RESEARCH ARTICLE
The Impact of a Parent Brochure on Perceptions of Their Child’s Hospitalization AUTHORS E. Berry Seelbach, MD,1 Megan Yunghans, MD,2 Padmaja Pavuluri, DO, MPH1 1
Children’s National Medical Center, Washington, District of Columbia 2 Kapi’olani Medical Center for Women and Children, Honolulu, Hawaii KEY WORDS communication systems, patient education systems ABBREVIATIONS FCR: family-centered rounds PCP: primary care provider PFCC: patient- and family-centered care www.hospitalpediatrics.org doi:10.1542/hpeds.2011-0023 Address correspondence to Elizabeth Berry Seelbach, MD, Children’s National Medical Center, 111 Michigan Ave, NW, Washington DC, 20010. E-mail: [email protected] HOSPITAL PEDIATRICS (ISSN Numbers: Print, 0031 - 4005; Online, 1098 - 4275). Copyright © 2012 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding.
abstract BACKGROUND AND OBJECTIVE: The primary purpose of family-centered rounds (FCR) is to improve communication and family satisfaction with care. However, hospital satisfaction surveys continue to identify parental concerns about communication with the medical team. The goal of this study was to evaluate the impact of a new “Division of Hospital Medicine” brochure on parent (ie, caregiver) identification of physician names, understanding of FCR, and overall satisfaction with the hospitalist team. METHODS: A prospective cohort study with historical controls compared parent responses on anonymous, self-administered predischarge surveys, before and after brochure implementation. A trifold brochure to explain physician roles, identify names of the attending and intern, and describe the purpose of FCR was provided to parents on admission. It included a photo card of hospitalist attending physicians and explanations of the role of a hospitalist and FCR. The brochure was available in English and Spanish. RESULTS: The overall response rate was 83% (183 of 220). The intervention group of parents identified physician names more accurately and felt more comfortable in FCR, but there was no significant difference in satisfaction. There were no difference between the control and intervention groups in relation to language, inpatient transfer, or length of stay, but the preintervention group did include more patients never before hospitalized. CONCLUSIONS: An informational brochure is a simple tool to improve physician identification and caregiver comfort with FCR. However, further research should explore other factors contributing to family satisfaction during hospitalization and the use of electronic media to provide the same information to families.
INTRODUCTION Hospital admission is often a very stressful time for children and their families. In addition to suffering a medical illness, the patient and family are placed in an unfamiliar environment with a myriad of care providers. A patient’s care team generally includes medical (both primary and consultant), nursing, and a variety of ancillary service providers. This situation is accentuated in an academic center where multiple levels of trainees and medical staff provide patient care. The sheer number of providers involved in each patient’s care often makes it difficult for patients and families to understand providers’ roles or even recall names and titles.1,2 However, according to recent studies, providing photographs of providers has been shown to help patients and their families improve identification.3,4
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To help improve satisfaction and communication with the medical team, patient- and family-centered care (PFCC) has emerged as a Joint Commission standard of care in both adult and pediatric inpatient settings.5 The Institute for Patient- and FamilyCentered Care identified the following 4 core concepts to deliver ultimate care: (1) respect and dignity: the practitioner listens to patients and families and honors their choices; (2) information sharing: the practitioner communicates complete and unbiased information with patients; (3) participation: patients and families are encouraged and supported in participating in decision making at the level they choose; and (4) collaboration: patients and families are included on an institution-wide basis.6 Family-centered rounds (FCR), in which all relevant inpatient providers participate in interactive decision making with the patient and family, have become a key method of delivering PFCC. FCR generally includes the primary medical providers, nursing, and other ancillary services. It is the most common rounding modality among pediatric hospitalist programs.7 Although parents desire to be included in rounds and generally view inclusion as a positive experience, studies have shown there is wide variability in the preparation provided for parents about the purpose and timing of FCR and their role within in it.8 The family’s confusion about FCR and the inability to identify their primary provider can lead to concerns of suboptimal communication and an overall dissatisfaction in care. The purpose of this study was to evaluate parent (or guardian) satisfaction with care after the distribution of an informational brochure (Figures 1 and 2) on admission to the hospitalist service 78 |
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at a large freestanding children’s hospital. Secondary study aims included evaluating the caregiver’s ability to identify the primary provider and comfort in FCR.
admitted for a variety of medical conditions. Unit assignments were performed by admission nurses unaware of the study. All patients admitted to the hospitalist teams were included in the study, unless English or Spanish was not their primary language.
METHODS Study Design and Setting
This was a prospective cohort study with historical controls comparing caregiver satisfaction and comprehension before and after brochure implementation. The study took place at a freestanding pediatric academic medical center in Washington, DC. Subjects included caregivers of pediatric patients admitted to 1 of 2 academic hospitalist teams from February 2009 through April 2009. All participants studied were admitted to a single 39-bed, multispecialty medical unit. Patients ranged from newborn to 21 years of age and were
Each hospitalist team was staffed by a pediatric hospitalist who rotated in 2-week blocks. The other team members included a third-year pediatric resident, 2 pediatric interns, and several third- and fourth-year medical students, all of whom rotated in staggered 4-week blocks. A pediatric hospitalist fellow was present during some weeks of the study. FCRs were conducted daily (Monday through Friday) each morning by the primary team. On nights and weekends, a child may be admitted and managed by a separate, on-call resident team and supervised by a separate in-house hospitalist. Routine communication by trainees,
FIGURE 1 Division of Pediatric Hospitalist Medicine Brochure from Children’s National Medical Center (front and back).
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items); and general comments about the caregiver’s experience (1 fill-in-the blank item). Survey Administration
FIGURE 2 Division of Pediatric Hospitalist Medicine Brochure from Children’s National Medical Center (inside).
attending physicians, and other team members with patients and families is generally verbal and highly variable. Intervention (Hospitalist Brochure)
We created a trifold brochure based on a literature review, as well as feedback from hospitalists, parents, nurses, and the public relations and marketing teams (Fig 1). Content included handwritten physician names completed by the admitting or on-service attending in the spaces provided on the front cover, a description of pediatric hospitalists and the roles of other physicians on the primary and consulting teams, general rounding and prerounding times, and a description of FCR. Finally, the brochure described the role of the child’s primary care provider (PCP) and general discharge planning. We developed the brochure at a sixthgrade reading level, and it was available in both English and Spanish. It
included a color photo card insert of all Children’s National Medical Center hospitalists and was distributed by the admitting or on-service hospitalist at or near the time of admission. Cost of the brochure was ∼80 cents per patient. Survey Instrument
A data collection survey tool was created based on a literature review and multidisciplinary feedback (Appendix). It was designed for a sixth-grade reading level; it was anonymous, selfadministered, and available in English and Spanish. The 14-item survey evaluated comprehension and application of core concepts described in the brochure but did not specifically reference the intervention. The survey included: number of previous hospitalizations (one fill-in-the blank item); names of patient’s primary inpatient physicians (2 fill-inthe-blank items); caregiver comprehension (10 five-point Likert scale
On weekdays during the pre- and postintervention phases, the hospitalist or study team physician, using a preestablished script, distributed the survey at or near the day of discharge. If the family was scheduled to be discharged over the weekend, the survey was distributed on Friday. Every English- or Spanish-speaking family who was discharged during a weekday was given the survey. The study team physician asked the caregiver to place the completed survey in a sealed envelope, later retrieved by the physician before discharge. To help ensure that we only evaluated patient knowledge, we did not mention the brochure (including confirming if the family had received a brochure) when the survey was distributed to the postintervention group. This was to prevent cueing the family to use the brochure as a “cheat sheet.” On retrieval, the physician completed final nonidentifying verification and demographic data, including primary team members, length of stay, and whether the patient had an intrahospital transfer. We instituted a 2-week washout period between the pre- and postintervention periods to minimize any effects of brochure distribution to caregivers of patients with extended hospitalizations. The study was approved by the institutional review board as exempt from full review with waiver of written consent. Data Analysis
An a priori sample size of 145, using G*Power version 3.1.0 (A. Buchner, E. Erdfelder, and F. Faul, Universitat Kiel, Germany, 1997), was calculated to
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achieve 80% power, an α level of .05, and a 30% improvement in satisfaction outcomes (very satisfied versus all other choices) because the goal was to deliver the highest level of satisfaction. Data analysis was conducted by using PASW Statistics release 18.0.0 (SPSS, Inc, Chicago, IL). Descriptive statistics were used to summarize demographic information, which was further compared by using χ2 analysis. Bivariate analyses were used to measure the association between intervention exposure and the outcome mea sures, including the ability to identify providers and overall satisfaction measures. Multivariate logistic regression was used to qualify these outcomes after adjusting for potential covariates, including language, length of stay, number of previous hospitalizations, and occurrence of intrahospital transfer.
implementation, there was a significant improvement to 52% and 22%. Similarly, caregivers’ comprehension of a hospitalist’s role increased significantly from 40% preintervention to 66% postintervention. Fifty-eight percent of preintervention respondents already felt comfortable with FCR, but 78% felt comfortable postintervention (Table 2). The number of positive responses for all other survey questions increased after the implementation of the brochure, but the increase was not statistically significant. For example, understanding the roles of various providers increased from 61% to 71% and understanding which physicians to ask for when parents had questions increased from 57% to 70%. Finally, the overall satisfaction with care, as measured by the respondents’ willingness to recommend future care by a hospitalist team, rose from 70% preintervention to 79% postintervention.
RESULTS Of the 220 potential subjects, 183 completed the survey (83% response rate). The study population was primarily English-speaking caregivers whose child had a short length of stay (≤3 days) and were not transferred from another inpatient unit. The postintervention group had a higher percentage of hospital-naive caregivers (Table 1). Before brochure distribution, caregivers could only identify the hospitalist’s and the intern’s name 9% and 5% of the time, respectively. After brochure
In addition, there were no consistent differences due to any of the confounding variables evaluated: language, length of stay, prior hospital exposure, or intrahospital transfer in the preand postintervention groups.
DISCUSSION An informational brochure describing the role of the hospitalist, the process of FCR, and identification of the PCP improved satisfaction with care; however, not all findings were at a statistically significant level.
TABLE 1 Respondent Characteristics Characteristic
Preintervention (No Brochure)
Postintervention (Brochure)
P
Response rate English-speaking
92% (100/109) 83%
75% (83/111) 80%
– .547
Length of stay ≤ 3 d
55%
55%
1.000
No previous intrahospital transfer
89%
92%
.418
No previous hospitalizations
69%
83%
.043*
* Statistically significant.
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Overall satisfaction with care was addressed by asking if the respondent “would recommend future care by a hospitalist team.” This indirect assessment likely limited the ability to accurately detect overall care satisfaction. Previous studies have also reported mixed results with improvement in satisfaction and caregiver identification. Francis et al3 placed physician photos in adult patients’ rooms and found that patients reported greater satisfaction in physician responsiveness and with how questions regarding their medical treatment were addressed. Questions in this study regarding satisfaction with physician care were asked in a more direct fashion, thus likely improving the ability to measure improved outcomes. In contrast, Arora et al2 found that decreased patient satisfaction was associated with improved ability to identify the physician in a study of adult patients on an inpatient medicine team. This study did not use any specific intervention to increase physician name recognition beyond standard introduction techniques. The authors postulated that perhaps physician name recall was higher in dissatisfied patients. Our study, in contrast, was conducted in a pediatric setting in which the respondents were adult caregivers instead of the patients themselves, and those caregivers may not have been present throughout the entire hospitalization. Dudas et al4 also demonstrated that a handout with physician pictures improved recognition of members of a pediatric health care team but focused on the inclusion of medical students as providers and how the family perceived care with trainees. Our intervention was broadly focused, incorporating physician names, hospitalist pictures, and information regarding the composition of FCR and the role of the PCP,
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TABLE 2 Outcomes Survey Items
Pre-Brochure, %
Provider identification accuracy Attending name Intern name Role comprehension Hospitalist role All inpatient physicians’ roles PCP role FCR Purpose Comfortable with participation Communication Knew which physicians to ask for questions Received updates from medical team Discharge process Overall satisfaction Recommend future care by hospitalist team
Post-Brochure, %
Unadjusted OR (95% CI)
Adjusted OR (95% CI)
9 5
52 22
13.53 (5.16–34.46)* 7.70 (2.12–27.96)*
14.55 (5.21–40.62)* 7.22 (1.92–27.09)*
40 61 68
66 71 75
3.16 (1.56–6.33)* 1.57 (0.78–3.14) 1.71 (0.80–3.64)
2.86 (1.38–5.93)* 1.52 (0.74–3.11) 1.80 (0.83–3.90)
58 58
60 78
1.26 (0.64–2.48) 2.63 (1.29–5.39)*
1.30 (0.64–2.66) 2.76 (1.31–5.82)*
57 77
70 82
1.78 (0.89–3.58) 1.36 (0.57–3.21)
1.72 (0.84–3.51) 1.34 (0.55–3.30)
68
74
1.36 (0.64–2.90)
1.30 (0.59–2.83)
70
79
1.85 (0.84–4.09)
1.69 (0.74–3.88)
OR, odds ratio. *Statistically significant.
and focused more on care provided by the whole team and comfort in FCR. Identification of providers improved significantly with the use of the brochure. Postintervention identification improved more for the hospitalist, identified by the photo card, than the intern, whose name was simply handwritten on the brochure. In addition, some respondents identified the senior resident, whose name was also handwritten on the brochure, as the intern. Because these roles were specifically explained in the brochure, this discrepancy may reflect the need to better identify each provider within a large group conducting FCR. This finding could also reflect caregivers’ connection with the senior resident, who typically is more actively engaged during FCR with the daily plans, so families may perceive the senior resident as the primary resident physician. The brochure increased caregivers’ understanding of the term and role of a hospitalist. Because hospital medicine is a relatively new field, especially in pediatrics, it is important to explain the
hospitalist’s purpose as well as the role of the PCP, whom the caregiver may expect to see, unless otherwise prepared. In addition, this study demonstrated that an informative brochure describing FCR is a simple way to increase caregivers’ comfort level participating in FCR. This is important because family presence and participation are essential to providing optimal PFCC. PFCC has become increasingly important to governing medical bodies and allows better communication between families and caregivers. All survey items showed a positive improvement after distribution of the brochure, although not all were statistically significant. Given the improvement in the responses, it appears that the brochure is an effective means of distributing information to families. It is a convenient method of communicating information at admission that can be referred to throughout hospitalization. Further studies with increased numbers should be conducted to determine if the other results are significant and reproducible.
This study has several important limitations. First, brochure distribution, dele gated to the admitting or onservice primary hospitalist, may have been variable, and brochure receipt by postintervention caregivers was not confirmed to caregivers blinded toward the specific survey purpose. Suboptimal brochure distribution could have limited postintervention gains. Second, our study occurred from February 2009 through April 2009. The latter half of this period corresponded to the postintervention period, during which there was an overall decreased census, although length of stay remained constant. With fewer patients, it is possible that hospitalists had the ability to spend proportionately more time with patients and caregivers, thus favorably influencing some results. Similarly, it is possible that the pre- and postdesign introduced seasonal variation of diagnoses, which could have affected caregiver comprehension and satisfaction. Although we develomped the survey instrument using diverse provider, nurse, and caregiver feedback, it was
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not validated. Data could also have been limited by respondent bias: respondents may have been those with stronger feelings, either positive or negative, than nonrespondents; however, an 83% response rate limits this variability. Similarly, even though surveys were collected in a sealed envelope and the anonymous nature of the study was explained, respondents may have altered their responses for increased desirability, especially because the survey was distributed and collected by the attending physician. Among the hospitalists, there could have been some selection bias (ie, distributing surveys to only caregivers with whom the hospitalist interacted favorably) or the Hawthorne effect (the hospitalist could have consciously or unconsciously modified his or her own behavior because of the pending evaluation). However, this bias would apply to both groups and should have been mitigated by the use of the script provided for survey distribution. Finally, the sample size was only powered for the primary outcomes and may have limited findings of significance among potential confounders.
FUTURE DIRECTIONS This informational brochure helped families identify the physicians caring for their children by name, helped them feel more comfortable in FCR, and understand the use of the term hospitalist, all which can be challenging
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in the changing landscape of inpatient medicine. Despite these improvements, the study did not show a statistically significant difference in overall care satisfaction scores before and after the intervention. Because FCR is an integral aspect of hospitalization and its importance will only continue to increase, future efforts to educate caregivers and integrate them into FCR should target improving brochure content based on feedback and refining specific survey items. Although our study did not specifically identify differences between the subgroups, orientation materials to FCR could be specifically targeted toward certain high-risk groups, such as those with low health literacy, with limited English proficiency, anticipated to have longer lengths of stay, or with increased involvement of ancillary or consultant services. Due to the resources necessary to maintain, update, and distribute the brochures, and ease of caregivers misplacing the brochure, future interventions should consider more automated and easily accessible formats, such as patient-specific electronic whiteboards. These formats can be more individualized to include photos and names of all providers, their roles, and other clinical information, thus providing a constant, accurate, real-time conduit for summarizing plans discussed in FCR. Although overall care satisfaction is a very important measure, future efforts
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should also target other areas affected by improved caregivers’ orientation to FCR, including contribution within FCR, staff satisfaction, medical errors, and measures of resource utilization, such as length of stay, unplanned readmissions, and hospitalization costs.
REFERENCES 1. Brockopp DY, Franey BN, Sage-Smith D, Romond EH, Cannon CC. Patients’ knowledge of their caregivers’ names. A teachinghospital study. Hosp Top. 1992;70(1):25–28. 2. Arora V, Gangireddy S, Mehrotra A, Ginde R, Tormey M, Meltzer D. Ability of hospitalized patients to identify their in-hospital physicians. Arch Intern Med. 2009;169(2): 199–201. 3. Francis JJ, Pankratz VS, Huddleston JM. Patient satisfaction associated with correct identification of physician’s photographs. Mayo Clin Proc. 2001;76(6):604–608. 4. Dudas RA, Lemerman H, Barone M, Serwint JR. PHACES (Photographs of Academic Clinicians and Their Educational Status): a tool to improve delivery of family-centered care. Acad Pediatr. 2010;10(2):138–145. 5. The Joint Commission. Available at: www. jointcommission.org/Advancing_Effective_ Communication/. Accessed October 19, 2011. 6. Institute for Patient- and Family-Centered Care. Available at: www.ipfcc.org/index.html. Accessed December 29, 2011. 7. Mittal VS, Sigrest T, Ottolini MC, et al. Family-centered rounds on pediatric wards: a PRIS network survey of US and Canadian hospitalists. Pediatrics. 2010;126(1):37–43. 8. Latta LC, Dick R, Parry C, Tamura GS. Parental responses to involvement in rounds on a pediatric inpatient unit at a teaching hospital: a qualitative study. Acad Med. 2008;83(3):292–297.
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APPENDIX CHILDREN’S NATIONAL MEDICAL CENTER PEDIATRIC HOSPITALISTS SURVEY
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The Impact of a Parent Brochure on Perceptions of Their Child's Hospitalization E. Berry Seelbach, Megan Yunghans and Padmaja Pavuluri Hospital Pediatrics 2012;2;77 DOI: 10.1542/hpeds.2011-0023
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The Impact of a Parent Brochure on Perceptions of Their Child's Hospitalization E. Berry Seelbach, Megan Yunghans and Padmaja Pavuluri Hospital Pediatrics 2012;2;77 DOI: 10.1542/hpeds.2011-0023
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://hosppeds.aappublications.org/content/2/2/77
Hospital Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 2012. Hospital Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 2154-1663.
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The Impact of a Parent Brochure on Perceptions of Their Child’s Hospitalization AUTHORS E. Berry Seelbach, MD,1 Megan Yunghans, MD,2 Padmaja Pavuluri, DO, MPH1 1
Children’s National Medical Center, Washington, District of Columbia 2 Kapi’olani Medical Center for Women and Children, Honolulu, Hawaii KEY WORDS communication systems, patient education systems ABBREVIATIONS FCR: family-centered rounds PCP: primary care provider PFCC: patient- and family-centered care www.hospitalpediatrics.org doi:10.1542/hpeds.2011-0023 Address correspondence to Elizabeth Berry Seelbach, MD, Children’s National Medical Center, 111 Michigan Ave, NW, Washington DC, 20010. E-mail: [email protected] HOSPITAL PEDIATRICS (ISSN Numbers: Print, 0031 - 4005; Online, 1098 - 4275). Copyright © 2012 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding.
abstract BACKGROUND AND OBJECTIVE: The primary purpose of family-centered rounds (FCR) is to improve communication and family satisfaction with care. However, hospital satisfaction surveys continue to identify parental concerns about communication with the medical team. The goal of this study was to evaluate the impact of a new “Division of Hospital Medicine” brochure on parent (ie, caregiver) identification of physician names, understanding of FCR, and overall satisfaction with the hospitalist team. METHODS: A prospective cohort study with historical controls compared parent responses on anonymous, self-administered predischarge surveys, before and after brochure implementation. A trifold brochure to explain physician roles, identify names of the attending and intern, and describe the purpose of FCR was provided to parents on admission. It included a photo card of hospitalist attending physicians and explanations of the role of a hospitalist and FCR. The brochure was available in English and Spanish. RESULTS: The overall response rate was 83% (183 of 220). The intervention group of parents identified physician names more accurately and felt more comfortable in FCR, but there was no significant difference in satisfaction. There were no difference between the control and intervention groups in relation to language, inpatient transfer, or length of stay, but the preintervention group did include more patients never before hospitalized. CONCLUSIONS: An informational brochure is a simple tool to improve physician identification and caregiver comfort with FCR. However, further research should explore other factors contributing to family satisfaction during hospitalization and the use of electronic media to provide the same information to families.
INTRODUCTION Hospital admission is often a very stressful time for children and their families. In addition to suffering a medical illness, the patient and family are placed in an unfamiliar environment with a myriad of care providers. A patient’s care team generally includes medical (both primary and consultant), nursing, and a variety of ancillary service providers. This situation is accentuated in an academic center where multiple levels of trainees and medical staff provide patient care. The sheer number of providers involved in each patient’s care often makes it difficult for patients and families to understand providers’ roles or even recall names and titles.1,2 However, according to recent studies, providing photographs of providers has been shown to help patients and their families improve identification.3,4
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To help improve satisfaction and communication with the medical team, patient- and family-centered care (PFCC) has emerged as a Joint Commission standard of care in both adult and pediatric inpatient settings.5 The Institute for Patient- and FamilyCentered Care identified the following 4 core concepts to deliver ultimate care: (1) respect and dignity: the practitioner listens to patients and families and honors their choices; (2) information sharing: the practitioner communicates complete and unbiased information with patients; (3) participation: patients and families are encouraged and supported in participating in decision making at the level they choose; and (4) collaboration: patients and families are included on an institution-wide basis.6 Family-centered rounds (FCR), in which all relevant inpatient providers participate in interactive decision making with the patient and family, have become a key method of delivering PFCC. FCR generally includes the primary medical providers, nursing, and other ancillary services. It is the most common rounding modality among pediatric hospitalist programs.7 Although parents desire to be included in rounds and generally view inclusion as a positive experience, studies have shown there is wide variability in the preparation provided for parents about the purpose and timing of FCR and their role within in it.8 The family’s confusion about FCR and the inability to identify their primary provider can lead to concerns of suboptimal communication and an overall dissatisfaction in care. The purpose of this study was to evaluate parent (or guardian) satisfaction with care after the distribution of an informational brochure (Figures 1 and 2) on admission to the hospitalist service 78 |
VOLUME 2 • ISSUE 2
at a large freestanding children’s hospital. Secondary study aims included evaluating the caregiver’s ability to identify the primary provider and comfort in FCR.
admitted for a variety of medical conditions. Unit assignments were performed by admission nurses unaware of the study. All patients admitted to the hospitalist teams were included in the study, unless English or Spanish was not their primary language.
METHODS Study Design and Setting
This was a prospective cohort study with historical controls comparing caregiver satisfaction and comprehension before and after brochure implementation. The study took place at a freestanding pediatric academic medical center in Washington, DC. Subjects included caregivers of pediatric patients admitted to 1 of 2 academic hospitalist teams from February 2009 through April 2009. All participants studied were admitted to a single 39-bed, multispecialty medical unit. Patients ranged from newborn to 21 years of age and were
Each hospitalist team was staffed by a pediatric hospitalist who rotated in 2-week blocks. The other team members included a third-year pediatric resident, 2 pediatric interns, and several third- and fourth-year medical students, all of whom rotated in staggered 4-week blocks. A pediatric hospitalist fellow was present during some weeks of the study. FCRs were conducted daily (Monday through Friday) each morning by the primary team. On nights and weekends, a child may be admitted and managed by a separate, on-call resident team and supervised by a separate in-house hospitalist. Routine communication by trainees,
FIGURE 1 Division of Pediatric Hospitalist Medicine Brochure from Children’s National Medical Center (front and back).
www.hospitalpediatrics.org
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HOSPITAL Pediatrics ®
AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
items); and general comments about the caregiver’s experience (1 fill-in-the blank item). Survey Administration
FIGURE 2 Division of Pediatric Hospitalist Medicine Brochure from Children’s National Medical Center (inside).
attending physicians, and other team members with patients and families is generally verbal and highly variable. Intervention (Hospitalist Brochure)
We created a trifold brochure based on a literature review, as well as feedback from hospitalists, parents, nurses, and the public relations and marketing teams (Fig 1). Content included handwritten physician names completed by the admitting or on-service attending in the spaces provided on the front cover, a description of pediatric hospitalists and the roles of other physicians on the primary and consulting teams, general rounding and prerounding times, and a description of FCR. Finally, the brochure described the role of the child’s primary care provider (PCP) and general discharge planning. We developed the brochure at a sixthgrade reading level, and it was available in both English and Spanish. It
included a color photo card insert of all Children’s National Medical Center hospitalists and was distributed by the admitting or on-service hospitalist at or near the time of admission. Cost of the brochure was ∼80 cents per patient. Survey Instrument
A data collection survey tool was created based on a literature review and multidisciplinary feedback (Appendix). It was designed for a sixth-grade reading level; it was anonymous, selfadministered, and available in English and Spanish. The 14-item survey evaluated comprehension and application of core concepts described in the brochure but did not specifically reference the intervention. The survey included: number of previous hospitalizations (one fill-in-the blank item); names of patient’s primary inpatient physicians (2 fill-inthe-blank items); caregiver comprehension (10 five-point Likert scale
On weekdays during the pre- and postintervention phases, the hospitalist or study team physician, using a preestablished script, distributed the survey at or near the day of discharge. If the family was scheduled to be discharged over the weekend, the survey was distributed on Friday. Every English- or Spanish-speaking family who was discharged during a weekday was given the survey. The study team physician asked the caregiver to place the completed survey in a sealed envelope, later retrieved by the physician before discharge. To help ensure that we only evaluated patient knowledge, we did not mention the brochure (including confirming if the family had received a brochure) when the survey was distributed to the postintervention group. This was to prevent cueing the family to use the brochure as a “cheat sheet.” On retrieval, the physician completed final nonidentifying verification and demographic data, including primary team members, length of stay, and whether the patient had an intrahospital transfer. We instituted a 2-week washout period between the pre- and postintervention periods to minimize any effects of brochure distribution to caregivers of patients with extended hospitalizations. The study was approved by the institutional review board as exempt from full review with waiver of written consent. Data Analysis
An a priori sample size of 145, using G*Power version 3.1.0 (A. Buchner, E. Erdfelder, and F. Faul, Universitat Kiel, Germany, 1997), was calculated to
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achieve 80% power, an α level of .05, and a 30% improvement in satisfaction outcomes (very satisfied versus all other choices) because the goal was to deliver the highest level of satisfaction. Data analysis was conducted by using PASW Statistics release 18.0.0 (SPSS, Inc, Chicago, IL). Descriptive statistics were used to summarize demographic information, which was further compared by using χ2 analysis. Bivariate analyses were used to measure the association between intervention exposure and the outcome mea sures, including the ability to identify providers and overall satisfaction measures. Multivariate logistic regression was used to qualify these outcomes after adjusting for potential covariates, including language, length of stay, number of previous hospitalizations, and occurrence of intrahospital transfer.
implementation, there was a significant improvement to 52% and 22%. Similarly, caregivers’ comprehension of a hospitalist’s role increased significantly from 40% preintervention to 66% postintervention. Fifty-eight percent of preintervention respondents already felt comfortable with FCR, but 78% felt comfortable postintervention (Table 2). The number of positive responses for all other survey questions increased after the implementation of the brochure, but the increase was not statistically significant. For example, understanding the roles of various providers increased from 61% to 71% and understanding which physicians to ask for when parents had questions increased from 57% to 70%. Finally, the overall satisfaction with care, as measured by the respondents’ willingness to recommend future care by a hospitalist team, rose from 70% preintervention to 79% postintervention.
RESULTS Of the 220 potential subjects, 183 completed the survey (83% response rate). The study population was primarily English-speaking caregivers whose child had a short length of stay (≤3 days) and were not transferred from another inpatient unit. The postintervention group had a higher percentage of hospital-naive caregivers (Table 1). Before brochure distribution, caregivers could only identify the hospitalist’s and the intern’s name 9% and 5% of the time, respectively. After brochure
In addition, there were no consistent differences due to any of the confounding variables evaluated: language, length of stay, prior hospital exposure, or intrahospital transfer in the preand postintervention groups.
DISCUSSION An informational brochure describing the role of the hospitalist, the process of FCR, and identification of the PCP improved satisfaction with care; however, not all findings were at a statistically significant level.
TABLE 1 Respondent Characteristics Characteristic
Preintervention (No Brochure)
Postintervention (Brochure)
P
Response rate English-speaking
92% (100/109) 83%
75% (83/111) 80%
– .547
Length of stay ≤ 3 d
55%
55%
1.000
No previous intrahospital transfer
89%
92%
.418
No previous hospitalizations
69%
83%
.043*
* Statistically significant.
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Overall satisfaction with care was addressed by asking if the respondent “would recommend future care by a hospitalist team.” This indirect assessment likely limited the ability to accurately detect overall care satisfaction. Previous studies have also reported mixed results with improvement in satisfaction and caregiver identification. Francis et al3 placed physician photos in adult patients’ rooms and found that patients reported greater satisfaction in physician responsiveness and with how questions regarding their medical treatment were addressed. Questions in this study regarding satisfaction with physician care were asked in a more direct fashion, thus likely improving the ability to measure improved outcomes. In contrast, Arora et al2 found that decreased patient satisfaction was associated with improved ability to identify the physician in a study of adult patients on an inpatient medicine team. This study did not use any specific intervention to increase physician name recognition beyond standard introduction techniques. The authors postulated that perhaps physician name recall was higher in dissatisfied patients. Our study, in contrast, was conducted in a pediatric setting in which the respondents were adult caregivers instead of the patients themselves, and those caregivers may not have been present throughout the entire hospitalization. Dudas et al4 also demonstrated that a handout with physician pictures improved recognition of members of a pediatric health care team but focused on the inclusion of medical students as providers and how the family perceived care with trainees. Our intervention was broadly focused, incorporating physician names, hospitalist pictures, and information regarding the composition of FCR and the role of the PCP,
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TABLE 2 Outcomes Survey Items
Pre-Brochure, %
Provider identification accuracy Attending name Intern name Role comprehension Hospitalist role All inpatient physicians’ roles PCP role FCR Purpose Comfortable with participation Communication Knew which physicians to ask for questions Received updates from medical team Discharge process Overall satisfaction Recommend future care by hospitalist team
Post-Brochure, %
Unadjusted OR (95% CI)
Adjusted OR (95% CI)
9 5
52 22
13.53 (5.16–34.46)* 7.70 (2.12–27.96)*
14.55 (5.21–40.62)* 7.22 (1.92–27.09)*
40 61 68
66 71 75
3.16 (1.56–6.33)* 1.57 (0.78–3.14) 1.71 (0.80–3.64)
2.86 (1.38–5.93)* 1.52 (0.74–3.11) 1.80 (0.83–3.90)
58 58
60 78
1.26 (0.64–2.48) 2.63 (1.29–5.39)*
1.30 (0.64–2.66) 2.76 (1.31–5.82)*
57 77
70 82
1.78 (0.89–3.58) 1.36 (0.57–3.21)
1.72 (0.84–3.51) 1.34 (0.55–3.30)
68
74
1.36 (0.64–2.90)
1.30 (0.59–2.83)
70
79
1.85 (0.84–4.09)
1.69 (0.74–3.88)
OR, odds ratio. *Statistically significant.
and focused more on care provided by the whole team and comfort in FCR. Identification of providers improved significantly with the use of the brochure. Postintervention identification improved more for the hospitalist, identified by the photo card, than the intern, whose name was simply handwritten on the brochure. In addition, some respondents identified the senior resident, whose name was also handwritten on the brochure, as the intern. Because these roles were specifically explained in the brochure, this discrepancy may reflect the need to better identify each provider within a large group conducting FCR. This finding could also reflect caregivers’ connection with the senior resident, who typically is more actively engaged during FCR with the daily plans, so families may perceive the senior resident as the primary resident physician. The brochure increased caregivers’ understanding of the term and role of a hospitalist. Because hospital medicine is a relatively new field, especially in pediatrics, it is important to explain the
hospitalist’s purpose as well as the role of the PCP, whom the caregiver may expect to see, unless otherwise prepared. In addition, this study demonstrated that an informative brochure describing FCR is a simple way to increase caregivers’ comfort level participating in FCR. This is important because family presence and participation are essential to providing optimal PFCC. PFCC has become increasingly important to governing medical bodies and allows better communication between families and caregivers. All survey items showed a positive improvement after distribution of the brochure, although not all were statistically significant. Given the improvement in the responses, it appears that the brochure is an effective means of distributing information to families. It is a convenient method of communicating information at admission that can be referred to throughout hospitalization. Further studies with increased numbers should be conducted to determine if the other results are significant and reproducible.
This study has several important limitations. First, brochure distribution, dele gated to the admitting or onservice primary hospitalist, may have been variable, and brochure receipt by postintervention caregivers was not confirmed to caregivers blinded toward the specific survey purpose. Suboptimal brochure distribution could have limited postintervention gains. Second, our study occurred from February 2009 through April 2009. The latter half of this period corresponded to the postintervention period, during which there was an overall decreased census, although length of stay remained constant. With fewer patients, it is possible that hospitalists had the ability to spend proportionately more time with patients and caregivers, thus favorably influencing some results. Similarly, it is possible that the pre- and postdesign introduced seasonal variation of diagnoses, which could have affected caregiver comprehension and satisfaction. Although we develomped the survey instrument using diverse provider, nurse, and caregiver feedback, it was
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not validated. Data could also have been limited by respondent bias: respondents may have been those with stronger feelings, either positive or negative, than nonrespondents; however, an 83% response rate limits this variability. Similarly, even though surveys were collected in a sealed envelope and the anonymous nature of the study was explained, respondents may have altered their responses for increased desirability, especially because the survey was distributed and collected by the attending physician. Among the hospitalists, there could have been some selection bias (ie, distributing surveys to only caregivers with whom the hospitalist interacted favorably) or the Hawthorne effect (the hospitalist could have consciously or unconsciously modified his or her own behavior because of the pending evaluation). However, this bias would apply to both groups and should have been mitigated by the use of the script provided for survey distribution. Finally, the sample size was only powered for the primary outcomes and may have limited findings of significance among potential confounders.
FUTURE DIRECTIONS This informational brochure helped families identify the physicians caring for their children by name, helped them feel more comfortable in FCR, and understand the use of the term hospitalist, all which can be challenging
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in the changing landscape of inpatient medicine. Despite these improvements, the study did not show a statistically significant difference in overall care satisfaction scores before and after the intervention. Because FCR is an integral aspect of hospitalization and its importance will only continue to increase, future efforts to educate caregivers and integrate them into FCR should target improving brochure content based on feedback and refining specific survey items. Although our study did not specifically identify differences between the subgroups, orientation materials to FCR could be specifically targeted toward certain high-risk groups, such as those with low health literacy, with limited English proficiency, anticipated to have longer lengths of stay, or with increased involvement of ancillary or consultant services. Due to the resources necessary to maintain, update, and distribute the brochures, and ease of caregivers misplacing the brochure, future interventions should consider more automated and easily accessible formats, such as patient-specific electronic whiteboards. These formats can be more individualized to include photos and names of all providers, their roles, and other clinical information, thus providing a constant, accurate, real-time conduit for summarizing plans discussed in FCR. Although overall care satisfaction is a very important measure, future efforts
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should also target other areas affected by improved caregivers’ orientation to FCR, including contribution within FCR, staff satisfaction, medical errors, and measures of resource utilization, such as length of stay, unplanned readmissions, and hospitalization costs.
REFERENCES 1. Brockopp DY, Franey BN, Sage-Smith D, Romond EH, Cannon CC. Patients’ knowledge of their caregivers’ names. A teachinghospital study. Hosp Top. 1992;70(1):25–28. 2. Arora V, Gangireddy S, Mehrotra A, Ginde R, Tormey M, Meltzer D. Ability of hospitalized patients to identify their in-hospital physicians. Arch Intern Med. 2009;169(2): 199–201. 3. Francis JJ, Pankratz VS, Huddleston JM. Patient satisfaction associated with correct identification of physician’s photographs. Mayo Clin Proc. 2001;76(6):604–608. 4. Dudas RA, Lemerman H, Barone M, Serwint JR. PHACES (Photographs of Academic Clinicians and Their Educational Status): a tool to improve delivery of family-centered care. Acad Pediatr. 2010;10(2):138–145. 5. The Joint Commission. Available at: www. jointcommission.org/Advancing_Effective_ Communication/. Accessed October 19, 2011. 6. Institute for Patient- and Family-Centered Care. Available at: www.ipfcc.org/index.html. Accessed December 29, 2011. 7. Mittal VS, Sigrest T, Ottolini MC, et al. Family-centered rounds on pediatric wards: a PRIS network survey of US and Canadian hospitalists. Pediatrics. 2010;126(1):37–43. 8. Latta LC, Dick R, Parry C, Tamura GS. Parental responses to involvement in rounds on a pediatric inpatient unit at a teaching hospital: a qualitative study. Acad Med. 2008;83(3):292–297.
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APPENDIX CHILDREN’S NATIONAL MEDICAL CENTER PEDIATRIC HOSPITALISTS SURVEY
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The Impact of a Parent Brochure on Perceptions of Their Child's Hospitalization E. Berry Seelbach, Megan Yunghans and Padmaja Pavuluri Hospital Pediatrics 2012;2;77 DOI: 10.1542/hpeds.2011-0023
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The Impact of a Parent Brochure on Perceptions of Their Child's Hospitalization E. Berry Seelbach, Megan Yunghans and Padmaja Pavuluri Hospital Pediatrics 2012;2;77 DOI: 10.1542/hpeds.2011-0023
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://hosppeds.aappublications.org/content/2/2/77
Hospital Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 2012. Hospital Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 2154-1663.
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