Safe Passages: A Toolkit to Ensure Quality Transitions From NICU To Ambulatory Ca

描述（由申请人提供）：早产儿或患有复杂先天性畸形的婴儿存活到出院的数量越来越多，通常需要在门诊环境中进行重要的监测和协调护理。这些复杂的婴儿一生都在医院里度过，在自己的家里也很陌生。虽然脆弱的儿童从重症监护专家到门诊护理提供者的转变在出院时就开始了，但在儿童接受初级保健儿科医生的适当门诊随访之前，这种转变是不完整的。在这段漫长的时间里，孩子特别容易受到与护理协调和沟通中断有关的错误的伤害，因为照顾病人的责任往往没有明确规定。我们的调查小组最近完成了从新生儿重症监护到门诊环境过渡的医疗失败模式和影响分析（HFMEA）。在本应用中，我们将针对HFMEA确定的高风险过程，并评估干预措施，以降低从新生儿重症监护病房（NICU）过渡到门诊随访的不良结局风险。该项目的具体目标是：1)通过重新设计出院流程和针对我们最近在HFMEA中确定的关键错误点，降低从新生儿重症监护室到门诊随访的护理过渡风险；2)与常规护理相比，确定重新设计的出院流程在改善出院后随访期间健康状况方面的有效性；3)开发一套材料（工具包），可推广到其他照顾脆弱新生儿的机构。该工具包将包括一个在儿科人群中使用的经过验证的护理过渡措施版本。我们将扩展由Coleman等人开发的护理过渡干预，解决从医院出院回家的老年人的问题。在这种模式下，高级执业护士，训练有素的教练，教病人和家庭协调照顾自己，培养独立性。其次，我们将设计一个标准化的出院流程，其中将包括使用个人健康记录，包括识别和自我管理这一人群中最常见问题的具体说明。第三，我们会运用资讯科技，加强与家庭和社区服务提供者，特别是基层医疗服务提供者的沟通。卫生信息技术有可能促进多个学科和门诊护理设置之间的沟通和协调。在确定了社区提供者在如何管理这些婴儿方面缺乏知识和技能是一个重要的风险点之后，我们将通过向初级保健提供者提供“及时”信息来增加Coleman干预，以提高他们管理新生儿托儿所毕业生常见问题的知识和技能，这些信息通过德州儿童医院（TCH）临床决策支持计划以电子方式提供。因此，我们的干预措施将解决所有必要的结构和过程要素，以实现脆弱婴儿的安全出院。

DESCRIPTION (provided by applicant): Infants born prematurely or with complex congenital abnormalities are surviving to discharge in growing numbers and often require significant monitoring and coordination of care in the ambulatory setting. These complicated infants have spent all of their lives in the hospital setting, and are strangers in their own homes. Although the transition of the fragile child from intensive care specialist to the ambulatory care provider begins at hospital discharge, it is incomplete until the child receives appropriate outpatient follow-up with a primary care pediatrician. Over this prolonged time period, the child is especially vulnerable to errors related to breakdowns in care coordination and communication because the responsibility for the patient's care is often not clearly specified. Our team of investigators has recently completed a Health Care Failure Modes and Effects Analysis (HFMEA) of the transition from neonatal intensive care to the ambulatory environment. In this application, we will target the high-risk processes identified by the HFMEA and evaluate interventions to decrease the risk of poor outcomes in the transition from the Neonatal Intensive Care Unit (NICU) to outpatient follow-up. The specific aims of this project are: 1)To reduce the risk of care transition from the neonatal intensive care nurseries to ambulatory follow-up by redesigning the discharge process and targeting critical error points identified in our recent HFMEA; 2)To determine the effectiveness of the redesigned discharge process to improve health outcomes in the post discharge follow-up period as compared with usual care; and 3) To develop a package of materials (a toolkit) that is generalizable to other institutions that care for fragile newborn infants. This toolkit will include a version of the Care Transitions Measure that is validated for use in a pediatric population. We will expand upon the Care Transitions Intervention developed by Coleman et al that addressed the problems of older adults who were discharged from hospital to home. In this model, advanced practice nurses, trained as coaches, taught patients and families to coordinate care for themselves, fostering independence. Second, we will design a standardized discharge process that will include the use of a personal health record, to include specific instructions to recognize and self-manage the most common problems in this population. Third, we will use information technology (IT) to enhance communication with families and with community providers, in particular the primary care provider. Health IT has the potential to facilitate communication and coordination of care between several disciplines and settings of ambulatory care. Having identified that lack of knowledge and skills on the part of community providers about how to manage these infants as an important risk point, we will add to the Coleman intervention by providing "just-in-time" information to the primary care providers to enhance their knowledge and skill in managing the common problems of neonatal nursery graduates, provided electronically via the Texas Children's Hospital (TCH) clinical decision support program. Hence, our interventions will address all the necessary structural and process elements needed to achieve a safe discharge for the fragile infant. PUBLIC HEALTH RELEVANCE: Infants born prematurely or with complex congenital abnormalities are surviving to discharge in growing numbers. During the transition to ambulatory care these infants are especially vulnerable to errors related to breakdowns in care coordination and communication. Based on our recently completed proactive risk assessment, we will implement a package of interventions to address all the necessary structural and process elements needed to achieve a safe passage for the fragile infant from the Neonatal Intensive Care Unit to ambulatory follow up.