Diana Scheetz , BSN, RN, CCM, CPN Marietta Morhardt , BSN, RN, CCM, CPN

1. Promoting Discharge Success: The Rooming-In Process for Transitioning Care of the Hospitalized Child to Parent Diana Scheetz,BSN, RN, CCM, CPN Marietta Morhardt, BSN, RN, CCM, CPN

2. Objectives • Identify the evidenced-based practice process used to develop an interdisciplinary rooming-in standard of care. • Describe the interdisciplinary process for transitioning care of the child to the parent through rooming-in. • Define the impact of a rooming-in program as it relates to readmission and enhanced discharge success.

3. JHNEBP* Model Translation Evidence Practice Conduct internal & external evidence search Appraise all evidence Summarize evidence Rate evidence strength Develop recommendations for change in care systems or processes based on the strength of the evidence Identify EBP question Define scope of practice question Assign responsibility for leadership Recruit interdisciplinary team Schedule team conference Determine appropriateness & feasibility of translating recommendations into practice setting (pilot) Create action plan Implement change Evaluate outcomes Report results of preliminary evaluation to decision makers Secure support to implement recommended change system wide Identify next steps Communicate findings *Johns Hopkins Nursing EBP Model

4. Background Readmission rate to inpatient within 7 days had increased organizationally

5. Background Case Management identified inconsistencies with the discharge process in preparing the caregiver for the transition of their medically or psychosocially fragile child to home This patient population is at risk for re-admission within 7 days of discharge due to complex care needs and family support No standard criteria or procedure existed for caregiver rooming-in: Assessment of when appropriate or necessary Procedure details Evaluation of caregiver readiness for discharge

6. PICO Question What is the best practice for caregivers of medically or psychosocially fragile pediatric patients to complete the rooming-in process in preparation of transitioning to home?

7. EBP Team • Nursing Case Management • Co-leader • Clinical Nurse Specialist • Co-leader • In-patient direct care nurses • Home Care Liaison nurse • Pharmacists • Respiratory Therapist • Social Workers • Hospital lawyer • Hospitalists • Neonatologists • Chief Medical Officer

8. Search for Evidence Search Strategies: Pediatrics English only No date limitations All publication types Search terms: rooming-in, pediatrics, medically fragile, discharge, transition to home Searched: Pub Med, CINAHL, Cochran, National Guideline Clearinghouse, Joanna Briggs Institute, Nursing Consult, AAP, ANA, AWHONN, SPN, NANN

9. Literature Findings • Our literature search yielded • No articles answering the PICO question – “best practice” for rooming-in • Several articles found supported the concept of rooming-in • Historical articles (1980s) found • related to newborn nursery and • mother-baby rooming-in

10. Benchmark Contacted community and regional hospitals Listserv queries: American Case Management Association Children’s Healthcare Association (CHA)

11. Benchmark Benchmark Themes: Rooming-In gives caregivers a practice opportunity using home equipment/meds, asking questions, and trouble shooting issues in a supportive environment Length is up to 2 days Use home equipment Hospital monitor is used Policy examples from two children’s hospitals

12. Recommendations A standardized procedure should be used for caregiver rooming-in to guide: Criteria for rooming-in Role expectations Documentation Multidisciplinary evaluation of readiness for discharge Discharge instructions complete before rooming-in Discharge teaching complete before rooming-in Home equipment used during rooming-in Home medications administered during rooming-in

13. Practice Changes Rooming-in procedure Documentation form Criteria Caregiver agreement Nurse documentation Final assessment Home medication administration Home equipment use policy & waiver

14. Criteria Complex and/or chronic conditions Technologically dependent Neurological or developmental deficit Surgical intervention requiring ongoing maintenance needs Multiple post-hospitalization medications and/or appointments Nutritionally compromised requiring special formula or alternate methods of nutrition administration Opportunity to practice child’s care, new skills, and develop new home routines Caregiver request

15. Caregiver Agreement • Identify primary and secondary caregivers • Define date/times of rooming-in period • Define caregiver responsibilities related to child’s care • ADLs, medication administration, home equipment use, treatments, etc. • What caregiver needs to do if leaves child’s room • Signature required

16. Nurse Responsibility • Ensure all discharge education is complete • Review discharge instructions and provide copy • Vital signs and assessments continue • Assess and document caregiver’s progress in their ability to provide total care for the patient • Discontinued rooming-in if patient assessment deteriorates • Participate in team assessment of caregiver readiness for home

17. Medication Administration • Home Meds not given by caregiver: controlled substances, IV solution, or injectable meds • Caregiver obtains prescriptions and brings to hospital • Pharmacist checks-in home medications • Medications are stored in locked cart at bedside • Caregiver requests medication when due and selects from med box • Nurse reviews and verifies correct preparation and administration practice with the caregiver • Nurse documents medication administered by caregiver

18. Home Equipment • All home equipment will be used • Waiver for Home Medical Equipment Use in the Hospital • Hospital lawyer • BioMed completes safety check • Caregiver responsible for operating home equipment & calling company with questions • Patients requiring apnea/brady monitors will have double monitors • Back-up hospital equipment available and used when: • Caregiver not present • Change in patient condition • Equipment malfunction

19. Documentation • “Rooming-In Documentation Form” • Nurse documents caregiver’s ability to provide all patient cares as agreed upon • Respiratory Therapist documents caregiver’s ability to provide RT related patient cares

20. Evaluation • Medical/multidisciplinary team evaluates the caregiver’s readiness to assume cares for home • Reviews rooming-in documentation • Includes family/caregiver input • Practitioner ultimately makes the final decision to discharge

21. Pilot Process Piloted for 7 months (Mar–Oct 2012) in two areas: Med-surgical and NICU Nursing Case Managers coordinated pilot and collected feedback 28 patients’ caregivers completed pilot Revisions were made to program based on multidisciplinary feedback Implementation hospital-wide October 2012

22. Outcomes During first 3 months of house-wide implementation: 18 patients completed rooming-in 2 patients were re-admitted within 7 days Complex medical home care patient with young first time parents Fragile oxygen dependent neonate

23. Parent Feedback Very helpful to learn medication routine during rooming-in Appreciated that sibling was able to stay during rooming-in Dad stated that without rooming-In he potentially would have overdosed the child’s Lasix. The medication practiced taught him about the decimals. Able to learn babe’s routine including fussy periods which may potentially decrease ED visits Experience helped become comfortable with complex med administration Mom stated, “Couldn’t take babe home without this practice.”

24. Case Scenario 6 month old complex congenital heart s/p repair with bypass related renal injury; hospitalized since birth; rooming-in experience included: • Complex single ventricle protocol • Complex medications • Equipment – scale, oximeter, NG tube, feeding pump • Mother roomed in for 48 hours with 3 y.o. sibling present • Father as secondary caregiver was unable to room-in • Mother’s feedback: • Positive experience that helped her learn to care for child at home • Very pleased to be able to practice with medications

25. Case Scenario Mom RN – child with new trach on mechanical ventilator without back-up caregiver at home • Rooming-in experience included: • Using home ventilator in hospital • Doing all trach cares & suctioning • G-tube feeds • Meds, including respiratory treatments

26. Case Scenario Infant with congenital heart disease • During previous hospitalization roomed-in with both parents successfully • Primary caregiver died • Grandparent to assist remaining caregiver • Admitted for feeding issues and re-evaluation • Grandparent took hospitalization opportunity to participate in rooming-in to learn the cares

27. Case Scenario 24 week premature infant hospitalized for 3 months • Dismissed with BPD and seizure disorder • Oxygen and apnea/bradymonitor ordered for home • Multiple medications • Synthroid, NaCl, Phenobarbitol, Hydrocortisone stress dosing • Re-admitted several days later after appropriate response to apnea monitor alarm • Father performed CPR at home and called 911 • Mom requested to room-in again because she appreciated the practice with nursing backup for questions

28. Outcomes Go-Live 10/30/12 Start Pilot 3/12 Start EBP Project 5/11

29. JHNEBP Timeline Translation Evidence Practice 9 months Conduct internal & external evidence search Appraise all evidence Summarize evidence Rate evidence strength Develop recommendations for change in care systems or processes based on the strength of the evidence 2 months Identify EBP question Define scope of practice question Assign responsibility for leadership Recruit interdisciplinary team Schedule team conference 8 months Determine appropriateness & feasibility of translating recommendations into practice setting (pilot) Create action plan Implement change Evaluate outcomes Report results of preliminary evaluation to decision makers Secure support to implement recommended change system wide Identify next steps Communicate findings

30. References • Alexander, D. et al (1988). Anxiety levels of rooming-in and non-rooming-in parents of young hospitalized children. Maternal-Child Nursing Journal, 17(2):79-99. • Consolvo, C.A. (1986). Relieving parental anxiety in the care-by-parent unit. JOGNN, 154-159 • Hayward, E.A. & Sikora, M. (1988) Rooming in: A preventative Health care measure in the NICU. Neonatal Network, 7(3):29-34. • Lerrett, S.M. (2009). Discharge readiness: An integrative review focusing on discharge following peds hospitalization. 14(4): 245-255. • Smith, L. & Daughtrey, H. (2000). Weaving the seamless web of care: an analysis of parents’ perceptions of their needs following discharge of their child from hospital. Journal of Advanced Nursing, 31(4): 812-820. • Weiss, M. et al (2008). Readiness for discharge in parents of hospitalized children. Journal of Pediatric Nursing, 23(4):282-295.

31. Questions