Does family-centred neonatal discharge planning reduce healthcare usage? A before and after study in South West England.

OBJECTIVE: To implement parent-oriented discharge planning (Train-to-Home) for preterm infants in neonatal care. DESIGN: Before and after study, investigating the effects of the intervention during two 11-month periods before and after implementation. SETTING: Four local neonatal units (LNUs) in South West England. PARTICIPANTS: Infants without major anomalies born at 27-33 weeks' gestation admitted to participating units, and their parents. TRAIN-TO-HOME INTERVENTION: A family-centred discharge package to increase parents' involvement and understanding of their baby's needs, comprising a train graphic and supporting care pathways to facilitate parents' understanding of their baby's progress and physiological maturation, combined with improved estimation of the likely discharge date. MAIN OUTCOME MEASURES: Perceived Maternal Parenting Self-Efficacy (PMP S-E) scores, infant length of stay (LOS) and healthcare utilisation for 8 weeks following discharge. RESULTS: Parents reported that the Train-to-Home improved understanding of their baby's progress and their preparedness for discharge. Despite a lack of change in PMP S-E scores with the intervention, the number of post-discharge visits to emergency departments (EDs) fell from 31 to 20 (p<0.05), with a significant reduction in associated healthcare costs (£3400 to £2200; p<0.05) after discharge. In both study phases, over 50% of infants went home more than 3 weeks before their estimated date of delivery (EDD), though no reduction in LOS occurred. CONCLUSIONS: Despite the lack of measurable effect on the parental self-efficacy scores, the reduction in ED attendances and associated costs supports the potential value of this approach.

Identifying facilitators and barriers for home injury prevention interventions for pre-school children: a systematic review of the quantitative literature.

Injuries are the leading cause of childhood death internationally; steep social gradients exist in mortality and morbidity. The majority of pre-school injuries occur in the home, but implementing research into practice for injury prevention has received little attention. This systematic review describes key facilitators and barriers when implementing injury prevention interventions. The review used articles included in a Cochrane systematic review of the effectiveness of home safety education, with or without the provision of safety equipment. Each paper was screened to ensure that children under 5 years, intervention details and process measures and/or barriers and facilitators were included. Two authors independently reviewed each paper and extracted data. Themes were identified and framework analysis used in an iterative process. Ninety-nine papers were identified, 42 excluded and 57 included in the analysis. Seven facilitators and six barriers were identified. Facilitators related to the approach used, focused messages, minimal changes, deliverer characteristics, equipment accessibility, behaviour change and including incentives. The barriers included complex interventions, cultural, socio-economic, physical and behavioural barriers and deliverer constraints. Barriers and facilitators should be addressed when implementing injury prevention interventions and studies should explicitly explore factors that help or hinder the process.

Risk taking in general practice: GP out-of-hours referrals to hospital.

BACKGROUND: Emergency admissions to hospital at night and weekends are distressing for patients and disruptive for hospitals. Many of these admissions result from referrals from GP out-of-hours (OOH) providers. AIM: To compare rates of referral to hospital for doctors working OOH before and after the new general medical services contract was introduced in Bristol in 2005; to explore the attitudes of GPs to referral to hospital OOH; and to develop an understanding of the factors that influence GPs when they refer patients to hospital. DESIGN OF STUDY: Cross-sectional comparison of admission rates; postal survey. SETTING: Three OOH providers in south-west England. METHOD: Referral rates were compared for 234 GPs working OOH, and questionnaires explored their attitudes to risk. RESULTS: There was no change in referral rates after the change in contract or in the greater than fourfold variation between those with the lowest and highest referral rates found previously. Female GPs made fewer home visits and had a higher referral rate for patients seen at home. One-hundred and fifty GPs responded to the survey. Logistic regression of three combined survey risk items, sex, and place of visit showed that GPs with low 'tolerance of risk' scores were more likely to be high referrers to hospital (P<0.001). CONCLUSION: GPs' threshold of risk is important for explaining variations in referral to hospital.