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
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.
JHNEBP* Model
Practice
Evidence
Identify EBP
question
Conduct internal &
external evidence search
Define scope of
practice question
Appraise all evidence
Assign responsibility
for leadership
Recruit
interdisciplinary
team
Schedule team
conference
Summarize evidence
Rate evidence
strength
Develop
recommendations for
change in care systems or
processes based on the
strength of the evidence
Translation
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
Background
• Readmission rate to inpatient within 7 days
had increased organizationally
Readmission to Inpatient Within 7 Days
Target
Readmission Rate
Average
8%
6.7%
7%
6.7%
6.1%
6%
6%
4.9% 4.8%
5%
4.8%
3.9%
3.7%
4%
3.4%
3.1%
3%
3.6%
3%
2.2%
5.1%
4.9%
3.1%
4%
3.1%
3.5%
3.2%
2%
2.8%
3%
2%
2%
1%
Ju
l-0
Au 9
g09
Se
p09
O
ct
-0
9
N
ov
-0
9
D
ec
-0
9
Ja
n1
Fe 0
b10
M
ar
-1
0
Ap
r10
M
ay
-1
0
Ju
n10
Ju
l-1
Au 0
g10
Se
p10
O
ct
-1
0
N
ov
-1
0
D
ec
-1
0
Ja
n1
Fe 1
b11
M
ar
-1
1
Ap
r11
M
ay
-1
1
Ju
n11
Ju
l-1
1
0%
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
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?
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
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
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
Benchmark
• Contacted community and regional hospitals
• Listserv queries:
– American Case Management Association
– Children’s Healthcare Association (CHA)
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
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
Practice Changes
• Rooming-in procedure
• Documentation form
–
–
–
–
Criteria
Caregiver agreement
Nurse documentation
Final assessment
• Home medication administration
• Home equipment use policy &
waiver
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
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
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
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
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
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
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
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
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
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.”
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
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
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
Case Scenario
24 week premature infant hospitalized for 3
months
• Dismissed with BPD and seizure disorder
• Oxygen and apnea/brady monitor 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
Outcomes
Readmission to Inpatient Within 7 Days
Target
Readmission Rate
Go-Live
10/30/12
Annual Average
Start Pilot
3/12
8%
Start EBP
Project 5/11
7%
6.7%
6.7%
6.0%
6%
7.4%
6.9%
6.1%
6.0%
5.5%
4.9%
5.1%
5%
4.8%
4.8%
4.9%
4%
3.9%
3.6%
2%
1%
0%
2.2%
4.0%
3.1%
3.5%
3.4%
3.0% 3.1%
3%
3.1%
3.2%
2.8%
4.7%
4.8%
4.7%
4.0%
3.7%
5.0%
5.1%
3.0%
3.7%
3.9%
3.4%
3.6%
2.9%
2.5%
2.0%
2.0%
2.1%
JHNEBP Timeline
Practice
2 months
Evidence
9 months
Identify EBP
question
Conduct internal &
external evidence search
Define scope of
practice question
Appraise all evidence
Assign responsibility
for leadership
Recruit
interdisciplinary
team
Schedule team
conference
Summarize evidence
Rate evidence
strength
Develop
recommendations for
change in care systems or
processes based on the
strength of the evidence
Translation
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
References
• Alexander, D. et al (1988). Anxiety levels of rooming-in and nonrooming-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): 812820.
• Weiss, M. et al (2008). Readiness for discharge in parents of
hospitalized children. Journal of Pediatric Nursing, 23(4):282-295.
Questions