procedures to be congruent with best practice at pediatric hospitals. When families are taught one way consistently in the hospital, and return home to see home healthcare workers doing things a different way, it can affect their trust in the nursing team.
The application also proposed to work together with a children’s hospital to implement a collaborative model of pediatric care transition. Key themes that were consistent in the literature and across our sectors were streamlining communication, supplies, timing of discharge/admission, challenges with recruiting and retaining skilled staff and gaps in continuity of care.
For the intervention, the current receptiveness to virtual care was leveraged to test out virtual admission visits prior to a child’s discharge from hospital. As this was already in place for complex care, the intervention instead focused on children being discharged from acute care or general pediatric units. These children are often discharged quickly and in the evenings when hospital and community support is less available. A major challenge that was identified during interviews with internal stakeholders and conducting case debriefs with nurses was timely access to appropriate supplies. Pediatric clients often require more specialized supplies and greater volumes than the standard packages that are received from the LHIN. This can result in families having to make multiple trips for supply pickup in the first days at home, and longer home admission visits to rectify the discrepancies. The intent of connecting with families and their care team prior to discharge was to address some of these challenges and promote a smooth the transition home.
Learning Goal and Objectives
The overall learning goal of the fellowship was to develop the skills and knowledge necessary to implement a clinical best practice guideline in a specific population within a large health organization. Work to date falls under four proposed learning objectives that follow the RNAO toolkit for implementation of best practice guidelines.
Objective 1: Identify, review, and select relevant knowledge.
A literature review and gap assessment were conducted and internal stakeholder feedback was obtained from other pediatric focused leaders at SE Health. To help inform best practice and policy alignment, the fellow attended many pediatric education opportunities. An analysis was also performed to identify external stakeholders, targeting a Children’s hospital to collaborate with and stakeholder interviews were conducted.
Objective 2: Adapt acquired best practice guideline knowledge to the local context
An observational placement was secured with Dr. Audrey Lim, of the McMaster Complex Care team, who is passionate about improving care transitions. As part of this collaboration, the fellow was able to observe some of the virtual discharge planning meetings and LHIN Complex Care rounds that were already in place.
The fellow and mentors initiated a pediatric working group at SE Health for leaders working with CMC to share knowledge and resources across each location across Ontario.
Objective 3: Select and implement interventions and strategies
Pediatric training at SE health was updated and disseminated to ensure it is aligned with current best practices, including the organization’s orientation and locally through monthly pediatric education rounds. As an intervention, virtual admission visits were piloted, following the Plan Do Study Act (PDSA) cycle to gain continual feedback and make real-time adjustments.
Objective 4: Evaluation of outcomes.
Continual stakeholder input was sought and obtained throughout the fellowship. As part of the PDSA cycles, family and provider feedback was used to inform revisions to the intervention. Improved access to supplies at admission was used as an indicator of positive client outcomes. The fellowship progress was presented to teams from both McMaster and SE Health to evaluate the impact of the identified themes, elicit feedback on the best mechanisms for knowledge translation and inform a sustainability plan.
Outcomes
Client and Family
While this fellowship focused primarily on internal changes at SE Health to implement the best practice guideline, it has laid the foundation for improved outcomes for clients and families. For children who are hospitalized for a lengthy stay, Dr. Lim shared that the discharge planning process starts early on and is very structured with defined goals and timelines. One of the anticipated outcomes of the fellowship was that it would decrease hospital readmission rates for CMC, but Dr. Lim also advised that their complex care clients have relatively low rates of readmission and unplanned ER visits.
Contacting families of children on acute care or general pediatric unitsfor a virtual admission visit prior to discharge from was a targeted intervention to pre-empt supply challenges. In addition to reviewing supply gaps prior to the nurse’s first in home visit, this also gave families a chance to “meet” a member of their healthcare team, know what to expect from home care nursing, and ask any questions they might have at that time. This intervention had just reached the implementation stage during the final month of the fellowship, therefore feedback was preliminary but positive. One family caregiver shared that the virtual admission calls helped them to understand what to expect from homecare nursing, helped to ease the transition home, and uncovered a supply issue so that was able to be rectified prior to the first home visit. One nurse felt that it was helpful for families to better understand how the system works, to know that there is communication during transition between hospital and home and to feel confident that support is going to be there for them. This approach has the potential to mitigate risk to clients by improving communication between healthcare providers, ensuring families know who to contact and ensuring that no care is delayed due to inadequate supplies.
Plans are in place to continue the PDSA cycle for this intervention beyond the fellowship to make it a sustainable part of the transition process.
Staff, Organization, and Stakeholders
Four major education modules were researched and updated, aligned with the training that families receive in hospital. A review of SE Health’s internal pediatric orientation content was completed and revisions suggested based on feedback from nurses and educators. Monthly virtual education forums, “Pediatric Power Rounds”, were implemented to disseminate the updated education modules, as well as use case studies submitted by staff to help translate the knowledge into practice. To date, four monthly sessions have been held, which were recorded and made available to staff that were unable to attend due to scheduling conflicts. This helped overcome barriers to access for nurses who work shifts at varying times of day. Nurses who have attended the education sessions reported value and relevance in the content, more awareness of potential risks events and how to manage them, and increased overall confidence in caring for pediatric clients. A sustainability plan has been established to continue these monthly sessions, and expand their reach and access.
Organizational outcomes include greater representation in external stakeholder forums, an improved knowledge dissemination mechanism for pediatric topics and issues and a formalized pediatric community of practice. Opportunities have also arisen to expand these specific strategies into other client populations at SE Health. For example, one leader shared that transitions home for the adult population in her LHIN have become more challenging during the pandemic. As families have less presence in hospital prior to a client’s discharge, more challenges have been observed related to presence of appropriate supplies in home before the visit. This highlighted that there would be great value in trialing the virtual admission visit prior to discharge in the adult population as well, and plans have been put in place to do so moving forward.
Overall experience
Overall Experience
The RNAO ACPF fellowship has been an amazing experience for me. As a nurse and educator working with Children with Medical Complexity, I have a heightened awareness to the experiences of families and children, as well as the nurses that work with them. During my Masters education, I was able to explore these experiences on a deeper level, and use literature to inform my ideas on how to improve them. The fellowship, however, gave me an opportunity to turn knowledge and ideas into action. It gave me the gift of time, which I used to make connections with other healthcare teams, connect with families, learn from my colleagues and observe what transitions processes and structures were already in place both internally and externally. By observing the discharge planning meetings and pathway for Complex Care clients at McMaster Children’s Hospital, I gained valuable insight into the processes that are currently in place, and how SE Health as a homecare provider can build on those to improve the experience for families coming home.
The fellowship also gave me experience using PDSA cycles to test a targeted intervention, use critical feedback to revise and refine it, and identify opportunities to scale it for use in other client populations.
It is hard to pick out one favourite moment, but I think that having an amplified voice for children and families, and the home care nurses that work with them was the best part. To gain feedback that this work increased nurses’ confidence and helped families feel more comfortable coming home was amazing. It has also been exciting to feel the support and encouragement from internal and external leaders for this work and the need to continue it. Although the fellowship is now complete, the lessons learned will continue to shape the approach to care transitions across client populations. I look forward to the opportunity to build on the learnings and organizational structures that have been put in place to continue to improve transitions for Children with Medical Complexity moving forward.
