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FIG 72.4 Standardized interstage discharge checklist ■ Assessment of outpatient pharmacy capability for compounding pediatric medications ■ Confirmation of home monitoring equipment (infant scale, pulse oximeter) and home nursing services in place prior to discharge ■ Coordination of a predischarge conference call between interstage care team, referring cardiologist, primary care provider, and parents ■ Scheduling necessary outpatient follow-up visits prior to discharge (referring cardiologist, interstage clinic, primary care, and other subspecialties as needed) ■ Identify outpatient emergency centers and action plan to contact primary cardiology team should need arise for acute evaluation Additional helpful discharge activities are included in the NPC-QIC Care Transition Bundle (Table 72.1).44 Table 72.1 National Pediatric Cardiology Quality Improvement Collaborative Care Transition Bundle (Discharge Preparation Activities) Bundle Elements Assign discharge coordinator Use standardized checklist format to confirm completion of Care Transition Bundle Activities Evaluate family's ability to obtain medications and refer for additional resources as needed Provide written materials for postdischarge care that are culturally and language appropriate Suggested Resources Trained and dedicated personnel Discharge checklist journey board Trained and dedicated personnel Medication list Nutrition plan Red flag action plan Home monitoring plan Offer training in infant CPR and provide a hard copy of CPR instructions Facilitate home scales and oxygen saturation monitors; ensure caregiver is competent in use Provide parents and infants “rooming-in” at least 24 h (e.g., simulating home environment, with independent feeding and care of infant) Use “teach back,” “demonstrate back,” or other confirmation methods to ensure family competency of key care elements Schedule appointments convenient to family with primary care physician, home health, cardiology clinic, etc 10 Set at least one follow-up contact or appointment with a health care provider within 72 h of discharge 11 Schedule conference call with all postacute caregivers (e.g., parents, primary care physician, HH, cardiologist) to communicate patient status and home monitoring plan Prevention plan/immunization list Interstage Emergency Card CPR instructions Home monitoring plan Use “teach back” methodology Rooming-in key driver diagram Rooming-in checklist Use “teach back” methodology Use “teach back” methodology Trained and dedicated personnel Trained and dedicated personnel Conference call agenda and script This transitional bundle prepares the provider team and parents for interstage discharge during the recovery phase after stage I palliation Several of the elements can be addressed prior to the patient being medically ready for discharge From National Pediatric Cardiology Quality Improvement Collaborative https://npcqic.org/resources Central to the discharge process is a shared understanding of the patient's inherent interstage risk and clear processes for escalation of care for the parents, outpatient providers, local emergency rooms, and inpatient providers should clinical status warrant action Necessary communication prior to discharge include: ■ 24-7 access (phone or pager) for the parents and outpatient providers to the interstage care team for breach of home monitoring criteria, change in clinical status, questions, or reassurance ■ Verbal communication between discharging inpatient team and referring cardiologist and primary ... plan to contact primary cardiology team should need arise for acute evaluation Additional helpful discharge activities are included in the NPC-QIC Care Transition Bundle (Table 72.1).44 Table 72.1 National Pediatric Cardiology Quality Improvement Collaborative... Several of the elements can be addressed prior to the patient being medically ready for discharge From National Pediatric Cardiology Quality Improvement Collaborative https://npcqic.org/resources Central to the discharge process is a shared understanding of the patient's... competency of key care elements Schedule appointments convenient to family with primary care physician, home health, cardiology clinic, etc 10 Set at least one follow-up contact or appointment with a health care provider within 72 h
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