Key result
Home nurse visits linked to higher hospital readmissions driven by low thresholds for escalating care.
Why the study?
In the H2O trial, children randomized to postdischarge nurse home visits unexpectedly had higher 30-day postdischarge reutilization rates than standard discharge, prompting investigation into stakeholder perspectives on this outcome.
Stakeholders identified that postdischarge home nurse visits may unintentionally direct pediatric patients back to the hospital due to low thresholds for escalating care and red flag instructions, suggesting a need for individualized visits and better primary care connection.
May warrant refining pediatric home nurse visit protocols to curb escalations; extends RCT by identifying modifiable mechanisms for future interventions.
BACKGROUND: The Hospital to Home Outcomes (H2O) trial was a 2-arm, randomized controlled trial that assessed the effects of a nurse home visit after a pediatric hospital discharge. Children randomized to the intervention had higher 30-day postdischarge reutilization rates compared with those with standard discharge. We sought to understand perspectives on why postdischarge home nurse visits resulted in higher reutilization rates and to elicit suggestions on how to improve future interventions. METHODS: We sought qualitative input using focus groups and interviews from stakeholder groups: parents, primary care physicians (PCP), hospital medicine physicians, and home care registered nurses (RNs). A multidisciplinary team coded and analyzed transcripts using an inductive, iterative approach. RESULTS: Thirty-three parents participated in interviews. Three focus groups were completed with PCPs (n = 7), 2 with hospital medicine physicians (n = 12), and 2 with RNs (n = 10). Major themes in the explanation of increased reutilization included: appropriateness of patient reutilization; impact of red flags/warning sign instructions on family's reutilization decisions; hospital-affiliated RNs "directing traffic" back to hospital; and home visit RNs had a low threshold for escalating care. Major themes for improving design of the intervention included: need for improved postdischarge communication; individualizing home visits-one size does not fit all; and providing context and framing of red flags. CONCLUSION: Stakeholders questioned whether hospital reutilization was appropriate and whether the intervention unintentionally directed patients back to the hospital. Future interventions could individualize the visit to specific needs or diagnoses, enhance postdischarge communication, and better connect patients and home nurses to primary care.
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Riddle et al. (2020) studied Pediatric hospital discharge (n=62). Postdischarge home nurse visit vs. Standard discharge was evaluated on Perspectives on why postdischarge home nurse visits resulted in higher reutilization rates and suggestions for improvement. Stakeholders identified that home nurse visits may have unintentionally directed patients back to the hospital due to low thresholds for escalating care and the impact of warning sign instructions.
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