Abstract
Purpose: Discharge readiness for the transition from hospital to home for medically complex children (MCC) involves both clinical stability of the child and comprehensive preparation of parents. This challenging period can be marked by significant risk and stress. Nursing teams play a critical role in providing discharge planning, teaching, and care coordination during this pivotal time. We aimed to identify key nurse-driven components of effective discharge preparation, and gaps requiring further research, to improve the transition from hospital to home in MCC.
Methods: Team members, including 12 PhD prepared nurses from the National Pediatric Nurse Scientist Collaborative, undertook a systematic scoping review of 9,910 English language articles published from January 2013 to March 2023. Guided by the Arksey and O’Malley (2015) scoping review framework, CINAHL, EMBASE, and Ovid MEDLINE were searched for subject headings and key text words. This strategy was developed collaboratively, and underwent peer review by a second librarian using the PRESS guidelines. After duplicates were removed, 6,599 records were screened by at least two reviewers. The team met monthly to review progress and for quality assurance.
Results: A total of 16 quantitative studies were included, with sample sizes ranging from 8 to 191 children and/or caregivers. Study designs included a randomized controlled trial (1), quasi-experimental studies (4), single-group pre-post intervention studies (4), descriptive studies (5), a retrospective chart review (1), and a prospective multi-site (1). Nurse-led contributions to the discharge process were tied to reduced 30-day hospital readmission, reduced cost of care, and increased caregiver confidence and satisfaction. Components of effective nurse-driven interventions/practices for discharge planning included customized plans, implementation of a multi-disciplinary videoconference, and consistent contact with caregivers. Effective components of discharge teaching included use of coaching strategies, and simulation. Components of effective interventions for discharge coordination included follow-up calls, and a focus on home care. None of the studies included all 3 components of discharge planning, teaching, and coordination.
Application to Practice: Transition to home for MCC may be improved by innovative nurse-led strategies that incorporate customized care plans, coaching, and care continuity through follow-up calls and home care.
Notes
References: Covidence. (2023). Covidence systematic review software. In Veritas Health Innovation. www.covidence.org
Huang, R.-Y., Lee, T.-T., Lin, Y.-H., Liu, C.-Y., Wu, H.-C., & Huang, S.-H. (2022). Factors related to family caregivers’ readiness for the hospital discharge of advanced cancer patients. International Journal of Environmental Research and Public Health, 19(13), 8097. https://www.mdpi.com/1660-4601/19/13/8097
Leyenaar, J. K., O'Brien, E. R., Leslie, L. K., Lindenauer, P. K., & Mangione-Smith, R. M. (2017). Families' priorities regarding hospital-to-home transitions for children with medical complexity. Pediatrics, 139(1). https://doi.org/10.1542/peds.2016-1581
Markham, J. L., Hall, M., Goldman, J. L., Bettenhausen, J. L., Gay, J. C., Feinstein, J., Simmons, J., Doupnik, S. K., & Berry, J. G. (2021). Readmissions following hospitalization for infection in children with or without medical complexity. J Hosp Med, 16(3), 134-141. https://doi.org/10.12788/jhm.3505
Poh, P.-F., Lee, J. H., Loh, Y. J., Tan, T. H., & Cheng, K. K. F. (2020). Readiness for hospital discharge, stress, and coping in mothers of children undergoing cardiac surgeries: A single-center prospective study. Pediatric Critical Care Medicine, 21(5), e301-e310. https://doi.org/10.1097/pcc.0000000000002276
Pugh, K., Granger, D., Lusk, J., Feaster, W., Weiss, M., Wright, D., & Ehwerhemuepha, L. (2021). Targeted clinical interventions for reducing pediatric readmissions. Hospital Pediatrics, 11(10), 1151-1163. https://doi.org/10.1542/hpeds.2020-005786
Weiss, M. E., Sawin, K. J., Gralton, K., Johnson, N., Klingbeil, C., Lerret, S., Malin, S., Yakusheva, O., & Schiffman, R. (2017). Discharge teaching, readiness for discharge, and post-discharge outcomes in parents of hospitalized children. Journal of Pediatric Nursing, 34, 58-64. https://doi.org/10.1016/j.pedn.2016.12.021
Williams, C. N., Hall, T. A., Francoeur, C., Kurz, J., Rasmussen, L., Hartman, M. E., O’meara, A. I., Ferguson, N. M., Fink, E. L., Walker, T., Drury, K., Carpenter, J. L., Erklauer, J., Press, C., Wainwright, M. S., Lovett, M., Dapul, H., Murphy, S., Risen, S. (2022). Continuing care for critically ill children beyond hospital discharge: Current state of follow-up. Hospital Pediatrics, 12(4), 359-393. https://doi.org/10.1542/hpeds.2021-006464
Sigma Membership
Iota Iota
Type
Presentation
Format Type
Text-based Document
Study Design/Type
Other
Research Approach
Other
Keywords:
Academic-Clinical Partnership, Implementation Science, Mentoring and Coaching
Recommended Citation
Platt, Christine Rae; Moore, Emily F.; Gallegos, Cara; Waldron, Mia; Giambra, Barbara; Lerret, Stacee; Sarik, Danielle; Sajwani-Merchant, Zara; Sumeyye Kutahyalioglu, Nesibe; Gampetro, Pamela; Groshong, Susan L.; Weiss, Marianne; Hernandez, Terri; and Staveski, Sandra, "Transition to Home for Children With Medical Complexity: Insights from a Scoping Review" (2025). International Nursing Research Congress (INRC). 70.
https://www.sigmarepository.org/inrc/2025/presentations_2025/70
Conference Name
36th International Nursing Research Congress
Conference Host
Sigma Theta Tau International
Conference Location
Seattle, Washington, USA
Conference Year
2025
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All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record.
Review Type
Abstract Review Only: Reviewed by Event Host
Acquisition
Proxy-submission
Transition to Home for Children With Medical Complexity: Insights from a Scoping Review
Seattle, Washington, USA
Purpose: Discharge readiness for the transition from hospital to home for medically complex children (MCC) involves both clinical stability of the child and comprehensive preparation of parents. This challenging period can be marked by significant risk and stress. Nursing teams play a critical role in providing discharge planning, teaching, and care coordination during this pivotal time. We aimed to identify key nurse-driven components of effective discharge preparation, and gaps requiring further research, to improve the transition from hospital to home in MCC.
Methods: Team members, including 12 PhD prepared nurses from the National Pediatric Nurse Scientist Collaborative, undertook a systematic scoping review of 9,910 English language articles published from January 2013 to March 2023. Guided by the Arksey and O’Malley (2015) scoping review framework, CINAHL, EMBASE, and Ovid MEDLINE were searched for subject headings and key text words. This strategy was developed collaboratively, and underwent peer review by a second librarian using the PRESS guidelines. After duplicates were removed, 6,599 records were screened by at least two reviewers. The team met monthly to review progress and for quality assurance.
Results: A total of 16 quantitative studies were included, with sample sizes ranging from 8 to 191 children and/or caregivers. Study designs included a randomized controlled trial (1), quasi-experimental studies (4), single-group pre-post intervention studies (4), descriptive studies (5), a retrospective chart review (1), and a prospective multi-site (1). Nurse-led contributions to the discharge process were tied to reduced 30-day hospital readmission, reduced cost of care, and increased caregiver confidence and satisfaction. Components of effective nurse-driven interventions/practices for discharge planning included customized plans, implementation of a multi-disciplinary videoconference, and consistent contact with caregivers. Effective components of discharge teaching included use of coaching strategies, and simulation. Components of effective interventions for discharge coordination included follow-up calls, and a focus on home care. None of the studies included all 3 components of discharge planning, teaching, and coordination.
Application to Practice: Transition to home for MCC may be improved by innovative nurse-led strategies that incorporate customized care plans, coaching, and care continuity through follow-up calls and home care.
Description
This scoping review evaluated nurse-led components of hospital discharge for medically complex children transitioning from hospital to home. A scoping review of 9,910 articles identified 16 quantitative studies examining interventions in discharge planning, teaching, and care coordination. Nursing interventions significantly improved outcomes. Customized care plans, coaching, and care continuity led by nurses are recommended.