Portal de Periódicos da CAPES

Neonatal Intensive Care Unit Graduate Home Visit: A Learning Opportunity for Pediatric Interns

2012; Elsevier BV; Volume: 161; Issue: 2 Linguagem: Inglês

10.1016/j.jpeds.2012.04.062

1097-6833

Margaret G. Parker, Karen Kamholz, Dara Brodsky, Barry Zuckerman,

Infant Health and Development

We created a neonatal intensive care unit (NICU) graduate home visitation program in April 2010 to increase awareness among pediatric first-year residents (ie, interns) of the difficulties parents face when caring for recently discharged infants. One year later, we surveyed the participating interns to examine the feasibility of the NICU Home Visit Program and determine whether participation in this program improved resident self-report of comfort with anticipating needs of NICU infants after discharge. We will describe our NICU Home Visit Program and survey results in this commentary. The hospitalization of an infant in the NICU is extremely stressful for parents and caregivers, who may be separated from their child for weeks at a time. Shaw et al demonstrated that one-third of these parents experience acute stress disorder during the early stages of hospitalization.1Shaw R.J. Deblois T. Ikuta L. Ginzburg K. Fleisher B. Koopman C. Acute stress disorder among parents of infants in the neonatal intensive care nursery.Psychosomatics. 2006; 47: 206-212Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar Discharge from the NICU can also be challenging, as parents of medically complex infants need to provide continued medical care to their child. In fact, many parents with acute stress disorder will meet the criteria for posttraumatic stress disorder for months after birth.2Shaw R.J. Bernard R.S. Deblois T. Ikuta L.M. Ginzburg K. Koopman C. The relationship between acute stress disorder and posttraumatic stress disorder in the neonatal intensive care unit.Psychosomatics. 2009; 50: 131-137Abstract Full Text Full Text PDF PubMed Scopus (199) Google Scholar Others report increased rates of “vulnerable child syndrome” among NICU graduates. In this condition, parents may develop separation anxiety toward their “vulnerable child,” struggle with limit setting, and exhibit excessive concerns over trivial illnesses.3Maypole J. Trozzi M. Augustyn M. Prematurity and parental expectations: too early and now too much.J Dev Behav Pediatr. 2011; (Epub ahead of print.)PubMed Google Scholar Understanding and anticipating these issues are of utmost importance to medical providers who care for these infants and families after discharge. We found that residents were unaware of the magnitude of stress and anxiety experienced by many parents of NICU graduates and were subsequently unequipped to support parents through the transition-to-home process. Home visitation has been described as a learning model for internal medicine and family medicine residents to understand the chronic care of elderly patients.4Matter C.A. Speice J.A. McCann R. Mendelson D.A. McCormick K. Friedman S. Medina-Walpole A. Clark N.S. Hospital to home: improving internal medicine residents' understanding of the needs of older persons after a hospital stay.Acad Med. 2003; 78: 793-797Crossref PubMed Scopus (33) Google Scholar, 5Laditka S.B. Fischer M. Mathews K.B. Sadlik J.M. Warfel M.E. There's no place like home: evaluating family medicine residents' training in home care.Home Health Care Serv Q. 2002; 21: 1-17Crossref PubMed Scopus (18) Google Scholar, 6Neale A.V. Hodgkins B.J. Demers R.Y. The home visit in resident education: program description and evaluation.Fam Med. 1992; 24: 36-40PubMed Google Scholar, 7Sadovsky R. Brecher D. Structuring a home visit program for residents.Fam Med. 1986; 18: 361-362PubMed Google Scholar Assessment of these programs found that residents rated home visits positively and reported that they were able to provide their patients with better care.5Laditka S.B. Fischer M. Mathews K.B. Sadlik J.M. Warfel M.E. There's no place like home: evaluating family medicine residents' training in home care.Home Health Care Serv Q. 2002; 21: 1-17Crossref PubMed Scopus (18) Google Scholar Residents also thought that participation in home visits improved their understanding of the impact of environmental, familial, and social factors on patient health.7Sadovsky R. Brecher D. Structuring a home visit program for residents.Fam Med. 1986; 18: 361-362PubMed Google Scholar We found only one report of home visitation as an educational tool for pediatric residents. Pediatric interns visited patients who were homebound (eg, ventilator-dependent), had missed follow-up appointments, or had transportation difficulties. Similar to previous studies, interns reported these home visits as a worthwhile and feasible experience.8Steinkuller J.S. Home visits by pediatric residents. A valuable educational tool.Am J Dis Child. 1992; 146: 1064-1067Crossref PubMed Scopus (12) Google Scholar We developed an NICU graduate home visitation program to improve pediatric resident awareness about the stresses faced by parents of NICU graduates and to enhance their ability to provide care in a family-centered, compassionate manner. We hoped that exposure to the home environment shortly after discharge would help trainees understand the depth of the psychosocial, economic, and medical needs faced by NICU graduates and their families. We initiated our program in April 2010 at Boston Medical Center, 1 of the 2 hospitals in which our pediatric interns complete a 4-week NICU rotation. This inner-city hospital serves a predominantly minority, low socioeconomic population. Our pediatric interns first identified an infant and family and arranged a home visit within 1 to 2 weeks of discharge. The interns selected a family that lived within a 30-minute drive from the hospital and spoke a language that they were comfortable speaking. We assigned a faculty member to accompany the intern on the visit. Faculty members were neonatologists, primary care or developmental pediatricians, or general academic pediatric or developmental-behavioral pediatric fellows. Prior to the visit, interns received a concrete list of objectives and potential topics to discuss with the family (Appendix; available at www.jpeds.com). We emphasized that transitioning to home from the NICU is an extremely stressful process and that many families will have concerns about normal infant behaviors (eg, sleeping and feeding) and medical (eg, medication administration, multiple follow-up visits), social (eg, care of other children in the house, lack of social support), financial (eg, shortened mater-nity leave), or transportation issues. We also conveyed to the residents that parents may show signs of anxiety or depres-sion. Upon completion of the visit, we asked the interns to complete a 1- to 2-paragraph reflection on their visit. One year after starting the program, we electronically surveyed residents to determine feasibility of the program and assess their opinions about the visit. Of 42 second-year residents who had recently finished their intern year, 25 (60%) completed the survey. Thirteen (52%) of the 25 participated in a visit, and 7 (28%) completed NICU rotations at a different hospital with no home visit program. The remaining 5 (20%) were unable to schedule a visit because of unexpected inclement weather, difficulty finding time for the visit when the census was high, and inability to identify an infant who was discharged during the intern's 4-week rotation and lived within 30 minutes of the hospital and whose family spoke a language with which the intern was comfortable. To address some of these barriers, we sent periodic e-mail reminders to the interns about scheduling their home visit. We also reminded the junior or senior residents and neonatologists that they should collectively “cover” patient care responsibilities for the interns during the home visit. Among interns who did attend a home visit, most traveled by car (50% used their own car, and 42% were driven by the accompanying faculty member) and 92% had no difficulty finding the home. Including travel time to and from the hospital, 58% of the visits required 1 to 2 hours and the remaining visits lasted 2 to 3 hours. Ninety-two percent of the participants reported that they had no concerns for their personal safety and that the family was receptive. We found that 83% of the interns felt supported by the accompanying faculty member and 17% felt somewhat supported. Because a breadth of pediatric faculty members accompanied interns, it is possible that interns felt less supported from faculty who had less experience caring for NICU graduates. In addition, many of the faculty members did not know the families prior to the visit. We have subsequently sent the home visit objectives to both the faculty and interns and made efforts to review the patient's clinical course with the accompanying faculty member prior to the visit. We also found that 67% of interns reported they would not feel comfortable attending the visit without an accompanying faculty member, and we have, therefore, continued our practice of home visits with faculty members present. Overall, most interns reported that their experience was excellent (17%), very good (50%), and good (17%). Fifty percent thought the experience was beneficial and 33% thought the experience was somewhat beneficial. When asked, “To what extent did your NICU home visit improve your ability to care for NICU infants, beyond what you have learned during your NICU rotation?” most thought that the visit increased their ability to prepare caregivers for postdischarge care (58%), understand challenges faced by families after discharge (75%), build rapport with caregivers (75%), and provide advice to caregivers (59%). Interns also thought that the visit improved awareness of economic (58%) and social (67%) issues, awareness of the home environment (83%), and empathy for families (83%). When we surveyed all interns, we found that 85% of interns who attended a home visit, compared with 67% of interns who did not attend a visit, felt comfortable anticipating medical issues of NICU graduates (P = .44). Interns who did and did not attend a home visit had similar comfort levels with anticipating social (50% vs 53%, P = .13) and economic (33% versus 23%, P = .58) issues. We were surprised that we did not observe greater differences between the groups because of the extremely positive reports by home visit participants, but acknowledge that we had relatively few interns who participated in our program in the first year. Perhaps our program could have had a stronger impact if the participating interns continued to care for the infants after their home visit. Furthermore, nonparticipating interns were possibly more confident in caring for NICU graduates than were participants because they did not experience the complex needs of the infants in their homes. We will continue to assess the feasibility and impact of our program to continue to improve this learning experience. We did not attempt to interview families of NICU graduates to assess caregiver satisfaction and whether the visit helped in the transition-to-home process. In the future, incorporation of feedback from families will further improve our NICU home visit program. Home visitation for NICU graduates is a novel method to expose pediatric interns to the issues faced by parents and caregivers of NICU graduates. A home visit program is feasible in a busy urban health center and well received by interns as a valuable learning experience. We strongly encourage other pediatric residency programs to implement such a program for NICU graduates or other medically complex hospitalized patients after discharge. 1.What was the pregnancy like for this family? (Many of the pregnancies of NICU babies are complicated.)2.What was it like having their child in the NICU? What was most difficult about the NICU stay?3.Did the family feel prepared to take the child home? What were their biggest concerns?4.What is the family structure? What is the role of the father in caretaking? What are the roles of other extended family members and children? How have they participated or supported the mother in caring for the new infant?5.What is the physical environment of the home and neighborhood? How does this impact the care of the infant?6.Do community supports exist that may help in the care of the infant?7.How does the family feel about the arrival of their infant into the home? Is the family adapting to life with a new infant at home?8.What concerns does the family have about their infant?9.How do the cultural or religious/spiritual beliefs of the family impact the care of the infant?10.How has the family changed its daily schedule to adjust to the needs of the infant? Does the mother, father, or other caretakers get paid or unpaid time off of work to care for the infant at home or attend medical appointments? Is transportation to and from appointments difficult?11.What medications or special formula is the infant receiving? How is the family administering or preparing these?12.Is there any evidence of exhaustion that may be worrisome? Is there any evidence of post-partum “blues” or depression?