Steps

Rationale/Points of Emphasis

Before the Day of Discharge

1 Begin discharge planning upon child’s admission and continue the process throughout the hospitalization.

Facilitates a smooth transition to home or other facility.

2 Collaborate with the healthcare prescriber, other multidisciplinary team members, and parents to ensure medical home principles are incorporated in planning for discharge/transfer. Notify Social Services and Case Management of impending discharge.

A pediatric medical home is a family-centered partnership within a community-based system that provides uninterrupted care with appropriate payment to support and sustain optimal health outcomes (American Academy of Pediatrics [AAP], 2014). Collaboration provides the most comprehensive understanding and approach to discharge needs, existing barriers, and available resources.

3 Identify the child’s primary caregivers in the home setting.

Allows teaching to be done with the appropriate individuals.

4 Assess the family’s knowledge regarding the child’s illness, possible complications, and care and treatments to be continued at home.

Understanding the child’s healthcare needs improves the likelihood of successful home care.

5 Monitor the family’s readiness and willingness to learn, and provide teaching regularly. For children with complex care needs, evaluate need for family to assume responsibility for providing total care before discharge, with nursing staff available to assist.

Ongoing teaching assists in knowledge retention and allows repeated opportunities to practice new skills. Family provision of care provides an opportunity to evaluate parent proficiency and reinforce teaching, and it reinforces parent competence and decreases anxiety.

6 Review cares and procedures that will need to be performed at home. Provide demonstrations and written instructions. Evaluate family understanding and perform return demonstration of proficiency; if unable to perform at a safe level, arrange for alternative providers (e.g., other family members, home healthcare, clinic visits).

Ensures skill proficiency and allows time for questions to be answered. Written materials reinforce in-hospital teaching once the child is at home.

7 Initiate referrals and orders for home care, supportive therapies, equipment, and supplies, as needed, and provide information about available community healthcare resources.

Aids continuity of care across the healthcare continuum.

caREminder

To create continuity of care between inpatient and outpatient care, consider a predischarge home evaluation when the child will go home technology dependent. This will help troubleshoot problems in the physical environment that may interfere with setup and care. Contact a home health nursing agency to give report and discuss plan of care (if applicable).

8 Assess the family’s emotional preparedness for discharge. Arrange predischarge contact with a support person or group, as needed.

Promotes healthy family coping skills.

caREminder

Arrange respite care for the family of a child with continuous medical needs to provide parents with periodic breaks from complex medical home care responsibilities.

9 Inform family of the anticipated date and time of discharge as soon as it is known. Notify Social Services if transportation may be needed.

Allows the family to make necessary arrangements and helps to prevent last-minute delays.

10 Educate family regarding the laws pertaining to use of a child restraint system in their motor vehicle. Assist in arranging for a special car seat or restraint system, as needed.

Increases safety of transport and ensures child does not have any cardiac or respiratory compromise due to poor positioning.

Provide education to parents regarding how to position infants and children properly in the care seat.

Children with special needs for whom standard care seats or restraint systems may not be appropriate include

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  Premature and low-birth-weight infants

  
  
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  Children with tracheostomies or poor head control

  
  
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  Children in a body or hip spica cast

  
  
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  Infants/children requiring prone or supine positioning

11 For preterm and low-birth-weight infants, complete a period of observation in a car safety seat (preferably their own). The period of observation should be a minimum of 90-120 minutes or the duration of travel, whichever is longer.

Child is observed to detect apnea, bradycardia, and oxygen desaturation.

Infants with documented desaturation, apnea, or bradycardia should travel in a Federal Motor Vehicle Safety Standard (FMVSS) 213-approved care seat in a supine or prone position.

On Day of Discharge

1 Review healthcare prescriber’s discharge orders for medications, treatments, equipment, or supplies.

Acts as a safeguard to double check the accuracy of discharge orders and provides a foundation for final discharge teaching.

2 Confirm arrangements for outpatient and continuing services, home medical care, and equipment with the appropriate vendor or agency.

Ensures that the family will have what they need to provide ongoing care at home.

3 Review the discharge care plan with the child (as appropriate) and the family.

Establishes common goals to be met for discharge.

4 Gather prescriptions and any hospital medications that have been relabeled for home use. Review with family the prescribed medications, including the proper dose, route, time schedule, and possible adverse reactions.

Helps to promote proper drug administration.

caREminder

To promote compliance with the medication regimen, ensure that the child’s medication schedule is compatible with the family’s normal routine.

5 Review cares and procedures that will need to be performed at home. Provide demonstrations and written instructions. Evaluate family caregiver understanding and ability to perform cares.

Ensures skill proficiency and allows time for questions to be answered. Written materials reinforce in-hospital teaching once the child is at home.

6 Review dietary or activity restrictions that are applicable and the reason that are necessary. Provide written instructions.

Helps to increase understanding of why adherence to a restriction may promote health.

7 Instruct family caregivers regarding follow-up appointments or outpatient procedures that are needed. Provide written instructions. Assist with scheduling when appropriate.

Promotes continuity of care after discharge.

8 Confirm transportation arrangements with the family. Notify Social Services if last-minute assistance is needed.

Decreases the likelihood of unnecessary discharge delays.

9 Verify that the child has been cleared for discharge through the financial and business offices. If not, refer parent/legal guardian to the appropriate office to arrange for clearance.

Ensures that the proper financial arrangements have been made regarding the hospitalization.

10 Perform a physical assessment of the child. Notify the healthcare prescriber of any abnormal findings.

An abnormal finding may warrant a change in the discharge plan.

11 Gather child’s belongings, including hospital hygiene supplies, into a bag. Make every effort to prevent hospital property from being removed with the child’s belongings.

Ensures that the child goes home with the appropriate belongings and controls costs for the family and the institution.

12 Have family member assist child to dress in street clothing.

Physically prepares the child for transition to home or other facility.

13a Obtain parent/legal guardians signatures on discharge instruction sheet and instruct them to bring it to the next follow-up appointment.

Verifies that instructions have been discussed and received and promotes continuity in follow-up care.

13b Answer any final questions.

Ensures understanding of home care responsibilities.

caREminder

Being able to understand the provided instructions at home is necessary for compliance with a therapeutic regimen. All written instructions should be in a language, reading level, and format that the family can understand. Use pictures or color coding, as necessary. Use an interpreter as necessary. The interpreter should not be anyone younger than 16 years and should not be a family member if possible.

14 Follow facility policy for checking identification of the parent/legal guardian before releasing the child into their care.

Acts as a security safeguard.

15 Once the child and the family has the child’s medications, prescriptions, belongings, and discharge instructions, escort the child, either walking or in a wheelchair, to the front lobby for transport home.

Ensures safety while exiting the hospital facility.

16 Remind family members to use appropriate car seat or child restraint system. If the child is going home with equipment, such as an apnea monitor, oxygen, or suction, instruct family on how to secure it in their motor vehicle.

Promotes safety.

caREminder

Prior to discharge, conduct a car safety seat observation.

17 Complete discharge summary (see Child and Family Evaluation and Documentation at end of this chapter).

Documents care given and child’s condition at discharge.

18 Once the child has left the patient care area, notify housekeeping, and arrange for the room to be cleaned.

Facilitates timely preparation of the room for a new patient.