Project IMPACT Pilot Report: Feasibility of Implementing a Hospital-to-Home Transition BundleLeah A. Mallory, MD, a Snezana Nena Osorio, MD, MS, b B. Stephen Prato, MA, a Jennifer DiPace, MD, b Lisa Schmutter, RN, b Paula Soung, MD, c Amanda Rogers, MD, c William J. Woodall, MPH, d Kayla Burley, MPH, d Sandra Gage, MD, PhD, c David Cooperberg, MD, d, e IMPACT Pilot Study Group

The transition from hospital-to-home

presents a safety risk to pediatric

patients. 1 – 3 Current practices do

not ensure that caregiver home

management skills are routinely taught

before hospital discharge. 1, 4 – 6 Errors

in medication use, failure to activate

contingency plans, and failure to

adhere to follow-up appointments stem

from lapses in provider-to-caregiver

handoffs before hospital discharge. 7 –9

Likewise, communication between

inpatient and outpatient medical

care providers is often delayed and

abstractBACKGROUND AND OBJECTIVES: To improve hospital to home transitions, a

4-element pediatric patient-centered transition bundle was developed,

including: a transition readiness checklist; predischarge teach-back

education; timely and complete written handoff to the primary care

provider; and a postdischarge phone call. The objective of this study was

to demonstrate the feasibility of bundle implementation and report initial

outcomes at 4 pilot sites. Outcome measures included postdischarge

caregiver ability to teach-back key home management information and

30-day reuse rates.

METHODS: A multisite, observational time series using multiple planned

sequential interventions to implement bundle components with non–

technology-supported and technology-supported patients. Data were

collected via electronic health record reviews and during postdischarge

phone calls. Statistical process control charts were used to assess outcomes.

RESULTS: Four pilot sites implemented the bundle between January 2014 and

May 2015 for 2601 patients, of whom 1394 had postdischarge telephone

encounters. Improvement was noted in the implementation of all bundle

elements with the transitions readiness checklist posing the greatest

feasibility challenge. Phone contact connection rates were 69%. Caregiver

ability to teach-back essential home management information postdischarge

improved from 18% to 82%. No improvement was noted in reuse rates,

which differed dramatically between technology-supported and non–

technology-supported patients.

CONCLUSIONS: A pediatric care transition bundle was successfully tested and

implemented, as demonstrated by improvement in all process measures,

as well as caregiver home management skills. Important considerations for

successful implementation and evaluation of the discharge bundle include

the role of local context, electronic health record integration, and subgroup

analysis for technology-supported patients.

QUALITY REPORTPEDIATRICS Volume 139 , number 3 , March 2017 :e 20154626

To cite: Mallory LA, Osorio SN, Prato BS, et al. Project

IMPACT Pilot Report: Feasibility of Implementing a

Hospital-to-Home Transition Bundle. Pediatrics.

2017;139(3):e20154626

aDepartment of Pediatrics, The Barbara Bush Children’s

Hospital at Maine Medical Center, Portland, Maine; bDepartment of Pediatrics, Weill Cornell Medicine and

The New York Presbyterian Hospital/Komansky Center

for Children's Health, New York, New York; cDepartment

of Pediatrics, Medical College of Wisconsin, Milwaukee,

Wisconsin; dDepartment of Pediatrics, Drexel University

College of Medicine, Philadelphia, Pennsylvania; and eSection of Hospital Medicine, St. Christopher’s Hospital for

Children, Philadelphia, Pennsylvania

Dr Mallory participated in the conceptualization

and design of the study, designed the data

collection instruments, supervised data collection

at 1 site, carried out initial analysis, drafted

the initial manuscript, and participated in

revisions; Drs Osorio and Gage participated in

the conceptualization and design of the study,

refi nement of the data collection instruments,

supervised data collection at individual sites,

carried out initial analysis, and revised the

manuscript; Mr Prato built the data collection

instrument, carried out initial analyses, and

reviewed the fi nal manuscript; Drs DiPace, Soung,

and Rogers, Mr. Woodall, Ms. Burley, and

Ms. Schmutter participated in project

implementation, data collection, initial data analysis,

and manuscript revision; Dr Cooperberg served as

central principal investigator,

led the conceptualization and design of the study,

helped design the data collection instruments,

supervised data collection, carried out initial

analysis, and revised the manuscript; and

all authors reviewed and approved the fi nal

manuscript as submitted.

DOI: 10.1542/peds.2015-4626

Accepted for publication Sep 28, 2016

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MALLORY et al

lacks essential information, 10 – 13

leading to confusion over ownership

of pending results and delays in

care.4, 14, 15 Ineffective hospital-to-

home transitions may contribute to

increased hospital reuse and overall

health care costs. 6, 16

Reducing reuse (readmission

to the hospital and/or return to

the emergency department) has

become a target for improvement

throughout the health care

community. Decreasing unplanned

reuse highlights each of the goals

of the Institute for Healthcare

Improvement’s Triple Aim

framework by improving the patient

experience of care, enhancing

population health, and reducing

per capita health care costs. 17

A review of literature showed

that no single intervention was

effective in reducing hospital reuse. 18

Several studies of geriatric patients,

including 2 randomized controlled

trials 19, 20 suggest that care transition

bundles can increase adherence to

follow-up plans and reduce hospital

reuse. 21 Key components of these

bundles include: use of a transitions

coach, predischarge confirmation

of patient/caregiver discharge

readiness, caregiver education

and understanding of essential

components of the care plan, and a

postdischarge phone call to review

and clarify information. 18 – 26

There is limited pediatric literature to

support the usefulness of individual

interventions. 27 Investigations of

pediatric posthospital reutilization

have suggested the importance

of discharge education, access to

discharge medications, a clear

follow-up plan, and caregiver

attitudes. 6, 28 –30 Efforts to improve

communication between pediatric

hospital and outpatient providers

have demonstrated improvement

in the relay of concise, accurate,

and timely information. 9, 31 The

importance of a comprehensive

approach to hospital-to-home

transitions has been demonstrated in

medically complex children. 29, 30

However, no universal pediatric

hospital-to-home transition care

bundle has been reported to date.31

The first 2 phases of the American

Academy of Pediatrics, Section on

Hospital Medicine Transitions of Care

Collaborative improved the timeliness

and defined the essential content

of pediatric hospitalist to primary

care provider (PCP) communication

during hospital-to-home care

transitions. 12, 32, 33 The current phase

of this collaborative seeks to promote

partnerships between parents/

caregivers and medical teams via

shared ownership of care transitions

at hospital discharge. To that end, the

Improving Pediatric Patient-Centered

Care Transitions (IMPACT) project,

a multicenter quality improvement

research collaborative, developed a

4-element patient-centered pediatric

care transitions (PACT) bundle based

on review of existing literature. The

objective of this pilot study is to

demonstrate the feasibility of bundle

implementation and to assess the

early impact of the bundle on outcome

measures, namely, caregiver’s home

management skills (primary outcome)

and reuse rates (secondary outcome).

We hypothesize that reliable

implementation of all 4 bundle

elements will be associated with an

improvement in both primary and

secondary outcomes.

METHODS

Context

Four pilot sites ( Table 1) instituted

the PACT bundle. The bundle

includes: a transition readiness

checklist; predischarge caregiver

teach-back of essential home

management skills; timely and

complete medical provider handoff;

and a postdischarge phone call

( Fig 1). Subjects were technology-

supported and non–technology-

supported patients, age 0 to 18

years who were discharged to home.

Technology-supported patients were

defined as patients with ≥1 of the

following: ventriculoperitoneal shunt,

tracheostomy tube, surgically placed

feeding tube, and/or indwelling

central venous catheter. The non–

technology-supported patients were

infants, toddlers, asthma patients

age 2 to 17 years old, or all patients

admitted to a specific geographic

area or unit. These subpopulations

were determined based on evidence

of increased reuse risk or availability

of evidence suggesting that targeted

predischarge interventions decreased

transition risks. 27, 34

We excluded patients with a

primary oncologic diagnosis and

those discharged from the newborn

nursery or critical care units. We

used a convenience sampling based

on each pilot site’s patient annual

volume, resource availability, and

organizational priorities.

Interventions

A pediatric hospitalist from each

site served as local improvement

team leader. The composition of

teams varied, but included patient/

family representatives, pediatric

hospitalists, subspecialists,

resident physicians, PCPs, nurses,

case managers, social workers,

pharmacists, information

technologists, and administrative

staff. Monthly conference calls

occurred between the 4 pilot

sites to facilitate resource sharing

and promote successful bundle

implementation. The project was

approved for American Board

of Pediatrics Maintenance of

Certification Part IV credit for eligible

participants.

Each pilot site improvement team

mapped local preintervention

processes for medical provider handoff

at discharge and parent/caregiver

education and used multiple planned

sequential interventions to implement

the 4 bundle elements ( Fig 2). The

transition checklist (Supplemental Fig

11) documents logistical components

of family and medical provider

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PEDIATRICS Volume 139 , number 3 , March 2017

handoffs including: parent/caregiver

perceptions of discharge readiness,

preferred language and arrangement

for professional interpretation

for teaching, and identification of

transportation, financial, or social

barriers to a safe transition. The

checklist existed as a paper document

or was integrated into the electronic

health record (EHR).

Teach-back is an evidence-based,

patient-centered, closed-loop

communication tool to confirm

understanding of information

provided by asking patients and

caregivers to explain in their own

words what they need to know or

do. 24 A teach-back curriculum, which

includes a “just-in-time” teach-back

primer, and video were developed at

1 pilot site and shared across other

sites (Supplemental Information).

Nurse educators at each site

trained staff nurses on teach-back

techniques.

Timely and complete communication

with the PCP was defined as

documentation of verbal or written

communication to the PCP within

1 day of discharge that included

7 essential elements ( Table 2). 12

At each site, essential information

elements were incorporated into

EHR discharge summary templates

(Supplemental Fig 12).

Staff nurses and/or care coordinators

performed postdischarge phone calls

within 3 days of discharge ( Table 1).

Phone call scripts were piloted,

revised, and standardized across

sites (Supplemental Information).

e3

TABLE 1 Institution of PACT Bundle

Measure (and Type) Description Time-Bound Goal (Denominator for Rates Is Entire

Enrolled Patient Population at Each Site)

Predischarge caregiver teach-back of

home management skills (P)

Must document successful teach-back of all 4

components:

Improve documentation of successful caregiver

explanation of all elements to 90% within 12 mo

medication use

follow-up appointments

contingency plan (when to call PCP or return to

emergency department)

equipment contact information (if applicable)

Transition readiness checklist (P) Checklist use in paper or electronic chart Improve to 90% complete checklist use within 12 mo

Any use: at least 1 item documented

Complete: all items documented

Timely and complete handoff to the PCP

(P)

Must include documentation of all 7 elements of

essential discharge communication content bundle:

(admission/discharge dates, discharge diagnosis,

medications, follow-up, results pending, immunizations

administered during hospitalization, brief description

of hospital course) and be sent within one day of

discharge

Improve rates of documented discharge summaries

including all 7 elements sent within one day to 90%

within 12 mo

Postdischarge phone call to caregiver

within 3 d of discharge (P)

Transcript of call in medical record used to measure

successful contact

Improve contact rate (from all enrolled patients) to 70%

within 12 mo

Postdischarge caregiver teach-back of

home management skills (O)

Caregiver demonstration of successful teach-back of all

4 components:

Improve documentation of successful caregiver

explanation to 90% within 12 mo (denominator is all

patients with successful phone contact) medication use

follow-up appointments

contingency plan (when to call PCP or return to

emergency department)

equipment contact information (if applicable)

Reuse (O) Return to emergency department within 3 d or

readmission within 30 d of index discharge date

Reduce by 10% from baseline within 24 mo

O, outcome; P, process.

FIGURE 1Patient-centered care transitions bundle elements.

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MALLORY et al

Measures

Specific aims of our initiative included

increased caregiver understanding

of home management skills and

timely and complete communication

between inpatient and outpatient

providers ( Table 2). Therefore, the

rates of nursing predischarge teach-

back documentation of essential home

management skills (contingency

plan, follow-up appointment,

medication management, and

medical equipment provider contact

information, if applicable) and rates

of timely transmission of a complete

discharge document were used as

process measures. Additional process

measures included the following:

postdischarge phone call attempt

and connectivity rates, as well as the

discharge (PACT) checklist completion

rates.

Outcome measures assessed the

effect of bundle implementation.

We used rates of caregivers’

postdischarge teach-back of the

essential home management skills

during a postdischarge phone call

as the primary outcome measure.

A 30-day reuse rate assessed our

secondary outcome.

Chart review was performed for all

included patient populations at each

site, including audit of transitions

checklist use, discharge education

documentation, discharge summaries,

transcripts from postdischarge phone

calls, and reuse episodes within

30 days. The components of each of

these bundle elements were assessed

individually. Element implementation

was considered complete if all

components of the domain were

documented in the EHR ( Table 2).

Additional information obtained in the

chart reviews included patient age,

gender, insurance type, and details of

any reuse event.

With multiple study personnel from

each site performing chart review and

data entry, several safeguards were

developed to ensure internal validity

of data. Each pilot site reviewed charts

for their identified study population

and entered data into an online,

password-protected, de-identified

database (REDCap). 35 This IMPACT

data collection tool was drafted

and revised based on investigator

feedback from each site. At each

pilot site, the initial chart review was

performed by all study personnel on

the same 10 charts and results were

compared for consistency. Ambiguous

choices for data entry were identified

and recommendations for consistent

interpretation were made to the

national group. Once consensus was

reached, a data collection manual and

data entry webinar were developed,

recorded, and shared.

Analysis

Statistical process control p-charts

were used to plot and analyze data.

The center line (CL) (mean) and

upper and lower control limits were

calculated using QI Charts (licensed by

Richard Scoville, Scoville Associates,

2009). Established rules for detecting

special cause were applied. 36

Ethical Considerations

Central institutional review board

(IRB) approval was obtained from

the primary investigator’s institution.

At each pilot site, IRB approval or

exemption was obtained according

to local IRB policies. Consent for

the study was waived at all sites,

except at site B, which required

verbal consent at initiation of the

postdischarge phone call.

RESULTS

During the pilot study phase (January

2014–May 2015), 4 sites reviewed

2601 patient records ( Table 1),

1394 of which had postdischarge

telephone encounters. Supplemental

Table 3 includes a detailed table of

interventions for each bundle element

at each site. The Supplemental

Information includes collaborative

and site-specific control charts for

each process and outcome measure.

Process Measures

Predischarge Teach-back

Composite completion of

predischarge teach-back improved

e4

FIGURE 2Plan-Do-Study-Act cycle ramp.

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PEDIATRICS Volume 139 , number 3 , March 2017 e5

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MALLORY et al

from 30% to 52% ( Fig 3). Categories

of interventions included:

interprofessional engagement/

education; EHR modifications; and

family engagement (Supplemental

Table 3). As new sites joined,

decreased composite performance

was noted ( Fig 3). One site (site C)

achieved the aim using interventions

noted ( Fig 4).

Timely and Complete Hospitalist-to-PCP Handoff at Hospital Discharge

Composite rates of timely and

complete hospitalist-to-PCP handoff

improved from 51.9% to 77.7%

( Fig 5). Interventions included:

interprofessional education/

engagement and integrating

essential handoff elements into

EHR systems (Supplemental Table 3).

Site A linked a percentage of

physician compensation to quality

metrics in timely and complete

handoff performance. This

contributed to a significant increase

in performance from 74% to 87.6%

( Fig 6).

Transition Checklist

For the discharge readiness checklist,

both efforts to integrate a paper

checklist into existing workflows and

attempts to incorporate the checklist

into the EHR encountered multiple

barriers. Improvement cycles aimed

to decrease redundancy in workflow,

increase institutional support for EHR

change, and promote interprofessional

buy-in (Supplemental Table 3). One

site (site A) successfully integrated the

checklist into the EHR in January 2014

(Fig 7).

Postdischarge Phone Call Connection Rates

Figure 8 depicts the composite

phone call attempt and contact

rates. Strategies to improve

connection rates included ensuring

documentation of the correct

telephone number in the EHR, calling

within 24 hours after discharge (site A),

and partnership with outpatient

providers (site D).

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PEDIATRICS Volume 139 , number 3 , March 2017

Outcome Measures

Caregiver Understanding of Essential Discharge Home Management Skills

Caregiver performance of teach-back

of essential home management skills

during a postdischarge phone call

was a primary outcome measure and

there was significant improvement

from 17.7% to 81.8% as bundle

implementation advanced. A decline

in rates were noted with the late

addition of site D (Fig 9).

Hospital Reuse

Decreasing hospital reuse rates was

an additional outcome measure;

however, to date, no improvement

in this measure has been noted

(Supplemental Information).

Composite reuse rates increased with

the addition of site D (November

2014). Stratification of reuse rates

between technology-supported

and non–technology-supported

patients showed dramatically

different reuse rates between the 2

populations (Fig 10) and explain the

effect of the addition of site D (high

proportion of technology-supported

patients) on the composite chart (see

control charts in the Supplemental

Information). Reuse rates for non–

technology-supported patients have

remained unchanged (CL = 7.2%,

Fig 10B), whereas reuse rates for

technology-supported patients have

shown more variability (CL= 27%,

Fig 10A).

DISCUSSION

The main objective of this pilot

quality improvement report was

to demonstrate the feasibility of

the implementation of the PACT

bundle. The secondary objective

was to demonstrate the early

impact of the PACT bundle on

outcome measures. With regards

to the primary objective, the

pilot sites have implemented the

4-element PACT bundle, showing

an improvement in all process

measures: teach-back, timely and

complete handoff, follow-up phone

call connectivity, and discharge

checklist use. Individual pilot sites

had different implementation rates

for individual bundle elements,

and no site implemented all bundle

elements, which is consistent with

the influence of local context. Bundle

implementation was associated

with a significant improvement

in our main outcome, caregiver

ability to teach-back essential home

management skills. Although reuse

rates were comparable to previously

published rates, 37 they remained

unchanged during the pilot study.

This is not surprising, because

we did not reach reliable

implementation of all bundle

elements and the number of

technology-supported patients

enrolled was relatively small.

As previously reported, several

large collaboratives (Solution for

Patient Safety Network, Pedi-Boost,

Children’s Hospital Association)

have been working to improve

care transitions and reduce

readmissions. 31 Although each

collaborative is using a different

set of tools, to date there are no

e7

FIGURE 3Composite predischarge teach-back rates (n = 2601). Composite control p-chart showing percent of patients receiving teach-back by month. Multiple interventions at each site led to overall improvement (Supplemental Table 3). Sites D and C joined as noted with corresponding decreases in rates. LCL, lower control limit; UCL, upper control limit.

FIGURE 4Site C predischarge teach-back rates (n = 615). Site C control p-chart showing percent of patients receiving teach-back by month. EHR modifi cation, monthly data sharing, and real-time performance feedback were instrumental in achieving aims at site C. LCL, lower control limit; UCL, upper control limit.

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MALLORY et al

published reports on pediatric

bundle implementation. Similar to

reported adult bundles, the PACT

bundle consists of evidence-based

and patient-centered tools. 5, 19, 20

Implementation of the teach-back

communication tool varied between

sites and was highly dependent

on the degree of nursing buy-in

and the availability of EHR teach-

back documentation templates.

High-impact interventions, such as

EHR modification to capture teach-

back documentation coupled with

interprofessional education, were

the most useful in improving this

metric. Teach-back, contingency

planning, and follow-up telephone

calls are useful bundle elements

that address the recently described

limited ability of caregivers to

process information gathered during

hospitalization (ie, the “in a fog”

concept), the need for individually

tailored “red flags” (what to watch for

after hospitalization), and additional

support after hospitalization. 38, 39

For example, we employed follow-up

telephone calls not only to ensure

caregiver understanding of home

management skills, but also as a

safety tool to detect and correct

misunderstandings. Once again,

local context greatly influenced the

postdischarge telephone call. As a

relatively “high-resource” bundle

element, processes developed to

accomplish postdischarge phone calls

differed across sites. Connectivity

rates varied based on several key

factors, including the availability of

dedicated personnel, the population

type enrolled, and whether a culture

of making postdischarge calls

predated the initiation of the project.

Although the composite phone call

connection rate (68.8%) was near the

goal of 70%, higher rates are needed

to generalize bundle effects across

patient populations. 40 Identifying

the correct telephone number

and calling within 24 hours after

hospital discharge were among the

interventions that helped improve

the connectivity rates. At this point

in time, the influences of the type of

caller (inpatient versus outpatient

provider, nurse versus physician) on

the success of the caregiver’s teach-

back of essential home management

skills are unknown.

The transition checklist was the

most challenging bundle element

to implement, and ultimately to

integrate, into the EHR. This EHR-

integrated checklist is meant to

provide a prominently visible

multidisciplinary display of a

patient’s progress toward identified

discharge readiness elements.

This requires EHR editing access

of a single document by multiple

interprofessional users. Current

EHR products do not support this

functionality. 41, 42 However, a recent

report highlights new solutions

and has served as a model to avoid

redundant documentation. 33

With respect to hospitalist-to-PCP

handoff at discharge, previously

identified essential discharge

content (7 elements) aligned well

with the content of continuous

care documentation as well as

meaningful use requirements, a

universal incentive for hospitals. 43

e8

FIGURE 5Composite perfect handoff rates (n = 2601). Composite control p-chart showing percent of discharge communication within 1 day of discharge that included 7 required elements. Financial incentives and EHR modifi cations led to signifi cant improvements. For a complete list of site-specifi c interventions, see Supplemental Table 3. LCL, lower control limit; UCL, upper control limit.

FIGURE 6Site A perfect handoff (n = 1265). Site A control p-chart showing aim achieved by using addition of fi nancial incentives. There was a decline after attainment of goal secondary to chart review delay and lack of real-time feedback of lapses to providers. LCL, lower control limit; UCL, upper control limit.

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PEDIATRICS Volume 139 , number 3 , March 2017

Therefore, modifications of the EHR

to add missing elements to discharge

summary templates (pending

laboratories and immunizations

received during hospitalizations) were

expedited across sites, requiring only

1 to 2 Plan, Do, Study, Act cycles to

complete. Educational interventions

were focused on improving physicians’

(trainees and attending physicians)

adherence to complete and timely

delivery of discharge information to

outpatient providers.

With bundle implementation, we

observed a significant improvement

in the main outcome, caregiver

teach-back of home management

skills during follow-up telephone

calls across all sites. As stated above,

during the pilot study, we were not

able to demonstrate the impact of the

PACT bundle on reuse. Larger sample

size and reliable implementation

of all bundle elements is needed to

demonstrate change. 31, 37

This is an observational study

and causation cannot be inferred.

Feasibility and local context precluded

randomization of sites. Similarly, with

the exception of reuse data, it was

not feasible to collect baseline data

because bundle elements were newly

introduced at most sites.

In cases where randomization is not

practical or not feasible as in the pilot

study, other strategies can be used

to overcome this limitation. The use

of center points at the beginning,

middle, and end of the study as

controls has been suggested. This

replication can be used to check for

special cause variation that may

have occurred during the study. 44 In

addition, data collected during the

early months of the pilot phase can

help to define the baseline.

Preliminary power calculations

suggested that a larger number

of participants are needed to

demonstrate 20% change in reuse

rates; 10 000 for a baseline rate of

2.5% and 650 for 24%. The spread

phase with additional sites will likely

help realize this goal. Additional

limitations include the lack of

direct observation of in-person and

telephone teach-back and therefore

the quality of “yes” checked for both

metrics.

Furthermore, our ability to generalize

the success of caregiver’s self-

management skills during follow-up

telephone calls is limited by relatively

low connectivity rates. Additional

analyses are needed to prospectively

identify risk factors associated with

decreased access to follow-up care

(including visits and phone calls) and

the impact this may have on adequate

home management and hospital

reuse.

e9

FIGURE 7Site A transition checklist use rates (n = 1264). Site A control P-chart showing the rate of use of the transition checklist. A, Any use of checklist. B, Completed checklist. Checklist audit led to a meaningful increase in checklist completion rate (see Supplemental Table 3). LCL, lower control limit; UCL, upper control limit.

FIGURE 8Composite control p-chart of postdischarge phone call contact rates for (A) all patients enrolled and (B) patients for whom a call was attempted. No interventions contributed to signifi cant improvement in the connectivity rate (Supplemental Table 3). High census affected both rates when resources were insuffi cient to call all patients. LCL, lower control limit; UCL, upper control limit.

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MALLORY et al e10

FIGURE 9Composite postdischarge teach-back rates (n = 1394 phone contacts). Composite control p-chart of postdischarge phone call teach-back rates. The addition of site D coincided with a decline in rates. High census affected rates negatively. LCL, lower control limit; UCL, upper control limit.

FIGURE 10Reuse rates (technology supported versus not). Composite control p-charts showing reuse rates by month per study population for (A) technology-supported versus (B) non–technology-supported patients. Note mild rises on both charts during high-census periods (March 2014 and 2015). Cumulative rates remain unchanged for both populations when evaluated separately. LCL, lower control limit; UCL, upper control limit.

CONCLUSIONS

Project IMPACT’s 17-month pilot

phase demonstrates that our

bundle is feasible to implement and

measure across 4 different sites. This

“grass roots” quality improvement

research collaborative capitalized

on the lessons learned at individual

sites, including optimization of

EHR functionality and the effect of

the local contextual factors on the

project’s success.

Through shared learning, our pilot

team identified which aims were

achievable, how to practically access

identified measures in the EHR and

how to differentiate general issues

versus those embedded in local

context. These early insights are

critical in guiding the spread phase

to other sites and can be applied to

improvement efforts in a variety of

other health care settings.

The next steps will include enhancing

internal validity (use the American

Academy of Pediatrics Section on

Hospital Medicine–sponsored data

entry webinar for all participating sites,

adopt identified EHR-specific solutions,

standardize the role of callers across

sites), and external validity (increasing

enrollment for all subject populations,

particularly technology-supported

patients). In addition, the spread phase

will allow us to evaluate the impact of

bundle adherence on reuse and study

other transition metrics, including

composite metrics and providers’ and

patients’ satisfaction.

ACKNOWLEDGMENTS

We acknowledge Niccole Alexander

and the American Academy of

Pediatrics Section on Hospital Medicine

for supporting collaborative meetings,

both telephonic and at annual

meetings. We also acknowledge the

following individuals: David Caplan,

Deana Guerrero, Joel McMullin, and

Wendy Craig for analytic support and

family-centered care representatives,

Sharon Cray, Amy Whifen, and Brandy

Robertson.

ABBREVIATIONS

CL:  center line

EHR:  electronic health record

IMPACT:  Improving Pediatric

Patient-Centered Care

Transitions

IRB:  institutional review board

PACT:  patient-centered pediatric

care transition

PCP:  primary care physician

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PEDIATRICS Volume 139 , number 3 , March 2017

REFERENCES

1. Moore C, Wisnivesky J, Williams S,

McGinn T. Medical errors related to

discontinuity of care from an inpatient

to an outpatient setting. J Gen Intern

Med. 2003;18(8):646–651

2. Tsilimingras D, Miller MR, Brooks

RG. Postdischarge adverse events in

children: a cause for concern. Jt Comm

J Qual Patient Saf. 2009;35(12):620–621

3. van Walraven C, Oake N, Jennings A,

Forster AJ. The association between

continuity of care and outcomes: a

systematic and critical review. J Eval

Clin Pract. 2010;16(5):947–956

4. Moore C, McGinn T, Halm E. Tying up

loose ends: discharging patients with

unresolved medical issues. Arch Intern

Med. 2007;167(12):1305–1311

5. Balaban RB, Weissman JS, Samuel

PA, Woolhandler S. Redefi ning and

redesigning hospital discharge to

enhance patient care: a randomized

controlled study. J Gen Intern Med.

2008;23(8):1228–1233

6. Weiss M, Johnson NL, Malin S,

Jerofke T, Lang C, Sherburne E.

Readiness for discharge in parents of

hospitalized children. J Pediatr Nurs.

2008;23(4):282–295

7. Forster AJ, Clark HD, Menard A,

et al Adverse events among medical

patients after discharge from hospital.

CMAJ. 2004;170(3):345–349

8. Forster AJ, Murff HJ, Peterson JF,

Gandhi TK, Bates DW. The incidence

and severity of adverse events

affecting patients after discharge

from the hospital. Ann Intern Med.

2003;138(3):161–167

9. Kripalani S, Price M, Vigil V, Epstein

KR. Frequency and predictors of

prescription-related issues after

hospital discharge. J Hosp Med.

2008;3(1):12–19

10. Kripalani S, LeFevre F, Phillips CO,

Williams MV, Basaviah P, Baker

DW. Defi cits in communication

and information transfer between

hospital-based and primary care

physicians: implications for patient

safety and continuity of care. JAMA.

2007;297(8):831–841

11. Harlan GA, Nkoy FL, Srivastava R,

et al Improving transitions of care at

hospital discharge–implications for

pediatric hospitalists and primary

care providers. J Healthc Qual.

2010;32(5):51–60

12. Coghlin DT, Leyenaar JK, Shen M,

et al. Pediatric discharge content: a

multisite assessment of physician

preferences and experiences. Hosp

Pediatr. 2014;4(1):9–15

13. Solan LG, Sherman SN, DeBlasio

D, Simmons JM. Communication

challenges: a qualitative look

at the relationship between

pediatric hospitalists and primary

care providers. Acad Pediatr.

2016;16(5):453–459

14. Roy CL, Poon EG, Karson AS, et al.

Patient safety concerns arising

from test results that return after

hospital discharge. Ann Intern Med.

2005;143(2):121–128

15. Ruth JL, Geskey JM, Shaffer ML,

Bramley HP, Paul IM. Evaluating

communication between pediatric

primary care physicians and

hospitalists. Clin Pediatr (Phila).

2011;50(10):923–928

16. Kripalani S, Jackson AT, Schnipper

JL, Coleman EA. Promoting effective

transitions of care at hospital

discharge: a review of key issues

for hospitalists. J Hosp Med.

2007;2(5):314–323

17. Berwick DM, Nolan TW, Whittington

J. The triple aim: care, health,

and cost. Health Aff (Millwood).

2008;27(3):759–769

18. Hansen LO, Young RS, Hinami K,

Leung A, Williams MV. Interventions

to reduce 30-day rehospitalization: a

systematic review. Ann Intern Med.

2011;155(8):520–528

19. Jack BW, Chetty VK, Anthony D, et al.

A reengineered hospital discharge

program to decrease rehospitalization:

a randomized trial. Ann Intern Med.

2009;150(3):178–187

20. Coleman EA, Parry C, Chalmers

S, Min SJ. The care transitions

intervention: results of a randomized

controlled trial. Arch Intern Med.

2006;166(17):1822–1828

21. Koehler BE, Richter KM, Youngblood L,

et al Reduction of 30-day postdischarge

hospital readmission or emergency

department (ED) visit rates in high-

risk elderly medical patients through

delivery of a targeted care bundle.

J Hosp Med. 2009;4(4):211–218

22. Society of Hospital Medicine.

BOOSTing care transitions resource

room. Available at: http:// www.

hospitalmedicine. org/ Web/ Quality_

Innovation/ Implementation_ Toolkits/

Project_ BOOST/ Web/ Quality___

Innovation/ Implementation_ Toolkit/

Boost/ Overview. aspx. Accessed

January 9, 2017

23. Institute for Healthcare Improvement.

State actions on avoidable

rehospitalizations (STAAR). Available

at: www. ihi. org/ staar. Accessed

December 23, 2015

24. Schillinger D, Piette J, Grumbach

K, et al. Closing the loop: physician

communication with diabetic patients

who have low health literacy. Arch

Intern Med. 2003;163(1):83–90

25. Braun E, Baidusi A, Alroy G, Azzam

ZS. Telephone follow-up improves

e11

Address correspondence to David Cooperberg, MD, Department of Pediatrics, Drexel University College of Medicine, Section of Hospital Medicine, St. Christopher’s

Hospital for Children, 160 E. Erie Ave, Philadelphia, PA 19134. E-mail: david.cooperberg@drexelmed.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2017 by the American Academy of Pediatrics

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

FUNDING: No external funding.

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

by guest on January 2, 2021www.aappublications.org/newsDownloaded from

e12

patients satisfaction following

hospital discharge. Eur J Intern Med.

2009;20(2):221–225

26. Voss R, Gardner R, Baier R, Butterfi eld

K, Lehrman S, Gravenstein S. The care

transitions intervention: translating

from effi cacy to effectiveness. Arch

Intern Med. 2011;171(14):1232–1237

27. Hatoun J, Bair-Merritt M, Cabral

H, Moses J. Increasing medication

possession at discharge for patients

with asthma: The Meds-in-Hand Project.

Pediatrics. 2016;137(3):e20150461

28. Lerret SM, Weiss ME. How ready

are they? Parents of pediatric solid

organ transplant recipients and

the transition from hospital to

home following transplant. Pediatr

Transplant. 2011;15(6):606–616

29. Smith VC, Hwang SS, Dukhovny

D, Young S, Pursley DM. Neonatal

intensive care unit discharge

preparation, family readiness and

infant outcomes: connecting the dots.

J Perinatol. 2013;33(6):415–421

30. Frei-Jones MJ, Field JJ, DeBaun MR.

Risk factors for hospital readmission

within 30 days: a new quality

measure for children with sickle

cell disease. Pediatr Blood Cancer.

2009;52(4):481–485

31. Auger KA, Simon TD, Cooperberg

D, et al. Summary of STARNet:

Seamless Transitions and (Re)

admissions Network. Pediatrics.

2015;135(1):164–175

32. Shen MW, Hershey D, Bergert L,

Mallory L, Fisher ES, Cooperberg D.

Pediatric hospitalists collaborate

to improve timeliness of discharge

communication. Hosp Pediatr.

2013;3(3):258–265

33. Leyenaar JK, Bergert L, Mallory LA,

et al. Pediatric primary care providers’

perspectives regarding hospital

discharge communication: a mixed

methods analysis. Acad Pediatr.

2015;15(1):61–68

34. Kenyon CC, Rubin DM, Zorc JJ,

Mohamad Z, Faerber JA, Feudtner

C. Childhood Asthma Hospital

Discharge Medication Fills and Risk

of Subsequent Readmission.

J Pediatr. 2015;166(5):1121–1127

35. Harris PA, Taylor R, Thielke R, Payne

J, Gonzalez N, Conde JG. Research

electronic data capture (REDCap)--a

metadata-driven methodology and

workfl ow process for providing

translational research informatics

support. J Biomed Inform.

2009;42(2):377–381

36. Shewhart, WA. The Economic Control of

Quality of Manufactured Products. New

York, NY: D Van Nostrand Company; 1931

37. Berry JG, Toomey SL, Zaslavsky AM,

et al. Pediatric readmission prevalence

and variability across hospitals

[published correction appears in

JAMA. 2013;309(10):986]. JAMA.

2013;309(4):372–380

38. Solan LG, Beck AF, Brunswick SA,

et al; H2O Study Group. The family

perspective on hospital to home

transitions: a qualitative study.

Pediatrics. 2015;136(6). Available at:

www. pediatrics. org/ cgi/ content/ full/

136/ 6/ e1539

39. Desai AD, Durkin LK, Jacob-Files

EA, Mangione-Smith R. Caregiver

perceptions of hospital to home

transitions according to medical

complexity: a qualitative study. Acad

Pediatr. 2016;16(2):136–144

40. Heath J, Dancel R, Stephens JR.

Postdischarge phone calls after

pediatric hospitalization: an

observational study. Hosp Pediatr.

2015;5(5):241–248

41. Garg T, Lee JY, Evans KH, Chen J, Shieh

L. Development and evaluation of

an electronic health record-based

best-practice discharge checklist for

hospital patients. Jt Comm J Qual

Patient Saf. 2015;41(3):126–131

42. Tyler A, Boyer A, Martin S, Neiman

J, Bakel LA, Brittan M. Development

of a discharge readiness report

within the electronic health record-A

discharge planning tool. J Hosp Med.

2014;9(8):533–539

43. Department of Health and Human

Services. Health information

technology: standards, implementation

specifi cations, and certifi cation

criteria for electronic health record

technology, 2014 edition. Revisions to

the permanent certifi cation program

for health information technology;

proposed rule 2012. Available at: www.

gpo. gov/ fdsys/ pkg/ FR- 2012- 03- 07/ html/

2012- 4430. htm. Accessed October 27,

2015

44. Moen RDNT, Provost LP. Quality

Improvement Through Planned

Experimentation. 3rd ed. New York, NY:

McGraw-Hill; 2012

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originally published online February 15, 2017; Pediatrics Gage, David Cooperberg and IMPACT Pilot Study Group

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