EDITORIAL NOTE :

Keeping a Watch After Hospital Discharge

 

Divya Menezes,

MBBS, MD (Paediatrics)

Assistant Editor

 

 

Should we remain vigilant after discharging our paediatric patients who have just recovered from a serious illness? If after discharge, the premorbid health status would be achieved immediately, there would not have been an increased incidence in hospital readmissions in the following months in these children. Knowledge about the key features of the aetiology and mechanism in sepsis, has guided current medical research to explain the reasons how and why it can debilitate a child long after hospital recovery. Post sepsis, the body loses its adaptive immunity, specifically there are fewer B and T cells, and that influences the post-discharge recovery period back to its premorbid condition as well as increases the risk for a re-emergent infection. Further, there are often various risk factors associated such as, immunocompromised states, premorbid health conditions, congenital anomalies, maternal conditions that influence neonatal immunity, nosocomial infections that reduce immunity, and several other conditions. Hence, after recovery from a severe illness it can take months to return to the baseline functional health status.

If we did not pay heed to these factors would we see less post discharge readmissions? Research has shown the contrary. A study in the United States has shown up to 50% incidence of readmission, and these are usually due to urgent or emergent causes.[1] In many countries, where the follow-up may not be easily done and patients get lost to follow-up, this rate in all likelihood is even higher. Hence, it is of utmost importance that this risk and its consequences be understood by all medical providers involved in the discharge of the patient and is also conveyed to the family members to stay vigilant during the immediate post discharge period.

Excellent discharge planning should be initiated early on during the road to recovery and should involve all aspects such as caregiver understanding of the diagnosis and why it happened, training (if required for meeting specific needs of the child such as nasogastric tube feeds or the use of home medical equipment), who will be the medical provider post discharge and establishing that connection if possible, and clearly explaining to the caregiver the critical need for close follow up and monitoring after discharge.

It has been seen that caregiver education and their understanding of the diagnosis and post discharge care is critical to the success of the discharge plan and this success directly influences the quality of care of the child and outcome. It is also necessary the inpatient medical team involved in the discharge understands the capabilities of the caregivers and future medical providers (if they are returning to a smaller city/town or rural area with limited medical facilities) and so appropriately designates the roles and responsibilities.[2] As much as possible, the team must ensure that follow-up specialist appointments are already made, post-discharge medications and equipment already brought, training is done for the same, and the caregiver can verbalise what they have understood. It should never be taken for granted that the instructions have been understood without asking the caregiver to verbalise it in their own words.

In this issue we have highlighted various paediatric cases, some common and others less frequently seen, and we hope that as medical health professionals who assess, diagnose, and treat paediatric illnesses and emergencies, we understand that continuing care extends far and well beyond hospital discharge. It should be integrated in our medical practice procedures. Rather than viewing a hospital discharge as an isolated event, it should be a transition point, bearing in mind the current clinical care practices, social structure of our society to which the patient and family return to, existing research, and current health care legislation.[3] 

A healthy, future outcome of our patients depends on our predictive actions and collective responsibility the moment the child leaves the hospital.

 

References:             

  1. Czaja AS, Zimmerman JJ, Nathens AB. Readmission and late mortality after pediatric severe sepsis. Pediatrics. 2009;123(3):849–857.
  2. Weiss M. Health literacy and patient safety: Help patients understand. Chicago, IL: American Hospital Association Foundation; 2007.
  3. Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to-Guide: Improving transitions from the hospital to community settings to reduce avoidable rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; 2012.