Transitions from hospital to home: A mixed methods study to evaluate pediatric discharges in Uganda

Background: The World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) guidelines recognize the importance of discharge planning to ensure continuation of care at home and appropriate follow-up. However, insufficient attention has been paid to post discharge planning in many hospitals contributing to poor implementation. To understand the reasons for suboptimal discharge, we evaluated the pediatric discharge process from hospital admission through the transition to care within the community in Ugandan hospitals. Methods: This mixed methods prospective study enrolled 92 study participants in three phases: patient journey mapping for 32 admitted children under-5 years of age with suspected or proven infection, discharge process mapping with 24 pediatric healthcare workers, and focus group discussions (FDGs) with 36 primary caregivers and fathers of discharged children. Data were descriptively and thematically analyzed. Findings: The typical discharge process is often not centered around the needs of the child and family. Discharge planning often does not begin until immediately prior to discharge and generally does not include caregiver input. Discharge education and counselling are generally limited, rarely involves the father, and does not focus significantly on post-discharge care or follow-up. Delays in the discharge process itself occur at multiple points, including while awaiting a physical discharge order and then following a discharge order, mainly with billing or transportation issues. Data Collection Methods: Journey mapping data were collected using the REDCap Mobile App and were then uploaded to a REDCap database hosted at the BC Children’s Hospital Research Institute (Vancouver, Canada). Study nurses conducted direct observation during in-hospital care as well as caregiver interviews at admission and 72 hours post-discharge using a series of checklists and close-ended questions with some open-entry questions to identify process outcomes as well as barriers and facilitators to the patient’s journey. Healthcare provider working groups engaged in two brainstorming sessions per hospital to develop a process map of each hospital’s current pediatric discharge process and to identify inefficiencies to care and potential solutions. Using paper, pens, and sticky notes, group members jointly mapped out the discharge pathways of their respective facilities and jointly identified all stages of the process. Data were captured using worksheets and audio recordings. A trained research assistant facilitated FGD two weeks after direct observation concluded with patient caregivers. Participants were asked to respond to open-ended questions that focused on their experiences regarding their child’s admission, hospital stay, discharge and post-discharge. All FGDs were digitally recorded, transcribed verbatim and translated into English by external individuals fluent in the languages. Healthcare provider working groups engaged in two brainstorming sessions per hospital to develop a map of each hospital’s current pediatric discharge process and to identify inefficiencies to care and potential solutions. Ethics Declaration: Ethical approvals were obtained from Makerere University (HDREC #850), Uganda National Council for Science and Technology (#HS929ES) and the University of British Columbia (UBC C&W REB # H20-02519). Study Protocol & Supplementary Materials: Smart Discharges Transition to Scale NOTE for restricted files: If you are not yet a CoLab member, please complete our membership application survey to gain access to restricted files within 2 business days. Some files may remain restricted to CoLab members. These files are deemed more sensitive by the file owner and are meant to be shared on a case-by-case basis. Please contact the CoLab coordinator at [e-mail] or visit our website.背景：世界卫生组织（World Health Organization, WHO）的儿童疾病综合管理（Integrated Management of Childhood Illness, IMCI）指南明确了出院计划对于保障家庭延续照护与规范随访的重要性。然而，当前诸多医院对出院后规划重视不足，导致该项工作实施效果欠佳。为探究出院流程不尽人意的根源，本研究针对乌干达各医院内儿科患者从入院到社区照护过渡的全流程出院流程展开评估。 方法：本混合方法前瞻性研究分三阶段招募共计92名研究对象：其一，对32名疑似或确诊感染的5岁以下住院儿童开展患者旅程映射；其二，联合24名儿科医护人员开展出院流程映射；其三，与36名出院儿童的主要照护者及患儿父亲开展焦点小组讨论（Focus Group Discussions, FGDs）。研究采用描述性分析与主题分析法对采集到的数据进行处理。 研究结果：典型的出院流程往往未以儿童与家庭的实际需求为核心。出院规划通常仅在出院前夕方才启动，且普遍未纳入照护者的参与意见。出院教育与咨询服务普遍有限，极少涉及患儿父亲，且未重点聚焦出院后照护或随访相关内容。出院流程本身在多个环节均存在延误，包括等待纸质出院医嘱阶段以及开具出院医嘱后的阶段，延误原因主要涉及缴费或交通相关问题。 数据采集方法：患者旅程映射数据通过REDCap移动应用采集，随后上传至托管于加拿大温哥华不列颠哥伦比亚儿童医院研究所（BC Children’s Hospital Research Institute）的REDCap数据库。研究护士在住院照护期间开展直接观察，并在患儿入院时及出院后72小时，通过一系列搭配少量开放式问题的核查清单与封闭式问题对主要照护者进行访谈，以明确流程结局以及患者旅程中的阻碍因素与促进因素。各医院的医护人员工作组开展两次头脑风暴会议，旨在绘制各医院当前儿科出院流程图谱，并梳理照护环节的低效之处与潜在解决方案。小组成员借助纸笔与便利贴共同勾勒出所在机构的出院路径，并共同确认流程的所有阶段。相关数据通过工作表与录音进行采集。在对患儿照护者的直接观察结束两周后，由经过专业培训的研究助理主持焦点小组讨论。参与者需针对儿童入院、住院、出院及出院后照护的相关经历回应开放式问题。所有焦点小组讨论均进行数字化录音，逐字转录后由精通当地语言的外籍人员翻译为英文。各医院的医护人员工作组开展两次头脑风暴会议，绘制各医院当前儿科出院流程图谱，并梳理照护低效环节与潜在解决方案。 伦理声明：本研究已获得马克雷雷大学（Makerere University，HDREC #850）、乌干达国家科学技术委员会（Uganda National Council for Science and Technology，#HS929ES）以及不列颠哥伦比亚大学（University of British Columbia, UBC C&W REB # H20-02519）的伦理批准。 研究方案与补充材料：《智能出院过渡至规模化应用》（Smart Discharges Transition to Scale）。 受限文件说明：若您尚未成为CoLab成员，请在2个工作日内完成会员申请调查以获取受限文件的访问权限。部分文件可能仅对CoLab成员开放。文件所有者认为此类文件敏感性更高，将按个案审核的方式进行共享。请联系CoLab协调员（邮箱：[e-mail]）或访问我们的官方网站。