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

描述（由申请人提供）：早产或患有复杂先天性异常的婴儿存活出院的人数越来越多，并且通常需要在门诊环境中进行大量监测和护理协调。这些复杂的婴儿在医院里度过了他们的一生，在他们自己的家里是陌生人。虽然脆弱的儿童从重症监护专家到门诊护理提供者的过渡从出院开始，但直到儿童接受初级保健儿科医生的适当门诊随访，这是不完整的。在这一长时间内，儿童特别容易受到与护理协调和沟通中断有关的错误的影响，因为对患者护理的责任往往没有明确规定。我们的研究团队最近完成了从新生儿重症监护过渡到门诊环境的医疗保健失败模式和影响分析（HFMEA）。在本申请中，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室（NICU）过渡到门诊随访的不良结局风险。本项目的具体目标是：1）通过重新设计出院流程和针对我们最近HFMEA中确定的关键错误点，降低从新生儿重症监护托儿所到门诊随访的护理过渡风险; 2）确定重新设计的出院流程与常规护理相比在改善出院后随访期间的健康结局方面的有效性;和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。该工具包将包括经过验证可用于儿科人群的护理过渡措施版本。我们将扩展科尔曼等人开发的护理过渡干预，该干预解决了从医院出院到家中的老年人的问题。在这种模式中，高级实习护士，培训教练，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，我们会利用资讯科技，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。健康信息技术有可能促进几个学科和门诊护理环境之间的沟通和协调。在确定社区提供者缺乏如何管理这些婴儿的知识和技能是一个重要的风险点后，我们将通过向初级保健提供者提供“及时”信息来增加科尔曼干预措施，以提高他们管理新生儿护理毕业生常见问题的知识和技能，通过德克萨斯儿童医院（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实现脆弱婴儿安全出院所需的所有必要结构和过程要素。 公共卫生相关性：早产或患有复杂先天性异常的婴儿存活出院的人数越来越多。在过渡到流动护理，这些婴儿特别容易受到错误有关的故障，在护理协调和沟通。根据我们最近完成的主动风险评估，我们将实施一揽子干预措施，以解决所有必要的结构和过程要素，使脆弱的婴儿从新生儿重症监护室安全通过，以进行门诊随访。

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.