Transcription:
From Hospital to Home: Improving the Outpatient Transition for Pediatric Heart Patients

Hal Altman, MD (Host): Welcome to Pediatric Insights, advances and innovations with Children's Health, where we explore the latest in pediatric care and research. Today, we'll examine the challenges of outpatient transition for pediatric heart patients with our guest, Dr. Nicolas Madsen. I'm your host, Dr. Hal Altman. For most of us, home is a place of comfort. For children with heart conditions, home may offer feelings of safety and security, better sleep and thus the best opportunity for healing. Today, we're speaking with Dr. Nicolas Madsen about collaborative and focused efforts to improve the transition from the Cardiac ICU to inpatient bed and ultimately to home. Dr. Madsen is the Co-Director of the Heart Center and Chief of Cardiology at Children's Health and Associate Professor of Cardiology at the University of Texas Southwestern. Dr. Madsen, it's a pleasure to welcome you to the podcast.

Nicolas Madsen, MD (Guest): Thanks very much. Pleasure to be here.

Host: Great. Dr. Madsen, today's world of pediatric cardiology is caring for patients with conditions that require cutting edge expertise, coupled with amazing technological support. Timely transition to a home setting for these patients can be intimidating to families and to their primary providers alike. In your opinion, what are the benefits for pediatric patients who are able to heal at home rather than at the hospital?

Dr. Madsen: Yeah, thanks very much that question. I think really well described, we are a constant development of new technology be it monitoring, or management strategies while we continue to successfully treat and manage ever increasing complex diseases within the pediatric cardiology sphere. However, I think there is no doubt both in the scientific literature, but even just in direct observation, how healing the benefits are of being in a home environment, both for the patient and certainly for a mom and dad and other caregivers. And so, we are at this intersection of how to navigate all of that technology, all of that disease complexity, and that rudimentary or basic fact that a home is, is where we want to be. And, certainly where we aim to be as, as a measure of success. what we are working on is a constant partnership with our patients and families in developing successful strategies to ease that transition. We are employing new technologies, to enable that transition And we are constantly alert to the needs around communication and process development, so that when we, transition a child from the hospital to home, it is reliable. It is safe and it is, you know, right for that patient each and every time.

Host: So with all of that in mind, can you tell us the ways you're focusing on improving transition from hospital care to the outpatient world?

Dr. Madsen: Yeah. One of the key elements, which sounds simple in its description, but actually is difficult enough to achieve that, that it takes the entirety of the team. And that is, we begin to plan for going home the day someone arrives at the hospital. So, what, what has often been the, the sort of default mechanism is that you start to prepare for home the last 24 hours of your hospital stay.

And, and there are times when the complexity is, is so basic or simple, that you can achieve the majority of things that you need to achieve in the last 24 hours. But that is increasingly not the case for our more complex patients and the needs, the care needs that that child may require. And so we really begin that process in earnest from the beginning and what that looks like is education with the patient and family. It's coordination of care. It's ensuring that the day you arrive, we're thinking about how will we send you home with a successful medication regimen that you can deliver where the medications are available as they should be. And they are, scheduled in such a way that the likelihood of success is much, much greater.

It is a simple, but very intentional or deliberate approach to the discharge process. Well, before maybe mom or dad or the patient, are even thinking about it.

Host: So understanding that the team concept is key to getting patients ready, how can bedside care teams better understand when a patient is ready for home and how do you ensure that transition criteria is standardized and applied to all patients equally?

Dr. Madsen: Yeah. So I think part of that proper, part of that process of preparing early is to share with the patient and their caregivers, what are our criteria for going home? What do those look like? There should really be no mystery. It, that is not the same thing as saying they can't evolve, as the child or the patient evolves, but they should be openly discussed and quite transparent to all involved.

And so we talk a lot about our discharge criteria as medical readiness criteria. When is a child medically ready to go home? What does that mean in terms of their medication regimen, in terms of testing, in terms of achieving certain benchmarks. And we talk about those very deliberately and reliably on rounds each and every day.

And it is something we share transparently with the patient and their family, as well as with the nursing staff. There, there should be no difference between expectations, in terms of what the nurse is targeting and what the rest of that core team of providers, as well as the patient and family are targeting.

And so, so we talk about these medical readiness criteria. We document them. We share them and then they evolve that in certain instances, the child comes in, the condition is quite discrete and the medical readiness criteria are what they are and they do not change from day of admission to day of discharge and other times where we run into unexpected complexities or an evolution of the child's condition, we may modify those criteria.

And when we do that, it is again communicated with all stakeholders so that there isn't any mystery about when those thresholds are met and how we can best prepare everyone to, to match that threshold of being ready for home.

Host: So are there specific ways that you're innovating to achieve readiness for home in the most effective and efficient manner other than what we've discussed?

Dr. Madsen: Yeah, I think we're increasingly using the electronic medical record as a tool to aid in the process, both in the communication of what those criteria are, as well as the reliability that we follow those criteria closely. One of the vulnerabilities of medicine, is that there is variability between providers from day to day or week to week.

And so in, in developing the tool through the electronic medical record, it ensures that as, as the physicians in charge change or, or the nighttime team that covers for what the daytime team has put in place, that it's consistent and doesn't necessarily change unless it needs to change because the child's condition changed.

We, we also in developing the strategy, because we look to find standards, because we look to, to utilize the best evidence, we are also using a lot of innovative strategies as we partner with other institutions. So it's, you know, it is important to match the child's recommendations to who they are, but if there are standards that can be applied and can be learned across dozens of institutions, then we should aim to do that. And we spend a lot of time investing in collaborative efforts or what we call learning networks that allow us to more rapidly translate innovation, more rapidly translate gains, and ensure that each and every child, be they in Dallas, Texas or Seattle, Washington, is receiving a more standard, a more reliable approach to their, to their care.

Host: So if we shift our focus to the home, how do you impact the home environment and enhance its readiness for a pediatric heart patient returning from the hospital?

Dr. Madsen: It's multifactorial. We employ specific strategies to help families manage the medication regimen in the home environment. So what does that look like? When does the house awake in the morning. if everyone awakes at 8:00 AM then it doesn't really make sense to schedule things at 6:00 AM or 7:00 AM.

So how do we adjust, in a way that is safe and appropriate for the child where making those modifications. We address educational strategies around preparing for the unexpected. How do you, how do you learn to identify red flags in terms of the child's wellness in the home environment. We think about preparation along the lines of teaching families how to incorporate the, the feeding regimen, especially if there are equipment needs. We prepare them in terms of preparing for the worst and ensuring that they are CPR educated. And then you know, more recently taking advantage of a great deal of innovation. What does monitoring look like at home?

We are accustomed to the great deal of monitoring that happens in the hospital. And then historically monitoring has ended at the time when you leave. Well, there is an opportunity to build a bridge in terms of that monitoring and to do it in such a way that you have the benefits of being home, but the watchfulness of monitoring, not to an excess.

There, there is a slippery slope to monitoring where, there is a potential for more harm than good, but at the same time, given the availability of some of these technologies, so that the family feels that they can take ownership and keep an eye on, on, on their child in a way that goes beyond gut intuition, which is actually quite important and what their eyes and ears appreciate directly. I think there are advantages and we certainly explore those.

Host: That's great. Dr. Madsen in your experience, what kinds of communication systems without patient based providers are best able to enhance continuity?

Dr. Madsen: Yeah, I think, communication is a cornerstone of healthcare and something that we all readily identify as important. But to be honest, tricky to achieve. An, a good example of that is how does the team that's been caring for a patient and a family for two weeks in the hospital environment, how do they transition that knowledge to the outpatient provider who will be caring for this patient, well, maybe during the first clinic visit five days after discharge or two weeks after discharge, but then caring for them for their life. And how do we ensure that the knowledge gained in that intensive environment in the hospital, is readily shared and, and available?

And, and so we do that in basic ways with phone calls and email communication, and we certainly do that, taking advantage of our electronic medical record so that we can ensure that a distillation of the most important facts or the ones that we think will impact day-to-day care are readily and reliably transferred.

It's seemingly easy because we communicate with each other each and every day. But to ensure that we do this effectively the same way each and every time and reach the targeted audience and provide them with information that is, that is digestible and, can be translated into the care that they provide, it is more subtle. So we work on our systems to do that. And again, using, you know, the telephone or mobile devices, and then ultimately, integrating it into our electronic health record.

Host: That's all very impressive Dr. Madsen and very innovative. In closing, do you have any final advice for providers who are seeking to improve their patients' transition to outpatient care?

Dr. Madsen: Yeah. I think the, you know, the advice that we live by, or that drives a lot of our work is the belief that being at home has measurable advantages and sometimes hard to measure advantages relative to being in the hospital. Certainly in a healthcare environment, we put safety as a top tier aim. And sometimes in doing that, we can be unintentionally conservative in our approaches. And that's not to say that we shouldn't be mindful because we certainly are, but I think we have to also appreciate the idea that being at home, being in an environment with less interruption, with the opportunity for better sleep, with the opportunity for easier coordination for the family, has healing effects as well just a day-to-day, conveniences. And so as we embark with that bias in mind, we look to then bridge those gaps that, that allow for a patient who otherwise, maybe would've spent an extra week or two or a month in the hospital to do so at home. And, we do that in coordination with home health and nursing services delivered at home. And we do it with new technologies, be they equipment related or, or monitoring related.

And then we do that by creating reliable systems of communication, that benefit the family and I will just quickly mention, inserting the family into the stream of communication; the patient and the family is critical. We have historically, as a field often simply been doctors speaking to doctors or nurses speaking to nurses, but how do we integrate the family who obviously couldn't be more invested in the positive outcome for their family member into that stream of communication? How do we allow them to have direct access to, to those services or helpful persons, in a way that is direct and again, very reliable? And so we've incorporated that in our approach and I think to great success.

Host: Well, thanks to you, Dr. Madsen and to our audience for participating in today's Pediatric Insights, advances, and innovations with Children's Health. Providers can gain more information about the Heart Center at Children's Health or refer patients by visiting the website at www.children's.com/heart. For updates on the latest on pediatric medical advances, breakthroughs and research, please follow us on your social channels. You are warmly invited to subscribe, rate, and review this podcast and all other podcasts from Children's Health. Goodbye, and thanks again for listening to Pediatric Insights, advances, and innovations with Children's Health.