Improving transitions of care for complex pediatric trauma patients from inpatient rehabilitation to home: an observational pilot study

BACKGROUND: Patients requiring inpatient pediatric rehabilitation following trauma or disabling illness often require complex care after hospital discharge. The patients and their families are at risk for loss of continuity of care and increased stress which can adversely affect functional and medical outcomes. This pilot study assesses the complexity of need and difficulty with obtaining services at the time of transition from inpatient to outpatient care for pediatric rehabilitation. Additionally we explored the intervention of a post discharge phone call from an experienced rehabilitation nurse to address any issues identified in this period. METHODS: A rehabilitation nurse made scripted post discharge phone calls to patients and families 1–2 weeks after discharge from inpatient pediatric rehabilitation inquiring about medical appointments, medications, therapies, adaptive equipment and transition back to school. Results were recorded by the nurse then analyzed and tabulated by a rehabilitation physician. RESULTS: Eighty two percent of patients had needs in 4–5 of the areas assessed as part of their discharge recommendations. Eighty four percent of those families contacted had difficulty with at least one area at discharge. In all cases of confusion or difficulty with the recommendations, the nurse was able to provide needed guidance to ameliorate the situation. CONCLUSIONS: This pilot study indicates that pediatric rehabilitation patient require complex care as they transition to an outpatient setting. There is significant confusion and families often have difficulty obtaining necessary care in an efficient and effective way during this transition. A post discharge phone call from an experienced rehabilitation nurse could address most of the issues that arise during the transition. This pilot study indicates a need for more investigation into interventions to improve the transition process for pediatric rehabilitation patients and suggests a post discharge phone call program could be useful intervention for pediatric rehabilitation patients and other patient populations requiring complex care such as polytrauma patients.