Direct Admission Program Implementation: A Qualitative Analysis of Variation Across Health Systems.

OBJECTIVES: Direct admission (DA) to the hospital has the potential to improve family satisfaction and timeliness of care by bypassing the emergency department. Using the RE-AIM implementation framework, we sought to characterize variation across health systems in the reach, effectiveness, adoption, and implementation of a DA program from the perspectives of parents and multidisciplinary clinicians. METHODS: As part of a stepped-wedge cluster randomized trial to compare the effectiveness of DA to admission through the emergency department, we evaluated DA rates across 69 clinics and 3 health systems and conducted semi-structured interviews with parents and clinicians. We used thematic analysis to identify themes related to the reach, effectiveness, adoption, and implementation of the DA program and applied axial coding to characterize thematic differences across sites. RESULTS: Of 2599 hospitalizations, 171 (6.6%) occurred via DA, with DA rates varying 10-fold across health systems from 0.9% to 9.3%. Through the analysis of 137 interviews, including 84 with clinicians and 53 with parents, we identified similarities across health systems in themes related to perceived program effectiveness and patient and family engagement. Thematic differences across sites in the domains of program implementation and clinician adoption included variation in transfer center efficiency, trust between referring and accepting clinicians, and the culture of change within the health system. CONCLUSIONS: The DA program was adopted variably, highlighting unique challenges and opportunities for implementation in different hospital systems. These findings can inform future quality improvement efforts to improve transitions to the hospital.

Healthcare Quality for Acute Illness during the COVID-19 Pandemic: A Multisite Qualitative Analysis.

The coronavirus disease 2019 (COVID-19) pandemic incited substantial changes to acute care delivery, including the rapid scale-up of telehealth and numerous changes to in-person care. This study explored health system changes associated with the COVID-19 pandemic and their influences on pediatric acute care delivery and quality of care. METHODS: We conducted 38 semistructured interviews May-November 2020 with families and clinicians from 3 US regions, eliciting their perspectives and experiences regarding changes to acute care delivery during the pandemic. Interviews were analyzed using a general inductive approach to identify relationships between clinical care infrastructure, care processes, and healthcare quality. RESULTS: Emerging knowledge of COVID-19 epidemiology and associated restrictions influenced care-seeking behaviors and clinical infrastructure and processes. Infrastructure changes included the closure of some clinics, limited "sick visit" hours and locations, and increased resources for telehealth. Modified care processes included the assignment of clinicians to specific roles, limitations on sibling attendance, increased referrals to other clinics, and iterative development of procedures and protocols. Although intended to increase safety, these changes appear to have decreased access, timeliness, and equity of care. High-quality care was supported by telephone triage processes, in-person visits following initial assessments by telehealth, and identification of diagnoses and populations best-suited to telehealth versus in-person care. CONCLUSIONS: Changes in acute care delivery during the COVID-19 pandemic may have negatively impacted healthcare quality in some domains. Implementation of pediatric-specific guidelines and decision aids describing diagnoses, populations, and procedures best-suited to telehealth may improve the quality of acute care delivery.